Challenges of Pediatric Anesthesia Services and Training Infrastructure in Tertiary Care Teaching Institutions in Pakistan: A Perspective From the Province of Sindh.

BACKGROUND: Pakistan is a lower middle-income country located in South Asia with a population of nearly 208 million. Sindh is its second largest province. The aim of this survey was to identify the current setup of pediatric services, staffing, equipment, and training infrastructure in the teaching hospitals of Sindh. METHODS: The survey was conducted between June 2018 and September 2018. A questionnaire was designed with input from experts and pretested. One faculty coordinator from each of 12 of the 13 teaching hospitals (7 government and 5 private) completed the form. Information was exported into Statistical Package for the Social Sciences (SPSS) version 22. Frequency and percentages were computed for all variables. Confidentiality was ensured by anonymizing the data. RESULTS: Anesthesia services are provided by consultants with either membership or fellowship in anesthesia of the College of Physicians and Surgeons of Pakistan (CPSP). All drugs on the World Health Organization (WHO) essential medication list were available, although narcotic supply was often inconsistent. Weak areas identified were absence of standardization of practice regarding premedication, preoperative laboratory testing, pain assessment, and management. No national practice guidelines exist. Pulse oximeters and capnometers were available in all private hospitals but in only 86% and 44% of the government hospitals, respectively. Some training centers were not providing the training as outlined by the CPSP criteria. CONCLUSIONS: Several gaps have been identified in the practice and training infrastructure of pediatric anesthesia. There is a need for national guidelines, standardization of protocols, provision of basic equipment, and improved supervision of trainees. One suggestion is to have combined residency programs between private and government hospitals to take advantage of the strengths of both. Recommendations by this group have been shared with all teaching hospitals and training bodies.

Quantitative analysis of tumor-associated tissue eosinophils and tumor-associated blood eosinophils in oral squamous cell carcinoma.

BACKGROUND: Stromal response to cancer is usually characterized by intense lymphoplasmacytic infiltrate. However, recently, the attention has shifted to tumor-associated tissue eosinophils (TATE). Tumor-associated blood eosinophils (TABE) are rare in solid cancers; however, carcinoma of the head and neck shows its prevalence. AIM: The aim of the study was to investigate the prevalence and relationship of tissue and blood eosinophils in various grades of oral cancer. The purpose of the article is to emphasize the possible clinical and biological significance of eosinophils in patients of oral squamous cell carcinoma (OSCC) so that appropriate therapeutic strategies can be devised accordingly. STUDY DESIGN: Thirty histologically confirmed cases of oral squamous cell carcinoma were divided into well, moderate and poorly differentiated carcinoma. Eosinophilic infiltration in the tissue was graded as low, moderate and massive TATE. The number of eosinophils per 100 WBCs was taken as the differential eosinophil count. Blood eosinophilia (BE) >6% was considered to be TABE. MATERIALS AND METHODS: Hematoxylin and eosin-stained tissue sections at 5 µ were evaluated. Prolonged staining in dilute 0.05% aqueous eosin demonstrated eosinophils selectively. Blood smears were stained by Leishman stain. STATISTICAL ANALYSIS: Student's t-test, Chi-square test, ANOVA, Newman-Keuls Multiple Comparison Test and Karl Pearson correlation coefficient® method were used. RESULTS: The mean TATE value was highest in poorly differentiated carcinoma. TABE was seen only in a few cases and was associated mostly with poorly differentiated OSCC. CONCLUSION: There was a statistically significant correlation between TATE and histological grades of OSCC. Eosinophilia of the peripheral blood is an adverse sign in patients with carcinoma.

Revisiting the "leading edge" of hospital privacy curtains in the medical intensive care unit.

