Effect of Erector Spinae Block and Pectoralis Block on Quality of Recovery and Analgesia After Modified Radical Mastectomy: A randomised controlled study.

Objectives: Post-operative pain after a modified radical mastectomy ranges from moderate to severe. Pectoralis (PECS) block has been found to be more effective than erector spinae block in reducing pain and the consumption of rescue analgesia in the post-operative period. This study aimed to compare the effect of erector spinae block and PECS block on the quality of recovery after modified radical mastectomy using the quality of recovery (QoR-40) score. Methods: This randomised controlled study was conducted at King George's Medical University, Lucknow, India, from 9th October 2020 to 9th October 2021. After general anaesthesia, patients were given blocks according to computer-generated randomisation: Group I: PEC I and PEC II (PECS) blocks; Group II: erector spinae plane (ESP) block; and Group III: control group (no intervention). The QoR-40 score was observed on the morning of the surgery and after 24 hours. Time to rescue analgesia and the total consumption of rescue analgesia in the first 24 hours were also observed. Results: A total of 90 patients were included (30 in each group). In the post-operative period after 24 hours, global QoR-40 scores were 183.64 ± 6.36, 179.68 ± 6.38 and 171.37 ± 6.88 in the PECS, ESP and control groups (P <0.0001). But there was no statistically significant difference between the QoR scores of PECS and ESP group patients (P = 0.0551). The total requirement of rescue analgesic was significantly lower in the PECS group (137.28 ± 31.46 mg) than in the ESP (189.46 ± 42.98 mg) and control (229.57 ± 46.80 mg) groups (P <0.0001). Time to first rescue analgesia was significantly higher in the PECS group (6.53 ± 2.78 hours) than in the ESP (4.05 ± 2.91 hours) and control (2.15 ± 1.51 hours) groups (P <0.0001). Conclusion: Both ESP and PECS blocks were effective in improving the QoR score and in reducing the consumption of rescue analgesia after modified radical mastectomy.

Improvement in Patient Satisfaction and Anxiety With Perioperative Music Therapy in Patients Undergoing Total Abdominal Hysterectomy: A Single-Blind Prospective Study.

Introduction Listening to music is a safe and low-cost way to reduce preoperative anxiety among patients, but more research is needed to evaluate its effectiveness fully. Aims The aim of the study is to identify the effect of intraoperative music therapy on the visual analogue scale for anxiety (VASA) scores (VASA 1 and VASA 2) and patient satisfaction score (PSS) perioperatively. Methods In a study of 188 patients aged 40-70, those in group A (94 patients) listened to pre-approved music during their surgery for abdominal hysterectomy, while group B (94 patients) did not. Both groups wore noise-cancelling earphones. VASA was recorded before (VASA 1) and after (VASA 2) the surgery. PSS was recorded in the postoperative ward. Music preferences were kept confidential from the investigator recording the scores. Result The two groups of patients had similar demographic profiles and baseline characteristics. The VASA 1 of both groups was similar, with a mean value of 4.36 ± 1.13 for group A and 4.23 ± 1.05 for group B (p = 0.606). However, group A had lower VASA 2 (1.79 ± 0.83) than group B (3.77 ± 0.98). The difference was statistically significant (p < 0.001). The patient satisfaction score in group A was notably higher than those in group B. A total of 52 patients were highly satisfied in group A as compared to none in group B (p < 0.001), and a total of 42 patients were moderately satisfied as compared to eight patients in group B (p < 0.001). Eighty-six patients in group B were unsatisfied. Conclusion According to our research, playing specific music at the right volume can significantly lower anxiety levels and increase patients' satisfaction scores for those who have had abdominal hysterectomy surgeries.

Comparison between LMA ProSeal and I-gel airway in anesthetized patients on spontaneous ventilation during daycare procedures: A prospective randomized study.

