How long to wait after local infiltration anaesthesia: systematic review.

BACKGROUND: Conflicting evidence exists regarding the optimal waiting time for stable analgesic and vasoconstrictive effects after local infiltration of lidocaine with epinephrine. An objective review is needed to dispel surgical dogma. METHODS: This systematic review (PROSPERO ID: CRD42022362414) included RCTs and prospective cohort studies. Primary outcomes were (1) onset of analgesia and (2) onset of stable hypoperfusion, assessed directly, or measured indirectly using perfusion imaging. Other data extracted include waiting strategies, means of outcome assessment, anaesthetic concentrations, volume/endpoint of infiltration, and injection sites. Methodological quality was evaluated using the Cochrane risk-of-bias tool for randomized trials. Articles describing waiting strategies were critically appraised by the Joanna Briggs Institute tools. RESULTS: Twenty-four articles were analysed, comprising 1013 participants. Ten investigated analgesia onset. Their pooled mean was 2.1 min (range 0.4-9.0 min). This varied with anatomic site and targeted nerve diameter. Fourteen articles investigated onset of stable hypoperfusion. Four observed bleeding intraoperatively, finding the minimum time to hypoperfusion at 7.0 min in the eyelid skin and 25.0 min in the upper limb. The ten remaining studies used perfusion imaging, reporting a wide range of results (0.0-30.0 min) due to differences in anatomic sites and depth, resolution and artefacts. Studies using near-infrared reflectance spectroscopy and hyperspectral imaging correlated with clinical observations. Thirteen articles discussed waiting strategies, seven relating to large-volume tumescent local infiltration anaesthesia. Different waiting strategies exist for emergency, arthroscopic and cosmetic surgeries, according to the degree of hypoperfusion required. In tumescent liposuction, waiting 10.0-60.0 min is the norm. CONCLUSION: Current literature suggests that around 2 min are required for most patients to achieve complete analgesia in all sites and with all anaesthesia concentrations. Waiting around 7 min in eyelids and at least 25 min in other regions results in optimal hypoperfusion. The strategies discussed inform decisions of when and how long to wait.

Unusual presentation of metastatic pancreatic carcinoma.

Pancreatic carcinoma is one of the most common and deadly cancers in the world. It typically presents with abdominal pain, vomiting and weight loss. Here, we report a case who presented with respiratory symptoms of cough, fever and decreased oral intake without any typical abdominal sign and symptoms. Later on, the patient's workup revealed that she had advanced/metastatic pancreatic carcinoma.

Selenium Supplementation Affects Physiological and Biochemical Processes to Improve Fodder Yield and Quality of Maize (Zea mays L.) under Water Deficit Conditions.

Climate change is one of the most complex challenges that pose serious threats to livelihoods of poor people who rely heavily on agriculture and livestock particularly in climate-sensitive developing countries of the world. The negative effects of water scarcity, due to climate change, are not limited to productivity food crops but have far-reaching consequences on livestock feed production systems. Selenium (Se) is considered essential for animal health and has also been reported to counteract various abiotic stresses in plants, however, understanding of Se regulated mechanisms for improving nutritional status of fodder crops remains elusive. We report the effects of exogenous selenium supply on physiological and biochemical processes that may influence green fodder yield and quality of maize (Zea mays L.) under drought stress conditions. The plants were grown in lysimeter tanks under natural conditions and were subjected to normal (100% field capacity) and water stress (60% field capacity) conditions. Foliar spray of Se was carried out before the start of tasseling stage (65 days after sowing) and was repeated after 1 week, whereas, water spray was used as a control. Drought stress markedly reduced the water status, pigments and green fodder yield and resulted in low forage quality in water stressed maize plants. Nevertheless, exogenous Se application at 40 mg L-1 resulted in less negative leaf water potential (41%) and enhanced relative water contents (30%), total chlorophyll (53%), carotenoid contents (60%), accumulation of total free amino acids (40%) and activities of superoxide dismutase (53%), catalase (30%), peroxidase (27%), and ascorbate peroxidase (27%) with respect to control under water deficit conditions. Consequently, Se regulated processes improved fodder yield (15%) and increased crude protein (47%), fiber (10%), nitrogen free extract (10%) and Se content (36%) but did not affect crude ash content in water stressed maize plants. We propose that Se foliar spray (40 mg L-1) is a handy, feasible and cost-effective approach to improve maize fodder yield and quality in arid and semi-arid regions of the world facing acute shortage of water.

Homocysteine level in patients with established transmural myocardial infarction.

OBJECTIVE: To evaluate the levels of serum total homocysteine in patients suffering from established transmural myocardial infarction and normal healthy subjects of local population. DESIGN: A case control study. PLACE AND DURATION OF STUDY: The present study was carried out at Dr. Hafiz Muhammad Ilyas (HMI) Institute of Pharmacology and Herbal Sciences in collaboration with National Institute of Cardiovascular Diseases, Karachi, from June 2001 to December 2001. PATIENTS AND METHODS: Eighty-four persons were included in a case control study. Sixty-three patients were cases suffering from transmural myocardial infarction of anterior wall and 21 normal healthy subjects were controls having no history of IHD ever before. Fasting venous serum was analyzed for total homocysteine using fluorescence polarization immunoassay (FPIA) while lipid parameters and plasma glucose were estimated by enzymatic colorimetric method. RESULTS: Mean serum total homocysteine and low density lipoprotein cholesterol (LDL-C) levels [19.43+/-2.46 umol/L, 124.97+/-45.31 mg/dl respectively] were found to be significantly higher in cases as compared to controls. The mean serum High density lipoprotein cholesterol (HDL-C) [27.57+/-15.31 mg/dl] was found to be significantly lower as compared to control. Mean serum glucose, total cholesterol and serum triacylglycerol [84.32+/-2.46 mg/dl, 174.35+/-27.08 mg/dl and 148.49+/-43.12 mg/dl respectively] were higher in patients as compared to control but difference was insignificant statistically. CONCLUSION: Significantly high levels of total homocysteine along with high levels of LDL-C and low levels of HDL-C appear to be the factors responsible for the increase risk of coronary artery disease in our local population.