A randomised controlled trial comparing weight adjusted dose versus fixed dose prophylactic phenylephrine infusion on maintaining systolic blood pressure during caesarean section under spinal anaesthesia

Background: Spinal anaesthesia is the standard of care for elective caesarean delivery. It has advantages over general anaesthesia. However the sympathetic blockade induced by spinal anaesthesia results in an 80 percent incidence of hypotension without prophylactic management. Current evidence supports co-loading with intravenous fluids in conjunction with the use of vasopressors as the most effective way to prevent and treat the hypotension. Phenylephrine is the accepted vasopressor of choice in the parturient. A prophylactic phenylephrine infusion combined with a fluid co-load is proven to be an effective and safe method of maintaining maternal hemodynamic stability. While most published studies have assessed the effectiveness of a prophylactic phenylephrine fixed dose infusion, few studies have assessed the effect of a prophylactic phenylephrine weight adjusted dose infusion on maintaining maternal hemodynamic stability following spinal anesthesia for a cesarean delivery. Objective: To compare the incidence of hypotension between women undergoing elective caesarean section under spinal anaesthesia, receiving prophylactic phenylephrine infusion at a fixed dose of 37.5 micrograms per minute versus a weight adjusted dose of 0.5 micrograms per kilogram per minute. Methods: One hundred and eight patients scheduled for non-urgent caesarean section under spinal anaesthesia were randomized into 2 groups; control group and intervention group using a computer generated table of numbers. Control group; Received prophylactic phenylephrine fixed dose infusion at 37.5 micrograms per minute. Intervention group; Received prophylactic phenylephrine weight adjusted dose infusion at 0.5 micrograms per kilogram per minute Results: The two groups had similar baseline characteristics in terms of ; Age, sex, weight and height. There was a 35.2% incidence of hypotension in the fixed dose group and an 18.6% incidence of hypotension in the weight adjusted dose group. This difference was found to be of borderline statistical significance p-value 0.05, and the difference in the incidence rates between the two groups was found to be statistically significant p= 0.03. The difference in the incidence of reactive hypertension and bradycardia between the two groups was not statistically significant: p-value of 0.19 for reactive hypertension and p-value of 0.42 for the incidence of bradycardia. There was also no statistically significant difference in the use of phenylephrine boluses, use of atropine, intravenous fluid used and the number of times the infusion was stopped. Conclusion: Among this population, the incidence of hypotension was significantly less in the weight adjusted dose group than in the fixed dose group. There was no difference in the number of physician interventions required to keep the blood pressure within 20% of baseline, and no difference in the proportion of reactive hypertension or bradycardia between the two groups. Administering prophylactic phenylephrine infusion at a weight adjusted dose of 0.5 micrograms per kilogram per minute results in a lower incidence of hypotension compared to its administration at a fixed dose of 37.5 micrograms per minute

Effect of target controlled propofol infusion versus intermittent boluses during oesophagogastroduodenoscopy: a randomized controlled trial

Background: Propofol is administered as intermittent boluses to achieve deep sedation to facilitate oesophagogastroduodenoscopy. Target controlled infusion (TCI) can be employed for this purpose. Methods: 176 adults were randomly allocated into two groups of 88 patients. Control group: Received an initial bolus of propofol 1mg/kg, with repeat boluses of 0.25mg/kg. Intervention group: Received an initial target effect-site concentration of 4mcg/ml, followed by maintenance target effect-site concentration of 2.5mcg/ml, titrated by 0.5mcg/ml from baseline infusion rate as needed. Oxygen saturation, blood pressure and heart rate were evaluated immediately before administering the sedative and at 2.50, 5.00, 7.50 and 10.00 minutes. Oxygen desaturation below 90% in both study groups was recorded. Sedation starting time, stopping time, waking up time and overall duration of time to recovery of participants in each study arm was recorded. Results: More hypoxic episodes were observed in the intermittent bolus group with statistically significant association between control and the incidence of hypoxia: Chi square test, p=0.037. There were more hypotensive episodes in the TCI group but not achieving statistical significance: Chi square test for association X2(1) = 0.962, p=0.327.The time to recovery between the two groups was comparable, with 18.84 ± 10.76 minutes in the bolus group and 19.72 ± 9.27 minutes in the TCI group; no statistically significant difference was shown: Student’s t-test, p=0.0564. Conclusion: TCI of propofol was associated with fewer episodes of hypoxia compared to intermittent bolus administration. Similar hemodynamic profiles and comparable time to recovery were demonstrated by these two sedation techniques

Effect of removal of AuraOnce™ laryngeal mask in awake or deep anaesthesia: a randomized controlled trial