Background: General anesthesia remains the most popular technique for ambulatory surgeries with patients, surgeons, and anesthesia providers. The supraglottic airway (SGA) devices result in fewer incidences of sore throat, laryngospasm, coughing, and hoarseness as compared to inserting a tracheal tube. This study was conducted to compare two second-generation SGA devices, LMA ProSeal and I-gel airway, in anesthetized patients on spontaneous ventilation during daycare procedures to establish the superior SGA device. Methodology: This prospective randomized study was done on 90 patients of either sex aged 15-60 years, ASA grade I-II, Mallampatti grade I and II, and BMI between 20 and 30 kg/m2 scheduled for elective surgeries of duration less than 90 min. Patients were randomly allocated into two groups-group A (I-gel) and group B (LMA ProSeal). Insertion parameters, hemodynamic responses, oxygenation, ventilation, peak airway pressure (PAP), and postoperative complications were recorded. Statistical analysis was done using SPSS version 21.0 statistical analysis software. Results: Mean insertion time of LMA ProSeal was found to be significantly higher as compared to I-gel (33.27 ± 3.88 vs 18.49 ± 3.18 s; P < 0.001). No significant difference was found between the groups in the number of attempts and of operators attempted for insertion, as well as in hemodynamic response, oxygenation, and ventilation. Postoperative complications were lesser in group A. Conclusion: I-gel is an easy-to-insert cuffless SGA device requiring lesser time for insertion, provides adequate ventilation with lesser postoperative complications and thus appears to be better than LMA ProSeal.

A Randomized, Double-Blind, Prospective Study to Evaluate the Effect of Oral Pregabalin in Upper Limb Surgeries Under Brachial Plexus Block.

Context The oral pregabalin administration preoperatively has been reported to reduce acute postoperative pain and prolong the duration of anesthesia produced by single-injection peripheral nerve blockade. Aim To study the effect of single dose pregabalin on duration of brachial plexus block Settings and design Prospective, randomised, double blind, comparative study Material and methods Patients were divided into two groups (groups A and B), with each group having 50 patients. In group A, the patient received a pregabalin capsule of 300 mg orally two hours before surgery with a sip of water. Group B received a placebo (vitamin B complex capsule) orally two hours before surgery. Brachial plexus block was performed, and data was collected. Statistical analysis Data analysis was done using SPSS version 21.0 statistical analysis software. Demographic data and clinical variables were compared using the student's t-test, chi-square test, and Mann-Whitney U test. Results The requirement of the first dose of analgesia was significantly earlier in group B as compared to group A (4:56±0:20 vs. 8:01±0:30 hours). Group B patients, as compared to group A patients, had significantly higher levels of pain after two hours of surgery (0.32±0.47 vs. 0.00±0.00) and at four hours of surgery (2.42±0.50 vs. 0.34±0.59). Conclusions Oral pregabalin prolongs analgesia from brachial plexus block without significant effect on the motor block. In addition, premedication with oral pregabalin increases the sensory block of brachial plexus block.

Comparison of Continuous Infusion of Ropivacaine and Fentanyl With Intermittent Bolus Doses of Ropivacaine and Fentanyl for Epidural Labor Analgesia: A Randomized Open-Label Study.

Background The purpose of this study was to compare the efficacy of continuous epidural infusion with intermittent bolus doses for labour analgesia using ropivacaine 0.2% and opioids. Methods In this study, 70 primigravida patients were randomly divided into two groups of 35 each. Both groups received a loading dose of 10ml of 0.2% ropivacaine and 1µg/ml fentanyl in 5ml incremental doses while monitoring blood pressure and heart rate. Subsequently, Group I received a continuous epidural infusion of 0.2% ropivacaine with fentanyl at 10ml/hr, while Group II received 10 ml of 0.2% ropivacaine with fentanyl in bolus form every hour manually, with the first dose given after one hour of the initial loading dose. A rescue bolus dose of 5ml of 0.2% ropivacaine was given in both groups when they complained of breakthrough pain (VAS score >3). An additional 5ml bolus dose was given in both groups at the time of crowning. The blood pressure, heart rate, and severity of pain using the visual analogue scale (VAS) were assessed. Total drug volume utilized, the number of bolus doses, duration of the first and second stage of labour, rate of instrumental delivery and cesarean section, and neonatal Apgar scores were also recorded. Results The total volume of drugs consumed and the number of boluses required for breakthrough pain were both significantly lower in Group II. There was a similar decrease in hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) from baseline in both the groups with no significant difference between them. The onset of analgesia was significantly faster in Group I with both groups achieving optimum analgesia (VAS ≤ 3) within 20 minutes of the loading dose. Maternal motor blockade scores, the duration of the first and second stage of labour, the rate of instrumental delivery, cesarean section, and neonatal Apgar scores, did not show any statistically significant difference between the two groups. Conclusion Both techniques, i.e. continuous epidural infusion and intermittent epidural boluses are effective for providing labour analgesia. But consumption of drugs and episodes of breakthrough pain was higher in the continuous infusion group (Group I).

Deciphering the growth stage specific bioactive diversity patterns in Murraya koenigii (L.) Spreng. using multivariate data analysis.

