A comparison of morphine and nalbuphine for intraoperative and postoperative analgesia

Introduction: Short acting narcotics are not available in Pakistan and the supply of drugs like morphine and pethidine is short and erratic; therefore there is a need for investigating acceptable alternatives for analgesia, to be used for balanced anaesthesia.Objective: We studied the agonist-antagonist narcotic nalbuphine compared to morphine, for intra and postoperative pain relief in total abdominal hysterectomies.Methods: In a randomised double blind trial, fifty ASA I and II patients in two groups of twenty five each were given equianalgesic doses of morphine and nalbuphine. Hemodynamic stability, intraoperative analgesia, recovery profiles, incidence of side effects and need for postoperative supplements were compared using standard anaesthesia technique for induction, maintenance and reversal. Postoperative analgesia profile was studied by the need for supplements in twenty four hours using the unidimensional verbal category scale.Results: We found that patients in the morphine group showed a rise of mean blood pressure and heart rate to 20% above the baseline in response to intubation whereas in the nalbuphine group it remained within 20% of baseline. Twelve out of twenty five patients in the morphine group and four out of twenty five patients in the nalbuphine group needed intraoperative supplements. Recovery profiles were similar in the two groups; postoperative nausea and vomiting and need for postoperative supplements was significantly less in the nalbuphine group.CONCLUSION: We conclude that nalbuphine provides better haemodynamic stability and better analgesia, recovery profile and postoperative pain relief compared to morphine in patients undergoing total abdominal hysterectomy

Pulmonary hypertension: An important predictor of outcomes in patients undergoing non-cardiac surgery

SummaryObjectivesPerioperative risk associated with pulmonary hypertension (PH) in patients undergoing non-cardiac surgery (NCS) remains poorly defined. We report perioperative outcomes in a large cohort of patients undergoing NCS, comparing those with and without PH.MethodsPatients undergoing NCS at our institution between January 2002 and December 2006, were cross matched with a Right Heart Catheterization (RHC) database for the same period. Patients were excluded if they were <18 years old and if they underwent cardiac surgery prior to NCS or minor procedures using local anesthesia or sedation. Controls were defined as patients who underwent similar NCS with mean pulmonary arterial pressure (MPAP) ≤ 25 mmHg.Results173 patients underwent RHC and NCS during the specified period and were included in the analysis. Of these 96 (55%) had PH. Mean pulmonary arterial pressure (p = 0.001), American Association of Anesthesiology Class (p = 0.02), and chronic renal insufficiency (p = 0.03) were determined as independent risk factors for post-operative morbidity. Patients with PH were more likely to develop congestive heart failure (p < 0.001; OR: 11.9), hemodynamic instability (p < 0.002), sepsis (p < 0.0005), and respiratory failure (p < 0.004). Patients with PH needed longer ventilatory support (p < 0.002), stayed longer in the ICU (p < 0.04), and were more frequently readmitted to the hospital within 30 days (p < 008; OR 2.4).ConclusionsIn addition to the traditionally known risk factors for outcomes after NCS such as coronary artery disease, diabetes mellitus, chronic renal insufficiency, American Society of Anesthesiology class, the presence of underlying PH can have a significant negative impact on perioperative outcomes

Places of interchange in the northeast corridor transportation system

Massachusetts Institute of Technology. Dept. of Architecture. Thesis. 1965. M.Arch.Includes bibliographies.Jerry Gibson ... [et al.].v.1. Places of interchange in the northeast corridor transportation system by Jerry Gibson, Harold A. Hanen, Ronald D. Lindgren, Asghar T. Minai, Thomas J. Rosengren, and Ralph H. Tolbert, Jr.--v.2. Case studies of interchanges.--A. A place of interchange in a new metropolitan sub-center, by Jerry Gibson.--B. A place of interchange in a new metropolitan sub-center, by Harold A. Hanen.--C. A place of interchange in central Boston, by Ronald D. Lindgren.--D. A prototype place of interchange in a metropolitan center, by Asghar T. Minai.--E. The place of interchange in the central core of Boston, by Thomas J. Rosengren.--F. A prototype place of interchange of an above-ground inner loop of the regional HSGT network, by Ralph H. Tolbert, Jr.M.Arch

Networked buffering: a basic mechanism for distributed robustness in complex adaptive systems

A generic mechanism - networked buffering - is proposed for the generation of robust traits in complex systems. It requires two basic conditions to be satisfied: 1) agents are versatile enough to perform more than one single functional role within a system and 2) agents are degenerate, i.e. there exists partial overlap in the functional capabilities of agents. Given these prerequisites, degenerate systems can readily produce a distributed systemic response to local perturbations. Reciprocally, excess resources related to a single function can indirectly support multiple unrelated functions within a degenerate system. In models of genome:proteome mappings for which localized decision-making and modularity of genetic functions are assumed, we verify that such distributed compensatory effects cause enhanced robustness of system traits. The conditions needed for networked buffering to occur are neither demanding nor rare, supporting the conjecture that degeneracy may fundamentally underpin distributed robustness within several biotic and abiotic systems. For instance, networked buffering offers new insights into systems engineering and planning activities that occur under high uncertainty. It may also help explain recent developments in understanding the origins of resilience within complex ecosystems. \ud \u