BACKGROUND: Privacy curtains within medical intensive care unit (MICU) rooms are a potential contributor to health care associated infections. The "leading edge" of a hospital curtain, estimated to be the edge most frequently touched, likely plays a role in health care associated infections at hospitals. The aims of this study were to (1) compare the bacterial load of the edge vs the middle of curtains in the MICU, and (2) determine the identity and distribution of relevant pathogens colonizing them. METHODS: The edge and middle sections of 8 curtains in MICU rooms (4 contact precaution and 4 noncontact precaution) were sampled for culture on patient and staff sides. Bacterial loads of edges and middles were compared. Select isolates were further analyzed for species identification. RESULTS: There was a statistically significant difference for the contact (t = 2.10, P = .047) and noncontact (t = 2.62, P = .016) rooms, with the edges having a significantly higher median than the middles. Pathogens such as methicillin-resistant Staphylococcus aureus, Enterococcus, Klebsiella, and Acinetobacter were found on the curtains, though at lower rates than in previous studies. Opportunistic fungi were also found on all curtains. CONCLUSIONS: Results of this study confirm that hospital curtains, most notably the edge but also the middle, are contaminated with pathogens, and that these areas are frequently touched by health care workers in between hand hygiene.

Cardiopulmonary resuscitation discussions with patients admitted to acute oncology wards: A national audit of current practice.

OBJECTIVES: To map current practice regarding discussions around resuscitation across England and Scotland in patients with cancer admitted acutely to hospital and to demonstrate the value of medical students in rapidly collecting national audit data. METHODS: Collaborators from the Macmillan medical student network collected data from 251 patient encounters across eight hospitals in England and Scotland. Data were collected to identify whether discussion regarding resuscitation was documented as having taken place during inpatient admission to acute oncology. As an audit standard, it was expected that all patients should be invited to discuss resuscitation within 24 hr of admission. RESULTS: Resuscitation discussions were had in 43.1% of admissions and of these 64.0% were within 24 hr; 27.6% of all admissions. 6.5% of patients had a "do not attempt resuscitation" order prior to admission with a difference noted between patients receiving palliative and curative treatment (8.5% and 0.39%, respectively, p < .05). Discussions regarding escalation of care took place in only 29.3% of admissions. CONCLUSIONS: These data highlight deficiencies in the number of discussions regarding resuscitation that are being conducted with cancer patients that become acutely unwell. It also demonstrates the value of medical student collaboration in rapidly collecting national audit data.

Oral lichen planus in an 8-year-old child: A case report with a brief literature review.

Lichen planus (LP) is a chronic autoimmune condition of uncertain etiopathogenesis and usually affects the skin, oro-genital mucosa, nail and scalp appendages. LP is primarily seen in middle-aged individuals, and oral lesions of LP in children are relatively uncommon. Herewith, we report a case of oral LP in an 8-year-old boy, which regressed well with the treatment modality.

A quantitative and qualitative comparative analysis of collagen fibers to determine the role of connective tissue stroma in oral squamous cell carcinoma using special stains and polarized microscopy.

BACKGROUND: Solid tumors such as oral squamous cell carcinoma (OSCC) are composed of malignant epithelial cells and the stroma in which these cells are dispersed. As the tumor progresses, the extracellular matrix undergoes dramatic morphological and architectural changes. Special stains make analysis easy and less erroneous by highlighting the area of interest and can be used to study these changes. AIM: The aim of the study was to analyze morphological changes in collagen fibers in various histological grades of OSCC using Masson's trichrome (MT) and Picrosirius red (PSR). STUDY DESIGN: The study comprised 74 tissue samples, divided into two groups: Group I consisted of 63 cases of histologically proven OSCC (39 cases of well-differentiated squamous cell carcinoma [WDSCC], 17 moderately differentiated squamous cell carcinoma [MDSCC] and 7 poorly differentiated squamous cell carcinoma [PDSCC]) and Group II consisted of 11 cases of normal mucosa as controls. MATERIALS AND METHODS: Sections were stained with hematoxylin and eosin, MT and PSR and observed under light and polarizing microscope, respectively. STATISTICAL ANALYSIS: ANOVA, Tukey's honestly significant difference post hoc multiple comparison test, Chi-square test and paired t-test were used for the statistical analysis. RESULTS: As the grade of OSCC progressed, collagen fibers became thin, loosely packed and haphazard. The mean area fraction also decreased. They exhibited orange-red hue and strong birefringence in WDSCC, yellowish-orange hue and strong birefringence in MDSCC and greenish-yellow hue and weak birefringence in PDSCC. CONCLUSION: Initially, there is a reorganization of the collagen fibers in an attempt to prevent the invasion of tumor cells, but as cancer progresses, the stromal change enhances movement of the tumor cells within it, leading to metastasis.