The study was undertaken to characterize the total phenolics, flavonoids, essential oils, quinones, tannins and antioxidant activity of 15 samples of wild Murraya koenigii (L.) Spreng. (MK) leaves obtained from different locations of Himachal Pradesh at various growth stages. The results indicated a significant variation in total phenolic content which ranged from [(170.09 ± 4.59 to 303.57 ± 7.94) in pre-flowering, (266.48 ± 7.49 to 450.01 ± 11.78) in the flowering stage, and (212.72 ± 5.37 to 363.85 ± 9.79) in fruiting stage], expressed as mg tannic acid equivalents (TAE)/g. The total flavonoid content ranged from [(15.17 ± 0.36 to 33.40 ± 0.81) in pre-flowering, (25.16 ± 0.67 to 58.17 ± 1.52) in flowering stage, and (17.54 ± 0.42 to 37.34 ± 0.97) in fruiting stage], expressed as mg catechin equivalent (CE)/g. Total tannin content ranged from [(75.75 ± 1.69 to 143 ± 3.74) in pre-flowering, (116 ± 3.26 to 207 ± 5.42) in the flowering stage, and (47 ± 1.18 to 156 ± 4.05) in fruiting stage], expressed as mg TAE/g. The essential oil content ranged from (0.64 ± 0.01 to 0.89 ± 0.02%) in pre-flowering, (0.85 ± 0.02 to 1 ± 0.02%) in flowering stage, and (0.54 ± 0.01 to 0.7 ± 0.01%) in fruiting stage. Quinones ranged from [(2.05 ± 0.05 to 2.97 ± 0.07) in pre-flowering, (3.07 ± 0.07 to 4.95 ± 0.13) in flowering stage, and (1.02 ± 0.02 to 1.96 ± 0.04) in fruiting stage], expressed as mM/min/g tissue. Antioxidant activity ranged from [(4.01 ± 0.09 to 7.42 ± 0.17) in pre-flowering, (8.08 ± 0.19 to 13.60 ± 0.35) in flowering stage, and (3.11 ± 0.06 to 6.37 ± 0.15) in fruiting stage], expressed as µg/ml. Data was subjected to multivariate analysis using principal component analysis (PCA), hierarchical clustering analysis (HCA). This was used for elucidating the intricate relationships between the phytochemical properties. All evaluated phytochemical parameters significantly increased during the growth transition from pre-flowering to the flowering stage, followed by their gradual decrease during the fruiting stage. The present study can serve as rationale for commercializing MK for aromatic and phytopharmaceutical industries.

First report of Curvularia penniseti causing leaf blight of Bajra Napier hybrid grass in India.

Bajra Napier hybrid (Pennisetum glaucum x Pennisetum purpureum) is a perennial, high yielding grass and is widely grown for fodder in India. During August-2021, Bajra Napier hybrid germplasm line (NBN 15-2) showed severe leaf blight symptoms at ICAR-Indian Grassland and fodder research institute, Jhansi (25.527890 N, 78.5451400 E). Symptoms were initial irregular yellow spots on the leaf lamina, which later became brownish, coalesced and gave blighted appearance to the leaf surface. Disease severity recorded was 55 to 60 percent. To isolate the pathogen, 10 symptomatic leaf samples were cut into small pieces (~4 mm2), surface-sterilized with 70% ethanol for 30 seconds and rinsed with sterile water. Sterilized leaf pieces were transferred to potato dextrose agar (PDA) and incubated at 28°C for 7 days. Four similar fungal isolates (BNHCP-1 to BNHCP-4) were obtained from the affected portions. The colonies were grayish-brown with dark brown margins. Conidia were mostly clavate, elongated, straight or bent at the terminal cell, with 2-3 septa with dimensions of 17.5 to 30 µm × 10 to 12.5 µm (avg. 24 µm × 12 µm; n=40). The third cell from the base was broader and darker. These morphological characteristics were consistent with previous descriptions of Curvularia penniseti (Mitra) Boedijn (Ellis, 1971). To confirm the species, BNHCP-1 was chosen as representative isolate for further studies. Internal transcribed spacer (ITS) region and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) gene of isolate BNHCP-1 was amplified with primers ITS1F/ITS4R (White et al. 1990) and GDF/GDR (Templeton et al. 1992), and sequenced. The sequences were deposited in GenBank (ITS: OM073980; GAPDH: OM103702.2). BLASTn analysis showed 99.6% and 98% similarity of ITS and GAPDH gene respectively with GenBank accession numbers MH859833.1 (548 bp/550 bp) and MN688838.1 (130 bp/133 bp) of C. penniseti. A maximum-likelihood phylogenetic analysis based on concatenated sequences of ITS and GAPDH gene using MEGA X placed the isolate BNHCP-1 within a clade comprising C. penniseti. Pure culture of BNHCP-1 was deposited in National Agriculturally Important Microbial Culture Collection (NAIMCC), Maunath Bhanjan (Uttar Pradesh) with accession number NAIMCC-F-04251. For pathogenicity, root slips of Bajra Napier hybrid germplasm line NBN 15-2 were transplanted in pots (6 pots; 2 root slips per pot) and kept for fresh growth in a growth chamber at 25 0C for 21 days. Bajra-Napier hybrid plants were sprayed until runoff with conidial suspension (5 × 105 conidia/ml) made from 2-week old fungal colony grown on PDA petri dish. The pots were covered with plastic bag for 48 h to maintain humidity. Inoculated plants displayed small, brown, oval-shaped lesions within seven days on the lamina and edges of the leaf which later enlarged and gave blighted appearance to the leaf. Control plants were asymptomatic. The pathogen was re-isolated from the inoculated leaves and confirmed morphologically, fulfilling Koch's postulates. C. penniseti has been reported earlier from Pennisetum americanum, P. clandestinum, Sorghum and Triticum sp. from different parts of the world (Sivanesan, 1987). However, there is no report of C. penniseti in Bajra Napier hybrid. Thus, to the best of our knowledge, this is the first report of C. penniseti from Bajra-Napier hybrid grass in India. Further studies on economic impact of this disease on Bajra-Napier hybrid production and its presence on commercial cultivars are needed.