The developing role of occupational therapists in school-based practice: Experiences from collaborative action research in Pakistan

Knowledge Economy Partnership (KEP) funding from the British Council and the Higher Education Commission of Pakista

Combining Network Modeling and Gene Expression Microarray Analysis to Explore the Dynamics of Th1 and Th2 Cell Regulation

Two T helper (Th) cell subsets, namely Th1 and Th2 cells, play an important role in inflammatory diseases. The two subsets are thought to counter-regulate each other, and alterations in their balance result in different diseases. This paradigm has been challenged by recent clinical and experimental data. Because of the large number of genes involved in regulating Th1 and Th2 cells, assessment of this paradigm by modeling or experiments is difficult. Novel algorithms based on formal methods now permit the analysis of large gene regulatory networks. By combining these algorithms with in silico knockouts and gene expression microarray data from human T cells, we examined if the results were compatible with a counter-regulatory role of Th1 and Th2 cells. We constructed a directed network model of genes regulating Th1 and Th2 cells through text mining and manual curation. We identified four attractors in the network, three of which included genes that corresponded to Th0, Th1 and Th2 cells. The fourth attractor contained a mixture of Th1 and Th2 genes. We found that neither in silico knockouts of the Th1 and Th2 attractor genes nor gene expression microarray data from patients with immunological disorders and healthy subjects supported a counter-regulatory role of Th1 and Th2 cells. By combining network modeling with transcriptomic data analysis and in silico knockouts, we have devised a practical way to help unravel complex regulatory network topology and to increase our understanding of how network actions may differ in health and disease

Mechanisms Behind the Generalized Synchronization Conditions

A universal mechanism underlying generalized synchronization conditions in unidirectionally coupled stochastic oscillators is considered. The consideration is carried out in the framework of a modified system with additional dissipation. The approach developed is illustrated with model examples. The conclusion is reached that two types of the behavior of nonlinear dynamic systems known as generalized synchronization and noise-induced synchronization, which are viewed as different phenomena, actually represent a unique type of the synchronous behavior of stochastic oscillators and are caused by the same mechanism.Comment: 8 pages, 5 figure

Incidentalomas during imaging for primary hyperparathyroidism—incidence and clinical outcomes

Background: Imaging for pre-operative localisation of parathyroid glands in primary hyperparathyroidism is now routine. This has led to the detection of incidental lesions (incidentalomas) in other organs, the nature of which is not well characterised. The aim of this study was to determine the incidence, characteristics and outcomes in patients who had incidental findings on parathyroid imaging. Methods: Records of patients who underwent imaging for primary hyperparathyroidism over 2 years were reviewed to identify incidental lesions detected on parathyroid imaging. Patients with persistent or renal hyperparathyroidism were excluded. Details on the management of detected incidentalomas were obtained from patient records. Results: Incidentalomas were identified in 17 of 170 patients (10 %) undergoing parathyroid imaging. Incidentalomas included thyroid (n = 11), breast (n = 3), lateral compartment of the neck (n = 1), lung (n = 1) and clavicle (n = 1). However, no disease of clinical significance needing treatment was detected on further investigation. Conclusions: Although a significant proportion of patients undergoing parathyroid imaging had incidental lesions detected, these seem to be of little clinical significance. The morbidity and cost of further interventions on these incidentalomas need to be weighed against the benefits of routine imaging in improving outcomes of first-time surgery in patients with primary hyperparathyroidism. Keywords: Parathyroid gland, Primary hyperparathyroidism, Imaging, Incidentaloma

Injection-site reactions upon Kineret (anakinra) administration: experiences and explanations

Anakinra (Kineret), a recombinant form of human interleukin-1 (IL-1) receptor antagonist, is approved for the treatment of rheumatoid arthritis (RA) in combination with methotrexate. Kineret is self-administered by daily subcutaneous injections in patients with active RA. The mechanism of action of anakinra is to competitively inhibit the local inflammatory effects of IL-1. Kineret is generally safe and well tolerated and the only major treatment-related side effects that appear are skin reactions at the injection site. Due to the relatively short half-life of anakinra, daily injection of the drug is required. This, in combination with the comparably high rates of injection-site reactions (ISRs) associated with the drug, can become a problem for the patient. The present review summarises published data concerning ISRs associated with Kineret and provides some explanations as to their cause. The objective is also to present some clinical experiences of how the ISRs can be managed