Cell cannibalism in oral cancer: A sign of aggressiveness, de-evolution, and retroversion of multicellularity.

BACKGROUND: According to Darwin's theory of evolution, complex creatures evolve from more simplistic ancestors. Dollo's law of irreversibility states that evolution is irreversible. However, cancer cells tend to follow anti-Dollo's law. Unfavorable conditions such as hypoxia, acidic pH and low nutrients cause the cancer cells to switch their lifestyle atavistically in order to survive. They start behaving like a unicellular organism. There is a switch from normal metabolism to Warburg effect and finally cannibalism. Cannibalism is a cell eating cell phenomenon. It is defined as a large cell enclosing a smaller one within its cytoplasm and is known by odd names such as "bird's eye cells" or "signet ring cells." Smaller tumor cells are found in the cytoplasm of larger tumor cells with crescent-shaped nucleus. Cannibalistic cells (CCs) are a feature of aggressive tumors. These cell types are vulnerable to metastasis. AIM: The aim of this study is to identify CCs in various histological grades of oral squamous cell carcinoma (OSCC) and to relate them with the pattern of invasion, lymphocytic response (LR), and mitotic figures (Mfs). The purpose of the article is to establish it as a marker of aggressiveness and metastasis and as an evidence of de-evolution and retroversion of multicellularity. MATERIALS AND METHODS: Sixty-five histologically confirmed cases of OSCC were studied. Pattern of invasion, LR, number of CCs, and Mfs were recorded on 5 µ hematoxylin and eosin-stained tissue sections. ANOVA and t-test were applied; P < 0.05 was considered statistically significant. RESULTS: CCs were more in sections with patchy LR, increased Mfs, and grade IV pattern of invasion. CONCLUSION: With increase in dedifferentiation, tumor cells start behaving like unicellular organisms with cell eating cell characteristics.

Aberrant DNMT3B7 expression correlates to tissue type, stage, and survival across cancers.

Cancer cells are known for aberrant methylation patterns leading to altered gene expression and tumor progression. DNA methyltransferases (DNMTs) are responsible for regulating DNA methylation in normal cells. However, many aberrant versions of DNMTs have been identified to date and their role in cancer continues to be elucidated. It has been previously shown that an aberrant version of a de novo methylase, DNMT3B7, is expressed in many cancer cell lines and has a functional role in the progression of breast cancer, neuroblastoma, and lymphoma. It is clear that DNMT3B7 is important to tumor development in vitro and in vivo, but it is unknown if expression of the transcript in all of these cell lines translates to relevant clinical results. In this study, a bioinformatics approach was utilized to test the hypothesis that DNMT3B7 expression corresponds to tumor progression in patient samples across cancer types. Gene expression and clinical data were obtained from the Genomic Data Commons for the 33 cancer types available and analyzed for DNMT3B7 expression with relation to tissue type in matched and unmatched samples, staging of tumors, and patient survival. Here we present the results of this analysis indicating a role for DNMT3B7 in tumor progression of many additional cancer types. Based on these data, future in vitro and in vivo studies can be prioritized to examine DNMT3B7 in cancer and, hopefully, develop novel therapeutics to target this aberrant transcript across multiple tumor types.

An Immunohistochemical and Polarizing Microscopic Study of the Tumor Microenvironment in Varying Grades of Oral Squamous Cell Carcinoma.