Interactome of millet-based food matrices: A review.

Millets are recently being recognized as emerging food ingredients with multifaceted applications. Whole grain flours made from millets, exhibit diverse chemical compositions, starch digestibility and physicochemical properties. A food matrix can be viewed as a section of food microstructure, commonly coinciding with a physical spatial domain that interacts or imparts specific functionalities to a particular food constituent. The complex millet-based food matrices can help individuals to attain nutritional benefits due to the intricate and unique digestive properties of these foods. This review helps to fundamentally understand the binary and ternary interactions of millet-based foods. Nutritional bioavailability and bioaccessibility are also discussed based on additive, synergistic, masking, the antagonistic or neutralizing effect of different food matrix components on each other and the surrounding medium. The molecular basis of these interactions and their effect on important functional attributes like starch retrogradation, gelling, pasting, water, and oil holding capacity is also discussed.

Effect of Preoperative Duloxetine Hydrochloride on Reducing Postoperative Morphine Requirement after Open Radical Cholecystectomy in Cancer Patients: A Randomized Controlled Study.

Background: Recently, opoids are linked with cancer recurrence. Duloxetine hydrochloride (DH), an anxiolytic may reduce total opoid requirement after cancer surgery. Aims: We assessed the efficacy of a single dose of DH in reducing the total morphine requirement after open radical cholecystectomy. We also calculated the Visual Analog Scale (VAS) score, patient satisfaction score (PSS), and time taken to the use of the first rescue analgesic. Setting and Designes: This is a prospective, randomized, double blind, controlled study conducted in the patients aged 20-70 years (American Society of Anaesthesiologists classes I-III) undergoing open radical cholecystectomy under general anesthesia for carcinoma gall bladder. Materials and Methods: The patients were divided into two groups of 32 patients each by computer-generated randomization. Group A received oral DH (60 mg); Group B received identical placebo capsules 2 h before surgery with a sip of water. Postoperatively, intravenous morphine was given using a patient-controlled analgesia pump. After 24 h, total morphine consumption, the VAS score, time to the first rescue analgesia, and PSS were recorded. Statistical Analysis: Statistical Package for the Social Sciences software (SPSS version 22.0, IBM Corp., Chicago, IL, USA 2013). P value < 0.05 or 0.001 was considered statistically significant. Results: The total morphine consumption and VAS score were significantly lower in Group A. No significant effects was observed on PSS. Conclusion: A single 60 mg dose of DH administered 2 h before open radical cholecystectomy reduced total morphine consumption and improved VAS score postoperatively with no effect on PSS.

A Comparison Between Dexmedetomidine and Clonidine as Adjuvants to Levobupivacaine in Labour Analgesia.

