Evaluation of perfusion index as a predictor of successful caudal block in pediatric patients: A prospective randomized study.

Background and Aims: Caudal block is among the most widely administered regional anesthesia in pediatric patients. The clinical signs and objective assessments are not fast and reliable enough to provide a good feedback. Perfusion index (PI) is considered as a sensitive marker to assess the efficacy of caudal block. We aim to assess PI as an indicator for success of caudal block in pediatric patients. Material and Methods: Sixty pediatric patients scheduled for elective surgery of lower abdomen and below were included. Patients were randomly allocated into two groups (n = 30): Group 1 received caudal block after general anesthesia and Group 2 only received general anesthesia. PI, heart rate, mean arterial pressure, and anal sphincter tone (AST) were recorded at 5, 10, 15, and 20 min following induction of anesthesia. Results: A persistent increase in the PI value was observed in Group 1 starting from 5 min till 20 min, as compared to Group 2, at all the time intervals. When mean PI was statistically compared between both the groups, it was found to be highly significant (P = 0.001). Group 1 patients have progressive laxity of AST which was found to be significantly different from Group 2 (P < 0.001). Conclusion: We have found that both PI and AST are good indicators for assessing success of caudal block onset in pediatric patients but AST took slightly longer time (~20 mins). Therefore, we conclude that PI is simple, economical, and noninvasive monitor that predicts the caudal onset much earlier than AST.

A comparative study to evaluate the cervical spine movements during laryngoscopy using Macintosh and Airtraq laryngoscopes.

Background and Aim: Intubation with Macintosh requires flexing the lower cervical spine and extending the atlanto-occipital joint to create a "line of sight." Primary aim of study was to compare the extent of cervical spine movement during laryngoscopy using conventional Macintosh laryngoscope and Airtraq. Material and Methods: A total of 25 patients of either sex between the age group of 18 and 60 years, having American Society of Anesthesiologists (ASA) physical status of Grade-I and Grade-II, scheduled for elective surgery under image control requiring general anesthesia and intubation were enrolled. A baseline image of the lateral cervical spine including the first four cervical vertebrae was taken by an image intensifier. After administration of general anesthesia, laryngoscopy was first performed using a Macintosh laryngoscope and a second X-ray image of the lateral cervical spine was taken. The second laryngoscopy using a Airtraq laryngoscope was done and the third image of the lateral cervical spine was taken. Angles between occiput and C1; C1 and C2; C2 and C3; C3 and C4; and occiput and C4 were calculated. Atlanto-occipital distance (AOD) was calculated as the distance between occiput and C1. Results: Macintosh showed greater cervical movement as compared with Airtraq but a significant difference in the movement was observed at C2-C3 and C0-C4. Baseline mean AOD was 2.21 ± 1.25 mm, after Macintosh and Airtraq laryngoscopy was found to be 1.13 ± 0.60 and 1.6 ± 0.78 mm, respectively, and was found to be significant (P < 0.05). Conclusion: We conclude that Airtraq allows intubation with less movement of the upper cervical spine makes Airtraq preferred equipment for intubation in patients with a potential cervical spine injury.

Diabetes mellitus in acute exacerbation of chronic obstructive pulmonary disease - the tip of the iceberg.

COPD is a chronic respiratory disease characterized by systemic inflammation caused primarily by tobacco use, and it is associated with an increased susceptibility to respiratory infections, both viral and bacterial, which are responsible for acute COPD exacerbations (AECOPD). Diabetes mellitus is one of the most common co-morbidities in COPD patients. In our study, we attempted to detect previously undiagnosed diabetes in AECOPD patients who presented to our Institute. The study included 100 patients who had been diagnosed with AECOPD. Pearson's coefficient correlation analysis was used to assess the relationship between various parameters. The vast majority of patients belonged to Group 3. (diagnosed at the time of admission as having type II diabetes). HbA1c had a significant positive correlation with BMI, cholesterol, and TLC, but a negative correlation with SpO2. Using HbA1C, nearly two-thirds of the AECOPD were newly diagnosed with diabetes mellitus. Our findings suggest that diabetes is significantly underdiagnosed in COPD patients.

Roles of abscisic acid and auxin in plants during drought: A molecular point of view.

Plant responses to drought are mediated by hormones like ABA (abscisic acid) and auxin. These hormones regulate plant drought responses by modulating various physiological and biological processes via cell signaling. ABA accumulation and signaling are central to plant drought responses. Auxin also regulates plant adaptive responses to drought, especially via signal transduction mediated by the interaction between ABA and auxin. In this review, we explored the interactive roles of ABA and auxin in the modulation of stomatal movement, root traits and accumulation of reactive oxygen species associated with drought tolerance.