BACKGROUND: Invasion of epithelial cells into the connective tissue brings about massive morphological and architectural changes in the underlying stroma. Myofibroblasts reorganize the stroma to facilitate the movement of tumor cells leading to metastasis. The aim of this study was to determine the number and pattern of distribution of myofibroblasts and the qualitative and quantitative change that they cause in the collagen present in the stroma in various grades of oral squamous cell carcinoma (OSCC). METHODS: The study was divided into two groups with group I (test group, 65 cases) consisting of 29 cases of well-differentiated squamous cell carcinoma, 25 moderately differentiated SCC, and 11 poorly differentiated SCC, and group II (control group) consisting of 11 cases of normal mucosa. Sections from each sample were stained with anti-α-smooth muscle actin (α-SMA) antibodies, hematoxylin and eosin, and Picrosirius red. Several additional sections from each grade of OSCC were stained with Masson's trichrome to observe the changes in collagen. For the statistical analysis, Fisher's exact test, Tukey's post hoc honest significant difference test, ANOVA, and the chi-square test were used, and p < .05 was considered statistically significant. RESULTS: As the tumor stage progressed, an increase in the intensity α-SMA expression was seen, and the network pattern dominated in more dedifferentiated carcinomas. The collagen fibers became thin, loosely packed, and haphazardly aligned with progressing cancer. Additionally, the mean area fraction decreased, and the fibers attained a greenish yellow hue and a weak birefringence when observed using polarizing light microscopy. CONCLUSIONS: Myofibroblasts bring about numerous changes in collagen. As cancer progresses, there isincrease in pathological collagen,which enhances the movement of cells within the stroma.

Keratinizing pleomorphic adenoma: An unusual case report.

Pleomorphic adenoma (PA) is the most common benign tumor of major or minor salivary glands. PA exhibits a great histological diversity, such as differentiation into oncocytic, sebaceous, mucinous, squamous, chondroid, osseous or adipose cells. Squamous metaplasia rarely results in the formation of extensive keratin-filled cyst lined by squamous epithelium. Extensive squamous metaplasia can be mistaken for malignancy, including mucoepidermoid carcinoma and squamous cell carcinoma. Here, we report a case of slowly enlarging PA with extensive squamous metaplasia and keratin cyst formations in a minor salivary gland in hard palate and discuss its microscopic features.

Variability in the Calculation of Time in Therapeutic Range for the Quality Control Measurement of Warfarin.

Time in therapeutic range (TTR), a well-recognized performance metric of oral anticoagulation, measures the time when patients' international normalized ratios (INRs) are within the desired range. The TTR value can vary significantly depending on the type of method used and can be a skewed indicator of the overall quality of anticoagulation. As such, the present study was designed to compare three methods for TTR calculation (cross-sectional, traditional, and Rosendaal) to quantify their differences, biases, and trends. As part of this investigation, a 21-week retrospective analysis of patients on warfarin was conducted to compare TTR values obtained by these three methods. Paired t-tests, correlation studies between size and bias, and Bland-Altman plots were performed using SAS 9.4 (SAS Institute, Cary, NC, USA). It was revealed that the TTR values for the cross-sectional, Rosendaal, and traditional methods were 65.97, 58.12, and 51.55, respectively. The addition of tolerances to INR ranges of ± 0.2 and ± 0.5 increased TTR values to 81.79 and 91.53, respectively, for the cross-sectional method, and 66.86 and 82.69, respectively, for the traditional method. The use of the traditional method resulted in significantly higher TTR values than did use of the Rosendaal method, with high variability between the methods in both positive and negative directions. There was a demonstrated lack of independence between the methods, and zero bias could not be assumed. In conclusion, the different methods considered in the present study do not accurately measure whether a patient is in or out of the therapeutic range, and the addition of tolerances can further distort the perception of anticoagulation achieved. We recommend a standardized TTR calculation method as well as a uniform tolerance for use in clinical trials and quality control efforts.