Background The epidural analgesia technique is effective for labor analgesia and combinations of various local anesthetics with lipophilic opioids like fentanyl are used. However, fentanyl can cause an increased incidence of pruritus, urinary retention, nausea, vomiting, giddiness, shivering, and respiratory depression. Dexmedetomidine and clonidine are selective alpha 2 agonists with analgesic properties and have been used via the neuraxial route with local anesthetics for the same without the side effects of fentanyl. Thus, the primary objective was to assess and compare the analgesic efficacy of the two-drug combinations by the visual analog scale (VAS) score. Methods Fifty-four primigravida women were randomly allocated in two groups of 27 each and were given an initial bolus of 10 mL of 0.125% levobupivacaine with dexmedetomidine 0.5 ug/kg in Group A and with clonidine 1 µg/kg in Group B. Subsequently, each patient received a background infusion rate of 10 mL/h, a bolus dose of 5 ml, and a lock-out interval of 10 min via a patient-controlled-analgesia (PCA) pump. The blood pressure, heart rate, and severity of pain using VAS were assessed. Durations of the stages of labor, rate of instrumental delivery, and cesarean section, side effects, maternal sedation, and neonatal Apgar scores were also recorded. Results VAS scores in both the groups progressively decreased to <3 by 15 min with significant differences at five, 10, 15, and 120 min being lower in group A. Onset of analgesia and time for maximum analgesia was significantly shorter in group A. There was a significant decrease in hemodynamic parameters from baseline in both groups. The fall in heart rate was significantly greater in Group A and at almost all the time intervals after baseline, diastolic blood pressure (DBP) was also lower in group A. Maternal motor blockade scores, the intensity of maternal sedation, the incidence of maternal complications, the duration of the first and second stage of labor, the rate of instrumental delivery and cesarean section, total analgesic dose and PCA bolus requirement, and neonatal Apgar scores did not show a significant difference between the two groups. Conclusion Both dexmedetomidine and clonidine provide hemodynamically stable labor with a fall in heart rate and maternal blood pressure in the initial hours. Dexmedetomidine has the advantage of faster onset of analgesia and time for maximum analgesia.

Randomised Controlled Clinical Study of Injection Caroverine and Ginkgo Biloba Extract in Cochlear Synaptic Tinnitus.

Tinnitus, also known as phantom auditory perception, is an annoying symptom and 13-17% of population reports bothersome tinnitus. Cochlear synaptic tinnitus is the most common type. Many treatments have been tried but none is yet considered to be well established. To evaluate effect of Inj.Caroverine and Ginkgo Biloba extract in cochlear synaptic tinnitus in terms of improving tinnitus grading, tinnitus matching and quality of life of patient. It is Randomised controlled study, conducted in department of ENT, on 86 patients, who met inclusion criteria, divided into 4 groups. Gr1-Inj Caroverin, Gr2-Inj Placebo, Gr3-Ginkgo Biloba extract, Gr4-Placebo as extract. A single dose infusion of caroverine immediately improves tinnitus grading and matching and provides immediate relief in reducing severity of tinnitus in 54.54% cases but improvement was not sustained in caroverine group at 3 month and 6 month follow-up after infusion. Ginkgo biloba also is effective in improving tinnitus grading and matching in 31.8% cases and improvement was sustained in ginkgo biloba group even after 3 month of cessation of treatment i.e. at 6 month follow-up. It is suggested that Inj.Caroverine as intravenous infusion should be given in severe cases of tinnitus to reduce its severity immediately and then patient should be put on Tab.Ginkgo biloba for a period of 3 months to provide sustained and long lasting relief. Thus combination therapy of Inj.Caroverin and Tab.Ginkgo Biloba, appropriately tailored to the need of patient will provide better results in greater majority of patients.

Dexmedetomidine as an Anesthetic Adjuvant in Intracranial Surgery.

BACKGROUND: The basic principle of neuroanesthesia is to provide hemodynamic stability, provision of optimal operative conditions, maintenance of cerebral perfusion pressure, and cerebral oxygenation. AIM: This study was undertaken to see the effect of dexmedetomidine infusion on hemodynamics and its ability to act as an anesthetic adjuvant in patients undergoing supratentorial tumor surgery. SETTING AND DESIGN: Prospective randomized control double blind study. SUBJECTS AND METHODS: In this study, we compared two groups with 25 patients in each group. Group C patients received saline infusion during surgery and 4 µg/kg of fentanyl intravenously (i.v.) at the induction and at pin head application. Group D patients received dexmedetomidine infusion during surgery at the rate of 0.4 µg/kg/h and 2 µg/kg of fentanyl i.v. at the induction and at pin head application. STATISTICAL ANALYSES USED: Parametric data were analyzed using Student's t-test. The categorical data were studied using Chi-squared test or Fisher's test as appropriate. RESULTS: The vitals remained within 20% of baseline in both groups during the study period except at the time of extubation where the rise in heart rate was more than 20% in control group. The requirement of thiopentone for induction was significantly less in dexmedetomidine group. In dexmedetomidine group, less number of patients required intraoperative fentanyl (P < 0.05), and the time to rescue analgesic was also more in Group D (P < 0.05). CONCLUSION: Dexmedetomidine infusion started before surgery maintains hemodynamic stability intraoperatively and is effective in attenuating the cardiovascular responses to intubation, skull pin application, and extubation. It decreases the requirement of other anesthetic agents as well.