Background: The manufacturer Ambu® recommends that the AuraOnce™ laryngeal mask be removed once the patient is fully awake. Studies have shown benefit in removal of the laryngeal mask airway while a patient is deeply anaesthetized. Current evidence is inconclusive, as to which approach is preferable and safer in adults. Methods: one hundred and sixteen adult patients were randomly assigned to two groups of 58. For the deep arm; The AuraOnceTM laryngeal mask was removed after attaining an end tidal minimum alveolar concentration of Isoflurane of 1.15%. Occurrence of airway complication(s) (One or more of the following; Airway obstruction requiring airway manipulation; Laryngospasm; Desaturation to 90% or less on pulse oximetry) was noted until the subject was fully awake (appropriate response to command) in the post-anaesthesia care unit. For the awake arm; The AuraOnceTM laryngeal mask was removed on attaining an end tidal minimum alveolar concentration of Isoflurane of \u3c0.5% and an appropriate response to command or obtaining appropriate response to command irrespective of end tidal concentration. Occurrence of airway complication(s) in theatre and post anaesthesia care unit was recorded. Time to theatre exit was recorded for both groups. Results: Baseline demographic characteristics were similar between the groups. More airway complications were encountered in the Deep arm - 13 (22.4%) relative to the Awake arm -5 (8.6%), this was found to be statistically and clinically significant, P value P=0.040, odds ratio 3.0622; 95% CI, 1.0139 to 9.2483. Conclusion: The removal of the AuraOnceTM laryngeal mask while the patient is still deeply anaesthetised is not as safe as or safer than awake removal

A journey of transformation : A reflective recount of the evolution of AKES,P

This paper presents an overall picture of the evolution of the Aga Khan Education Service, Pakistan (AKES,P) over a century. Reaching out to the remotest areas of Pakistan, AKES,P, has been providing quality education for over a hundred years. The first school of AKES,P, was established in 1905 in Gwadar, Balochistan. Over a century later, AKES,P, now operates 179 schools and 5 hostels in Gilgit-Baltistan, Chitral, Punjab and Sindh, mostly in rural areas. These represent very diverse schools, ranging from a rural school with less than 30 children to a large urban school with over 3000 children. AKES,P, places special emphasis on improving educational practice; leadership and management in diverse and challenging settings; child-centred teaching methods; increasing use of ICT; female education; school-based teacher development; and working in partnership with the government and communities. The paper elucidates the institution’s journey since its inception, under five major themes, which include: Institutional Development, History of Teacher Development, Evolution of Teaching and Learning Practices, Creating a Child Friendly Environment, and Community Development

Effect of removal of AuraOnceTM laryngeal mask in awake or deep anaesthesia: a randomized controlled trial

Background: The manufacturer Ambu\uae recommends that the AuraOnce\u2122 laryngeal mask be removed once the patient is fully awake. Studies have shown benefit in removal of the laryngeal mask airway while a patient is deeply anaesthetized. Current evidence is inconclusive, as to which approach is preferable and safer in adults. Methods: one hundred and sixteen adult patients were randomly assigned to two groups of 58. For the deep arm; The AuraOnceTM laryngeal mask was removed after attaining an end tidal minimum alveolar concentration of Isoflurane of 1.15%. Occurrence of airway complication(s) (One or more of the following; Airway obstruction requiring airway manipulation; Laryngospasm; Desaturation to 90% or less on pulse oximetry) was noted until the subject was fully awake (appropriate response to command) in the post-anaesthesia care unit. For the awake arm; The AuraOnceTM laryngeal mask was removed on attaining an end tidal minimum alveolar concentration of Isoflurane of <0.5% and an appropriate response to command or obtaining appropriate response to command irrespective of end tidal concentration. Occurrence of airway complication(s) in theatre and post anaesthesia care unit was recorded. Time to theatre exit was recorded for both groups. Results: Baseline demographic characteristics were similar between the groups. More airway complications were encountered in the Deep arm - 13 (22.4%) relative to the Awake arm -5 (8.6%), this was found to be statistically and clinically significant, P value P=0.040, odds ratio 3.0622; 95% CI, 1.0139 to 9.2483. Conclusion: The removal of the AuraOnceTM laryngeal mask while the patient is still deeply anaesthetised is not as safe as or safer than awake removal

Effect of target controlled propofol infusion versus intermittent boluses during oesophagogastroduodenoscopy: a randomized controlled trial