Efficacy of pre-incisional peritonsillar infiltration of ketamine for post-tonsillectomy analgesia in children.

OBJECTIVE: To assess the efficacy of pre-incisional peritonsillar infiltration of two doses of ketamine on postoperative analgesia compared with peritonsillar normal saline in children undergoing tonsillectomy. STUDY DESIGN: Double blind, randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Anaesthesiology, Surgical Intensive Care and Pain Management, Civil Hospital, Karachi, Dow University of Health Sciences, from August 2008 to January 2009. METHODOLOGY: Seventy-five ASA physical status one patients, aged 5 - 12 years scheduled for tonsillectomy were enrolled in this study. Patients were divided into three groups of 25 each. Group-A received normal saline, Group-B, ketamine 0.5 mg/kg while group-C ketamine 1 mg/kg respectively. All medications were 2 ml and were applied 1 ml per tonsil; 3 minutes before tonsillectomy incision. Anaesthesia was induced and maintained with standard technique. All patients were monitored throughout surgery. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson sedation scale were used to evaluate pain levels and sedation respectively after operation. RESULTS: Mean duration of analgesia was significantly higher in group-C (17.28 ± 5.33 hours) as compared to group-B (11.36 ± 4.15 hours) and A (3.2 ± 0.71 hours) as well as group-B was also significantly higher than group-A (p < 0.05). Group-A had significantly higher pain scores than group-B and group-C. Both B and C groups had comparable pain scores, which were statistically significant at 6 and 8 hours. CONCLUSION: Single 0.5 or 1 mg/kg injection of ketamine given before surgical incision by peritonsillar infiltration provides efficient pain relief during postoperative period without significant side-effects in children undergoing tonsillectomy.

New single use supraglottic airway device with non-inflatable cuff and gastric tube channel.

OBJECTIVE: To assess ventilatory characteristics and airway complications associated with the use of I-gel in patients undergoing gynaecological surgeries. STUDY DESIGN: Experimental study. PLACE AND DURATION OF STUDY: Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Civil Hospital, Dow University of Health Sciences, Karachi, from July 2008 to June 2009. METHODOLOGY: One hundred adult female patients aged 15 - 75 years, ASA-I and II scheduled for elective gynaecologic surgical procedures under general anaesthesia with controlled ventilation were included in this study. After insertion of device, ease of insertion, time of insertion, peak airway pressure, leak pressure were noted. After proper placement of device, gastric tube was also passed in every patient. Pharyngolaryngeal morbidities (sore throat, dysphagia, dysphonia, neck pain and coughing at 1 hour and 24 hours postoperatively) were also noted. RESULTS: I-gel was inserted in the first attempt in 92% patients while second attempt was required in 8% of patients. Average time of insertion was 9.68 ± 2.69 seconds. Average leak pressure of 22.48 ± 2.07 cm H2O. After removal of I-gel no blood staining was found on any device. Coughing was noted in 6% patients after removal of device and mild sore throat was noted in only one patient after 24 hours of surgery. CONCLUSION: I-gel is a simple and easy to use supraglottic airway device. Its insertion do not require laryngoscopy and airway can be maintained in very short time in adult female patients.

Massive pulmonary embolism and acute limb ischaemia in a patient of hereditary spherocytosis and patent foramen ovale.

Paradoxical embolism accounts for 2% of patients who present with acute arterial embolism of extremities. We report a case of a 41 year-old male with hereditary spherocytosis who presented to the emergency department with acute limb ischaemia and pulmonary embolism. On further evaluation, he was found to have patent foramen ovale (PFO) and deep vein thrombosis (DVT), leading to paradoxical embolism. The purpose of this report is to emphasise that in a patient presenting with acute limb ischaemia without an obvious systemic arterial embolic source, an evaluation for a right-to-left shunting lesion, especially PFO, should be performed.

Recovery profile - a comparison of isoflurane and propofol anesthesia for laparoscopic cholecystectomy.