Selective nerve root blocks vs. caudal epidural injection for single level prolapsed lumbar intervertebral disc - A prospective randomized study.

BACKGROUND: Chronic lumbar radiculopathy has a lifetime prevalence of 5.3% in men and 3.7% in women. It usually resolves spontaneously, but up to 30% cases will have pronounced symptoms even after one year. AIMS: A prospective randomized single-blind study was conducted to compare the efficacy of caudal epidural steroid injection and selective nerve root block in management of pain and disability in cases of lumbar disc herniation. METHODS: Eighty patients with confirmed single-level lumbar disc herniation were equally divided in two groups: (a) caudal epidural and (b) selective nerve root block group, by a computer-generated random allocation method. The caudal group received three injections of steroid mixed with local anesthetics while selective nerve root block group received single injection of steroid mixed with local anesthetic agent. Patients were assessed for pain relief and reduction in disability. RESULTS: In SNRB group, pain reduced by more than 50% up till 6 months, while in caudal group more than 50% reduction of pain was maintained till 1 year. The reduction in ODI in SNRB group was 52.8% till 3 months, 48.6% till 6 months, and 46.7% at 1 year, while in caudal group the improvement was 59.6%, 64.6%, 65.1%, and 65.4% at corresponding follow-up periods, respectively. CONCLUSIONS: Caudal epidural block is an easy and safe method with better pain relief and improvement in functional disability than selective nerve root block. Selective nerve root block injection is technically more demanding and has to be given by a skilled anesthetist.

Impact of State Public Health Spending on Disease Incidence in the United States from 1980 to 2009.

OBJECTIVE: To understand the relationship between state-level spending by public health departments and the incidence of three vaccine preventable diseases (VPDs): mumps, pertussis, and rubella in the United States from 1980 to 2009. DATA SOURCES: This study uses state-level public health spending data from The Census Bureau and annual mumps, pertussis, and rubella incidence counts from the University of Pittsburgh's project Tycho. STUDY DESIGN: Ordinary least squares (OLS), fixed effects, and random effects regression models were tested, with results indicating that a fixed effects model would be most appropriate model for this analysis. PRINCIPAL FINDINGS: Model output suggests a statistically significant, negative relationship between public health spending and mumps and rubella incidence. Lagging outcome variables indicate that public health spending actually has the greatest impact on VPD incidence in subsequent years, rather than the year in which the spending occurred. Results were robust to models with lagged spending variables, national time trends, and state time trends, as well as models with and without Medicaid and hospital spending. CONCLUSION: Our analysis indicates that there is evidence of a significant, negative relationship between a state's public health spending and the incidence of two VPDs, mumps and rubella, in the United States.

Comparison between Thoracic Epidural Block and Thoracic Paravertebral Block for Post Thoracotomy Pain Relief.

INTRODUCTION: Postoperative pain after thoracotomy is being considered one of the most severe pain and if not treated well, can result in various respiratory and other complications. AIM: Present study was conducted with the aim to compare continuous thoracic epidural infusion with continuous paravertebral infusion for postoperative pain using Visual Analogue Scale (VAS) score and four point observer ranking. The secondary outcomes measured were pulmonary functions and any complication like hypotension, bradycardia, nausea, vomiting, urinary retention and neurological complications if any. MATERIALS AND METHODS: Sixty patients of age group 18-60 years posted for anterolateral thoracotomy surgery for lung resection were randomised either to epidural or paravertebral group in this randomised prospective double blind study. In Epidural group 7.5ml bolus of 0.125% Bupivacaine with 50µg Fentanyl and in Paravertebral group 15ml bolus of 0.125% Bupivacaine with 50µg Fentanyl was given 30 minutes before the anticipated end of surgery. Bolus dose was followed by infusion of 0.125% Bupivacaine with 2µg/ml Fentanyl at the rate of 5 ml/hr in both groups. Parameters noted were Mean Arterial Pressure (MAP), Heart Rate (HR), Oxygen Saturation (SpO2), Arterial Blood Gas (PaCO2, P/F ratio), Visual Analogue Scale (VAS) and Four Point Observer Ranking Scale (FPORS) for pain, number of sensory segments blocked (by checking for pinprick sensation), requirement of infusion top ups and rescue analgesia (Tramadol), pre and postoperative pulmonary function test {(Forced Expiratory Volume (FEV)1, Forced Vital Capacity (FVC), FEV1/FVC, Peak Expiratory Flow Rate (PEFR)} and complications from start of infusion till 24 hours in the postoperative period. RESULTS: Both the techniques were effective in relieving pain but pain relief was significantly better with epidural. Postoperatively, HR, SpO2, P/F ratio and PaCO2 were comparable between group E and P. There was significant decline in FeV1, FVC, FeV1/FVC and PEFR in postoperative period as compared to preoperative value in both the groups. Hypotension and bradycardia were more in group E. CONCLUSION: Both the techniques, continuous thoracic epidural block and continuous thoracic paravertebral block were effective for post-thoracotomy pain relief; however, epidural block provides better pain relief. The incidence of sympatholytic complications was more in epidural group. The effect on respiratory mechanics was equivalent. Hence, paravertebral block can be used in post thoracotomy pain relief in those patients where thoracic epidural is contraindicated.