Background: Propofol is administered as intermittent boluses to achieve deep sedation to facilitate oesophagogastroduodenoscopy. Target controlled infusion (TCI) can be employed for this purpose. Methods: 176 adults were randomly allocated into two groups of 88 patients. Control group: Received an initial bolus of propofol 1mg/kg, with repeat boluses of 0.25mg/kg. Intervention group: Received an initial target effect-site concentration of 4mcg/ml, followed by maintenance target effect-site concentration of 2.5mcg/ml, titrated by 0.5mcg/ml from baseline infusion rate as needed. Oxygen saturation, blood pressure and heart rate were evaluated immediately before administering the sedative and at 2.50, 5.00, 7.50 and 10.00 minutes. Oxygen desaturation below 90% in both study groups was recorded. Sedation starting time, stopping time, waking up time and overall duration of time to recovery of participants in each study arm was recorded. Results: More hypoxic episodes were observed in the intermittent bolus group with statistically significant association between control and the incidence of hypoxia: Chi square test, p=0.037. There were more hypotensive episodes in the TCI group but not achieving statistical significance: Chi square test for association X2(1) = 0.962, p=0.327.The time to recovery between the two groups was comparable, with 18.84 \ub1 10.76 minutes in the bolus group and 19.72 \ub1 9.27 minutes in the TCI group; no statistically significant difference was shown: Student\u2019s t-test, p=0.0564. Conclusion: TCI of propofol was associated with fewer episodes of hypoxia compared to intermittent bolus administration. Similar hemodynamic profiles and comparable time to recovery were demonstrated by these two sedation techniques

A randomised controlled trial comparing weight adjusted dose versus fixed dose prophylactic phenylephrine infusion on maintaining systolic blood pressure during caesarean section under spinal anaesthesia.

Background: Spinal anaesthesia is the standard of care for elective caesarean delivery. It has advantages over general anaesthesia. However the sympathetic blockade induced by spinal anaesthesia results in an 80 percent incidence of hypotension without prophylactic management. Current evidence supports co-loading with intravenous fluids in conjunction with the use of vasopressors as the most effective way to prevent and treat the hypotension. Phenylephrine is the accepted vasopressor of choice in the parturient. A prophylactic phenylephrine infusion combined with a fluid co-load is proven to be an effective and safe method of maintaining maternal hemodynamic stability. While most published studies have assessed the effectiveness of a prophylactic phenylephrine fixed dose infusion, few studies have assessed the effect of a prophylactic phenylephrine weight adjusted dose infusion on maintaining maternal hemodynamic stability following spinal anesthesia for a cesarean delivery. Objective: To compare the incidence of hypotension between women undergoing elective caesarean section under spinal anaesthesia, receiving prophylactic phenylephrine infusion at a fixed dose of 37.5 micrograms per minute versus a weight adjusted dose of 0.5 micrograms per kilogram per minute. Methods: One hundred and eight patients scheduled for non-urgent caesarean section under spinal anaesthesia were randomized into 2 groups; control group and intervention group using a computer generated table of numbers. Control group; Received prophylactic phenylephrine fixed dose infusion at 37.5 micrograms per minute. Intervention group; Received prophylactic phenylephrine weight adjusted dose infusion at 0.5 micrograms per kilogram per minute Results: The two groups had similar baseline characteristics in terms of ; Age, sex, weight and height. There was a 35.2% incidence of hypotension in the fixed dose group and an 18.6% incidence of hypotension in the weight adjusted dose group. This difference was found to be of borderline statistical significance p-value 0.05, and the difference in the incidence rates between the two groups was found to be statistically significant p= 0.03. The difference in the incidence of reactive hypertension and bradycardia between the two groups was not statistically significant: p-value of 0.19 for reactive hypertension and p-value of 0.42 for the incidence of bradycardia. There was also no statistically significant difference in the use of phenylephrine boluses, use of atropine, intravenous fluid used and the number of times the infusion was stopped. Conclusion: Among this population, the incidence of hypotension was significantly less in the weight adjusted dose group than in the fixed dose group. There was no difference in the number of physician interventions required to keep the blood pressure within 20% of baseline, and no difference in the proportion of reactive hypertension or bradycardia between the two groups. Administering prophylactic phenylephrine infusion at a weight adjusted dose of 0.5 micrograms per kilogram per minute results in a lower incidence of hypotension compared to its administration at a fixed dose of 37.5 micrograms per minute

