Ultrasound-guided pericapsular nerve block compared with IV opioids in hip injuries: A randomised controlled trial.

STUDY OBJECTIVES: The study aimed to compare the analgesic effect of USG-guided PENG (Peri capsular nerve group) block with Intravenous Nalbuphine hydrochloride (IVN) in patients with hip fracture coming to the emergency department (ED). The purpose was also to monitor the adverse effects and rescue analgesic requirements in both treatment modalities. METHODS: The study was an open-label randomised controlled trial (RCT) comparing PENG block versus IVN in treating patients with femoral head and neck fractures, as well as pubic rami fracture of the hip (HF). The participants in the PENG group received a USG-guided PENG block by injection of 25 ml of 0.25% bupivacaine, whereas the IVN group received 0.15 mg/kg of nalbuphine. An emergency physician with expertise in ultrasound-guided nerve blocks performed the PENG blocks. The primary outcome was to measure the improvement of the NRS (Numerical rating scale) score at 30 min in both static position (Patient-chosen position for the best comfort) and dynamic position (15-degree passive affected lower limb elevation). Secondary outcomes were to measure static and dynamic NRS pain scores at 2 h, 4 h, and 6 h after intervention in both groups. The requirement for rescue analgesia, adverse events and any block-related complications were also recorded. RESULTS: A total of 60 patients with HF were included in the final analysis. The static and dynamic NRS score was significantly lower in the PENG group compared to the IVN group at 30 min, 2 h, 4 h, and 6 h post-intervention. In the PENG group, the static NRS score was improved by 5.73 ± 1.17, while In the IVN group, the static NRS score was just improved by 2.13 ± 0.97 at 30 min. In the same duration, the Dynamic NRS score in the PENG group was improved by 6.13 ± 1.38, while In the IVN group, it improved just by 2.43 ± 1.28. Rescue analgesia was required in 50.0% of patients in the IVN group but none in the PENG group. Further, no block-related complications or adverse events were observed in the patients of the PENG group. CONCLUSION: The study provides evidence that the ultrasound-guided PENG block has a better analgesic effect and has fewer adverse events than IV opioids in patients with HF.

An overview on the prevalence and potential impact of antimicrobials and antimicrobial resistance in the aquatic environment of India.

India at present is one of the leading countries in antimicrobial drug production and use, leading to increasing antimicrobial resistance (AMR) and public health problems. Attention has mainly been focused on the human and food animals' contribution to AMR neglecting the potential contribution of the perceptibly degraded aquatic environment in India. The paper reviews the available published literature in India on the prevalence of antimicrobial residues and their dissemination pathways in wastewater of pharmaceutical industries, sewage treatment plants, hospitals, riverine, community pond water, and groundwater. The prevalence of antimicrobial residue concentration, pathogenic and non-pathogenic bacteria antimicrobial resistant bacteria (ARB), their drug resistance levels, and their specific antimicrobial resistant genes (ARGs) occurring in various water matrices of India have been comprehensively depicted from existing literature. The concentration of some widely used antimicrobials recorded from the sewage treatment plants and hospital wastewater and rivers in India has been compared with other countries. The ecotoxicological risk posed by these antimicrobials in the various water matrices in India indicated high hazard quotient (HQ) values for pharmaceutical effluents, hospital effluents, and river water. The degraded aquatic environment exhibited the selection of a wide array of co-existent resistant genes for antibiotics and metals. The review revealed improper use of antibiotics and inadequate wastewater treatment as major drivers of AMR contaminating water bodies in India and suggestion for containing the challenges posed by AMR in India has been proposed.

Ultrasound-guided selective peripheral nerve block for the snakebite pain management in the emergency department: Our experience.

Envenomation from snakebites (SBs) is a significant public health hazard globally. The venomous SB is associated with moderate-to-severe pain. Weak opioids such as tramadol or acetaminophen are commonly used for pain management but often provide inadequate analgesia. We hereby report our experience of using ultrasound-guided selective superficial peroneal, sural, and saphenous nerve blocks for pain management following SBs in nine patients. The selective peripheral nerve blocks are achieved with a small amount of local anesthesia and without loss of motor functions.

Anesthetic challenges in the management of Larsen syndrome: A rare congenital anomaly.

Larsen syndrome is a rare inherited disease associated with dislocations of multiple joints, typical syndromic facies, and multiple spine abnormalities. They often required multiple corrective orthopedic surgeries to regain their functional ability, thus needing repeated anesthesia. Apart from skeletal deformities, they have predicted difficult airway and need extreme care during intubation and positing of the patient. Abnormal posturing due to spinal deformity and poor pulmonary reserve due to kyphoscoliosis creates an extremely challenging situation for the anesthetist to manage the case during the perioperative period. Here we are describing the perioperative anesthetic management of a patient with Larsen syndrome.

Radial artery duplication: Unusual point-of-care-ultrasonography finding during arterial cannulation.