Transdermal Buprenorphine Patches for Postoperative Pain Control in Abdominal Surgery.

INTRODUCTION: Buprenorphine is a semi-synthetic derivative of thebaine; its low concentration is sufficient to provide effective pain relief. AIM: To evaluate the efficacy of transdermal buprenorphine patch in postoperative pain management. MATERIALS AND METHODS: After ethical approval and taking informed consent from the patients, they were randomized into three groups (n=30 in each group) using a computer generated random number table. Group A: placebo patch; Group B: buprenorphine (10mg) patch and Group C: buprenorphine (20mg) patch. Haemodynamic and analgesic effects were compared by using analysis of variance (ANOVA) followed by Turkey's post hoc test. The proportion of side effects was compared using the Chi-square test. RESULTS: Haemodynamic changes were not statistically different in all the three groups A, B and C, whereas at the end of surgery VAS score of Group A subjects was significantly higher (4.93±0.98) as compared to Group B (1.73±0.64) and Group C (1.40±0.50). On 2(nd) postoperative day, no pain was reported by the Group C patients and on 4(th) day after surgery, no pain was reported by Group B patients. CONCLUSION: The transdermal buprenorphine patch (20mg) was effective in attenuating postoperative pain, maintaining haemodynamic stability requiring no rescue analgesia, with fewer postoperative rescue analgesic requirements in low dose of buprenorphine patch (10mg) group.

Intercondylar humerus fracture- parallel plating and its results.

BACKGROUND: Intercondylar fracture of humerus is one of the commonest fractures of young adult and counts for about 30% of all elbow fractures. The treatment of these fractures continues to present challenges despite advances in internal fixation. Although orthogonal plating use to provid adequate functional results in these fractures, parallel plating is said to be mechanically more stable construct thus allowing early mobilization and better range of motion. AIM: AIM of the study is to assess the clinical as well functional results of these fractures treated with parallel plating. STUDY AND DESIGN: Prospective study in a tertiary care hospital. MATERIALS AND METHODS: A total of 23 fresh patients of intercondylar fracture of humerus from Jan 2013 to May 2014 were included in the study and were treated with parallel plating. These patients were followed at 3, 6, 12, 24 weeks and at 1year of follow up and assessed in terms of time for union, range of motion, MAYO score, DASH score and complication rate. RESULTS: At final follow up Mayo score was 96.32±04.96 from 5.00±01.26 and DASH SCORE was 31.42±2.04 which dropped from 150±05.34, Range of motion improved from 21.38±05.70 to 116.1±07.92 with 100% union rate and complications less than 19%. CONCLUSION: Parallel plating for intercondylar fracture of humerus is excellent method of fixation and results are similar to those treated with orthogonal plating.

Patient Controlled Epidural Labour Analgesia (PCEA): A Comparison Between Ropivacaine, Ropivacaine-Fentanyl and Ropivacaine-Clonidine.