Atypical Localizations of Hydatid Disease: Experience from a Single Institute

Introduction: The hydatid disease most often involves the liver and the lungs. The disease can involve any part of the body except the hair, teeth and nails. Primary extrahepaticopulmonary hydatid cysts are rare and only a few sporadic cases have been reported. Materials and Methods: Two hundred and forty-four patients with hydatid cysts managed surgically from January 2005 to December 2009 were evaluated retrospectively. Fourteen (5.7%) patients had isolated involvement of the atypical sites, while six (2.4%) also had a primary involvement of liver. Results: The cysts were present in gall bladder (0.4%), peritoneum (1.6%), spleen (1.6%), ovary (0.4%), subcutaneous (0.8%), seminal vesicle (0.4%), spinal (0.4%), pancreas (0.4%), kidney (0.4%), mediastinal (0.4%), muscle (0.4%), and brain (0.8%). Discussion and Conclusions: Involvement of sites other than liver and lungs by hydatid disease is rare. Symptoms are related to size, location or possible complication of the cyst. It should be strongly suspected in differential diagnosis of all abdominal cysts especially in an endemic area. Proper surgical and medical management to avoid any recurrences, and a regular follow-up, are of utmost importance to detect any late complications such as local recurrence of the disease and development of hydatidosis at the primary sites.Keywords: Atypical locations, hydatid, echinococcosisNigerian Journal of Surgery, Jan-Jun 2012 | Volume 18 | Issue

The spectrum of primary immunodeficiencies at a tertiary care hospital in Pakistan

Background: Primary Immunodeficiency Disorders (PIDs) are well-known disorders in the West. but the recognition and diagnosis of these disorders is challenging in developing countries. We present the spectrum of PIDs seen at a tertiary care center in Pakistan, identified using clinical case definitions and molecular methods.Methods: A retrospective chart review of children suspected to have PID was conducted at the Aga Khan University Hospital (AKUH) Karachi, Pakistan from 2010 to 2016. Data on demographics, clinical features, family history of consanguinity, sibling death, details of laboratory workup done for PID and molecular tests targeted panel next generation sequencing (NGS) or whole exome sequencing (WES) performed at the Geha laboratory at Boston Children\u27s Hospital, USA was collected. The study was exempted from the Ethical Review Committee of AKUH.Results: A total of 43 children visited the hospital with suspected PID during the study period. Genetic testing was performed in 31/43 (72.1%) children. A confirmed diagnosis of PID was established in 20/43 (46.5%) children. A pathogenic gene variant was identified in 17(85%) of the 20 confirmed cases (Table 1). Twelve (60%) of the confirmed cases of PID were male. The most common presenting symptom was recurrent diarrhea 11/20 (55%). The mean (±S.D) age of the cases at the time of diagnosis was 4.2 (±4.1) years. Chronic granulomatous disease (CGD) was the most common 6/20 (30%) disorder, followed by severe combined immunodeficiency (SCID) 3/20 (15%), leukocyte adhesion deficiency (LAD) 3/20 (15%), agammaglobulinemia/hypogammaglobulinemia 3/20 (15%), and Hermansky-Pudlak Syndrome (HPS) 2/20 (10%). Wiskott-Aldrich Syndrome, Immunodeficiency Centromeric Instability and Facial Anomalies Syndrome (ICF 2), Trichohepatoenteric syndrome (TRES), and C3 deficiency were each diagnosed once {1/20 (4.3%) each} (Table 1). Of these 20 confirmed cases, almost all 19/20 (95%) had a family history of consanguinity. Sibling death was reported in 5/20 (25%) of these cases. Five out of the 20 (25%) children died over the 7-year period for various reasons.Conclusion: PIDs are not uncommon in Pakistan; their diagnosis may be missed or delayed due to the overlapping of clinical features of PID with other diseases and a lack of diagnostic facilities. There is a need to build capacity for early recognition and diagnosis of PIDs to decrease morbidity and mortality

Search for dark matter produced in association with bottom or top quarks in √s = 13 TeV pp collisions with the ATLAS detector

A search for weakly interacting massive particle dark matter produced in association with bottom or top quarks is presented. Final states containing third-generation quarks and miss- ing transverse momentum are considered. The analysis uses 36.1 fb−1 of proton–proton collision data recorded by the ATLAS experiment at √s = 13 TeV in 2015 and 2016. No significant excess of events above the estimated backgrounds is observed. The results are in- terpreted in the framework of simplified models of spin-0 dark-matter mediators. For colour- neutral spin-0 mediators produced in association with top quarks and decaying into a pair of dark-matter particles, mediator masses below 50 GeV are excluded assuming a dark-matter candidate mass of 1 GeV and unitary couplings. For scalar and pseudoscalar mediators produced in association with bottom quarks, the search sets limits on the production cross- section of 300 times the predicted rate for mediators with masses between 10 and 50 GeV and assuming a dark-matter mass of 1 GeV and unitary coupling. Constraints on colour- charged scalar simplified models are also presented. Assuming a dark-matter particle mass of 35 GeV, mediator particles with mass below 1.1 TeV are excluded for couplings yielding a dark-matter relic density consistent with measurements