The radial artery is the most common choice for arterial cannulation, coronary interventions, and various interventional radiological procedures. Here, we describe a case of unilateral duplication of the radial artery detected during radial artery cannulation using point-of-care ultrasonography (POCUS). The duplication of the radial artery in the forearm can hinder trans-radial access secondary to variations in the diameter. An actual duplication also carries a high risk of accidental injury to the arterial wall during routine invasive procedures and other forearm procedures such as free flap construction. POCUS is invaluable for detecting arterial anomalies before proceeding with any interventional procedures.

Comparison of Ultrasound-Guided Anterior, Posterior and Combination of Quadratus Lumborum Block in Laparoscopic Abdominal Surgeries: A Pilot Study.

BACKGROUND: The quadratus lumborum block (QLB) is an effective technique to provide analgesia for upper and lower abdominal surgeries. There are various approaches described in the literature, but the best approach is still to be explored. This study aims to compare the analgesic efficacy of three different approaches of QLBs. METHODS: Sixty-five patients, aged 18-70 years posted for elective laparoscopic abdominal surgery under general anesthesia were enrolled after taking written informed consent. QLB was given using bupivacaine 0.25% 40 mL with injection dexmedetomidine 1 mcg/kg in all the groups. In Group 1 and Group 2, the drug was injected into the anterior and posterior aspects of the muscle respectively. In Group 3, a combination of the anterior-posterior approach was used. Pain scores at various intervals along with analgesic consumption and complications were observed. RESULTS: The demographic variables, hemodynamic parameters, and complications were comparable among the three groups. There were statistically significant differences between treatment groups in fentanyl requirement as assessed using the Kruskal-Wallis test (P = 0.012). Pairwise post-hoc analysis between block groups showed that the differences between Group 1 & Group 2 and Group 2 & Group 3 were significant (P = 0.0098 and P = 0.013). The tramadol requirement was comparable in all the groups (P = 0.75). Patient satisfaction was significantly higher in Group 3 compared to other groups (P = 0.024). CONCLUSION: Further studies can be planned to evaluate the best approach for QLB in terms of perioperative analgesia, which remains a dilemma in this pilot study. The anterior, posterior, and combined anterior-posterior QLB approaches appear equally efficacious as a component of multimodal analgesia in laparoscopic abdominal surgeries.

Discovery of Selective Estrogen Receptor Covalent Antagonists for the Treatment of ERαWT and ERαMUT Breast Cancer.

Mutations in estrogen receptor alpha (ERα) that confer resistance to existing classes of endocrine therapies are detected in up to 30% of patients who have relapsed during endocrine treatments. Because a significant proportion of therapy-resistant breast cancer metastases continue to be dependent on ERα signaling, there remains a critical need to develop the next generation of ERα antagonists that can overcome aberrant ERα activity. Through our drug-discovery efforts, we identified H3B-5942, which covalently inactivates both wild-type and mutant ERα by targeting Cys530 and enforcing a unique antagonist conformation. H3B-5942 belongs to a class of ERα antagonists referred to as selective estrogen receptor covalent antagonists (SERCA). In vitro comparisons of H3B-5942 with standard-of-care (SoC) and experimental agents confirmed increased antagonist activity across a panel of ERαWT and ERαMUT cell lines. In vivo, H3B-5942 demonstrated significant single-agent antitumor activity in xenograft models representing ERαWT and ERαY537S breast cancer that was superior to fulvestrant. Lastly, H3B-5942 potency can be further improved in combination with CDK4/6 or mTOR inhibitors in both ERαWT and ERαMUT cell lines and/or tumor models. In summary, H3B-5942 belongs to a class of orally available ERα covalent antagonists with an improved profile over SoCs.Significance: Nearly 30% of endocrine therapy-resistant breast cancer metastases harbor constitutively activating mutations in ERα. SERCA H3B-5942 engages C530 of both ERαWT and ERαMUT, promotes a unique antagonist conformation, and demonstrates improved in vitro and in vivo activity over SoC agents. Importantly, single-agent efficacy can be further enhanced by combining with CDK4/6 or mTOR inhibitors. Cancer Discov; 8(9); 1176-93. ©2018 AACR.This article is highlighted in the In This Issue feature, p. 1047.

Infrarenal aortic clamp reviving a patient from acute surgical haemorrhagic shock: a novel management technique.

Surgical management of renal cell carcinoma extending into the inferior vena cava (IVC) is almost always accompanied by massive intraoperative blood loss and associated complications. It is a widely recognised problem, and its active management is essential in improving the perioperative morbidity and mortality. We share our experience with a similar case of open radical nephrectomy with massive blood loss of twice the circulating volume in a duration of <8 surgical hours. Although we emphasise the goals of securing haemostasis, restoration of circulating volume, and efficient management by replacing blood components, in the present case, despite the above-mentioned goals being fulfilled, we were unable to extricate the patient from haemorrhagic shock by conventional means and therefore resorted to desperate measures, namely the novel approach of infrarenal aortic clamping along with higher than recommended vasopressor support. We resorted to this in order to maintain the haemodynamic parameters and to prevent avoidable morbidity and mortality related to persistent intraoperative hypotension. With such an approach, we successfully managed the patient perioperatively, ultimately resulting in the patient being discharged after a week of intensive care unit stay without major complications.