BACKGROUND: Feeling of pain is one of the most important emotional determinants which dominate the perception of females who undergo the process of labour and delivery. Patient controlled epidural labour analgesia (PCEA) is convenient and safer technique for this purpose. Very few studies compared clonidine and fentanyl with ropivacaine in labour analgesia in past. This study was undertaken to compare fentanyl and clonidine in PCEA. AIMS: To compare low concentration ropivacaine with or without fentanyl or clonidine for labour analgesia and its effect on maternal and foetal safety. SETTINGS AND DESIGN: Prospective, double blind, randomized, comparative study. MATERIALS AND METHODS: Ninety primegravida in labour were divided into three groups (n=30) and patient controlled epidural labour analgesia was given to them: Initial bolus of 10ml of ropivacaine 0.125% in Group I; with fentanyl 2 µg/ml in Group II and with clonidine 1µg/kg in Group III. Subsequently each group received ropivacaine 0.125% through patient controlled epidural analgesia (PCEA) as background infusion of 5 ml/hr with lockout interval time of 10min and subsequent bolus of 5ml. Hemodynamic parameters, sensory level, motor block and pain relief were noted. Total analgesic dose of local anaesthetic and feto-maternal adverse effects were also recorded. RESULTS: At baseline, groups were matched demographically, hemodynamically as well as for intensity of pain. There was a statistically significant decrease in hemodynamic parameters from baseline in all groups with maximum reduction in group III. A significant difference among groups in VAS was observed at zero min and from 120min till 240min intervals and lowest values were in Group III. No significant difference was observed among the groups for mode of delivery and expulsive efforts. Total analgesic dose and PCA bolus requirement was maximum in Group I and minimum in Group III and the difference was statistically significant among groups. Six (20%) patients had shivering in Group II and hypotension was recorded in only 1 (3.3%) patient of Group III. CONCLUSION: Ropivacaine 0.125% was effective in decreasing labour pain without any motor blockade. Clonidine 1µg/kg was superior to fentanyl 2µg/ml as an adjuvant in PCEA for labour without any significant feto-maternal adverse effects.

Experience with conventional radiofrequency thermorhizotomy in patients with failed medical management for trigeminal neuralgia.

BACKGROUND: To evaluate the results of conventional radiofrequency thermorhizotomy (CRT) for trigeminal neuralgia (TN) in patients with failed medical management. METHODS: Patients with Trigeminal neuralgia who were referred to us for 'limited intervention' during the time frame July-2011 to Jan-2013 were enrolled for this study. CRT was administered by the Sweet technique. Pain relief was evaluated by the principle investigator. RESULTS: Eighteen patients were enrolled and completed a mean follow-up of 18.0 months. Pain relief was observed in 14 of 18 (77.8%) patients on the post-operative day, 14 of 18 (77.8%) at 1-month follow-up, 14 of 17 (82.4%) at 3-months follow-up, 12 of 15 (80%) at 6-months follow-up, 7 of 11 (63.6%) at 1-year follow-up and 2 of 6 (33.3%) 1.5 years of follow-up. Four patients required a repeat cycle of CRT; two at six months of follow-up and two at one year of follow-up. One patient was transferred for surgical intervention at six months of follow-up. Side-effects included facial hypoesthesia (n = 6); nausea/vomiting (n = 2), diminished corneal reflex (n = 13) and difficulty in chewing (n = 11). Severity of adverse effects gradually diminished and none of the patients who are beyond 6 months of follow-up have any functional limitation. CONCLUSIONS: CRT is an effective method of pain relief for patients with Trigeminal neuralgia. Successful outcome (excellent or good) can be expected in 66.7% of patients after first cycle of CRF. The incidence and severity of adverse effects is less and the procedure is better tolerated by the patients.

Dexmedetomidine as an intrathecal adjuvant for postoperative analgesia.

BACKGROUND: Spinal anaesthesia is the most common approach which is used for lower limb surgery. Dexmedetomidine is the recent drug which acts on α2-adrenergic receptors in the dorsal horn of the spinal cord to produce analgesic effects. AIM: Efficacy and safety of intrathecal dexmedetomidine added to ropivacaine. SETTING AND DESIGN: Randomised double blind trial. METHODS: Sixty patients were randomly allocated to receive intrathecally either 3 ml of 0.75% isobaric ropivacaine + 0.5 ml normal saline (Group R) or 3 ml of 0.75% isobaric ropivacaine + 5 µg dexmedetomidine in 0.5 ml of normal saline (Group D). RESULTS: The mean time of sensory regression to S2 was 468.3±36.78 minutes in group D and 239.33±16.8 minutes in group R. Duration of analgesia (time to requirement of first rescue analgesic) was significantly prolonged in group D (478.4±20.9 minutes) as compared to group R (241.67±21.67 minutes). The maximum visual analogue scale score for pain was less in group D (4.4±1.4) as compared to group R (6.8±2.2). CONCLUSION: The addition of dexmedetomidine to ropivacaine intrathecally produces a prolongation in the duration of the motor and sensory block.