OBJECTIVE: To compare the recovery profile in terms of time of extubation, eye opening, orientation and mobility and frequency of Postoperative Nausea and Vomiting (PONV) between propofol and isoflurane based anesthesia in patients undergoing laparoscopic cholecystectomy with prophylactic antiemetic. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Anesthesia, Civil Hospital and Dow University of Health Sciences, Karachi, from January to April 2007. PATIENTS AND METHODS: After informed consent, a total of 60 ASA I-II patients scheduled for laparoscopic cholecystectomy were divided in two equal groups I and P. Anesthesia in all patients were induced by Nalbuphine 0.15 mg/kg, Midazolam 0.03 mg/kg, Propofol 1.5 mg/kg and Rocuronium 0.6 mg/kg. Anesthesia was maintained with Isoflurane in group I and propofol infusion in group P, while ventilation was maintained with 50% N2O/O2 mixture in both the groups. All patients were given antiemetic prophylaxis. Hemodynamics were recorded throughout anesthesia and recovery period. At the end of surgery, times of extubation, eye opening, orientation (by modified Aldrete score) and mobility (recovery profile) were assessed. PONV was observed and recorded immediately after extubation, during early postoperative period (0-4 hours) and late period (4-24 hours). Antiemetic requirements were also recorded for the same periods in both the groups. RESULTS: Propofol provided faster recovery (extubation and eye opening times) and orientation in immediate postoperative period with statistically significant differences between the groups (p<0.0001). Recovery characteristics were comparably lower in group I. More patients achieved full points (8) on modified Aldrete score at different time until 30 minutes in group P. Postoperative nausea and vomiting in early and late periods were significantly reduced in group P. Moreover, requirement of rescue antiemetic doses were significantly lower in group P in 24 hours (p<0.0001). CONCLUSION: In this series, recovery was much faster with earlier gain of orientation with propofol anesthesia compared to isoflurane in the early recovery periods. Propofol is likely to be a better choice of anesthesia because of its better antiemetic property that persists long into postoperative period and reduces the risk of PONV.

Single dose caudal tramadol with bupivacaine and bupivacaine alone in pediartic inguinoscrotal surgeries.

OBJECTIVE: To determine the postoperative analgesic effect of Tramadol when given with caudally administered Bupivacaine in children undergoing inguinoscrotal surgeries. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Anaesthesia, Dow University of Health Sciences and Civil Hospital Karachi, from July 2005 to March 2006. PATIENTS AND METHODS: A total of 60 children, undergoing inguinoscrotal surgeries, aged from 1 to 12 years, ASA 1 and 2, were included. The patients were divided into two equal groups. The group given Bupivacaine with Tramadol was called 'group BT' and the group which was given only Bupivacaine was labeled as 'group B'. Group BT was given 0.25%,0.8 ml/kg Bupivacaine and Tramadol 2 mg/kg while the other group B was given 0.25%, 0.8 ml/kg Bupivacaine through caudal route after induction of general anesthesia. No other analgesic was given intraoperatively. The postoperative pain was evaluated by using visual analogue scale/Ocher's face scale/CHEOPS and sedation was assessed by 5 points sedation score at immediate postoperative period 1, 2,3,4,6, 12 and 24 hours. Supplemental analgesia in the form of paracetamol suppositories and syrup Ibuprofen was given accordingly. SaO2, pulse, blood pressure, and motor block were monitored in all the patients. RESULTS: Addition of Tramadol with Bupivacaine resulted in meaningfully increased postoperative analgesic period (16.06 +/- 4.04 hours). No other side effects like respiratory depression, pruritus, urinary retention were found in both the groups except for nausea and vomiting. The demand for supplemental analgesia was more in the patients belonging to B group than BT group. The sedation scores were similar in both the groups. CONCLUSION: The use of Tramadol as an additive with local anesthetics can prolong the postoperative analgesic period when administered caudally. Its use is safe in children.