Integration of Auxin, Brassinosteroid and Cytokinin in the Regulation of Rice Yield.

Crop varieties with a high yield are most desirable in the present context of the ever-growing human population. Mostly, the yield traits are governed by a complex of numerous molecular and genetic facets modulated by various quantitative trait loci (QTLs). With the identification and molecular characterizations of yield-associated QTLs over recent years, the central role of phytohormones in regulating plant yield is becoming more apparent. Most often, different groups of phytohormones work in close association to orchestrate yield attributes. Understanding this cross talk would thus provide new venues for phytohormone pyramiding by editing a single gene or QTL(s) for yield improvement. Here, we review a few important findings to integrate the knowledge on the roles of auxin, brassinosteroid and cytokinin and how a single gene or a QTL could govern cross talk among multiple phytohormones to determine the yield traits.

Assessment of airway parameters in obstetric patients and comparing them at different phases in the perinatal period: A prospective observational study.

Background and Aims: Airway changes occur in different stages of pregnancy. We aimed to evaluate the changes in the upper airway in obstetric patients during pregnancy, labour and after delivery using multiple airway indices and identify the predictive factors of these changes. Methods: This observational study was conducted on 90 parturients aged >20 years, having monofoetal pregnancy. The patient's weight was noted, airway assessment including Mallampati grading (MPG), and thyromental distance (TMD), sternomental distance (SMD), neck circumference (NC) and Wilson's risk score were measured in the second trimester of pregnancy (T0), between 32 and 34 weeks of gestation (T1), at the time of admission for safe confinement, between 38 and 40 weeks of gestation (T2), 2 h after delivery of baby (T3) and, 24 h after delivery (T4). Unpaired t-test and analysis of variance test were applied. Results: Changes in mean (standard deviation [SD]) weight, recorded from T0 to T2, were from 56.96 (10.77) to 65.322 (11.49) kg (P = 0.001). A rise of one or two grades in MPG was detected as the pregnancy progressed, and a decrease of one grade was noted after delivery. A significant decrease in mean (SD) TMD was noted from 6.88 (0.65) to 6.36 (0.62) cm from T0 to T2 (P = 0.001). SMD also decreased in a similar manner as TMD. NC increased from T0 to T3 and then decreased at T4 (P = 0.004). Conclusion: Following the second trimester of pregnancy, MPG increased by either one or two grades, with a decrease in TMD and SMD and an increase in NC.

Comparison of oropharyngeal leak pressure of LMA Protector and LMA ProSeal in anaesthetised paralysed patients - A randomised controlled trial.

Background and Aims: In the present study, we hypothesised that the laryngeal mask airway (LMA) Protector would provide higher oropharyngeal leak pressure (OLP) than LMA ProSeal. Thus, we planned this study to compare the clinical performance of LMA Protector and LMA ProSeal in terms of OLP as a primary objective and insertion characteristics as secondary objectives. Methods: Ninety patients of either gender, aged 18-70 years, were randomised into groups PS (LMA ProSeal) and P (LMA Protector). Following anaesthetic induction, the device was inserted as per group allocation. OLP of both devices was taken as a primary objective. Secondary objectives such as insertion time, ease of insertion, number of attempts required, fibre-optic view grading, amount of air (mL) required to get a cuff pressure (CP) of 60 cm H2O, and CP adjustment required and complications, if any, were also noted. Data were analysed using coGuide statistics software, Version 1 (BDSS Corp. Bangalore, Karnataka, India). Results: The median (interquartile range) OLP was significantly higher with LMA protector than with LMA ProSeal [33.00 (27.0, 36.0) versus [29.50 (26.0, 32.0) (P = 0.009)]. First-attempt success rate was 95.4% (42/44) in group PS and 93% (40/43) in group P. Insertion time, ease of insertion, and fibre-optic view grading were not different between the groups. Gastric tube placement failed in one patient in group PS and in three patients in group P (P = 0.606). The median amount of air (mL) required to get a CP of 60 cm H2O was 26.5 (20, 28) in group PS and 12 (8,13) in group P (95% confidence interval [CI] =10.808-14.575) (P < 0.001). At all time points, CP was significantly higher, and more CP adjustments were needed in group PS than in group P (P < 0.001). Incidence of blood staining and post-operative sore throat at 1 and 24 h were not different between the groups. Conclusion: LMA Protector provided a significantly higher OLP and less requirement of CP adjustments but comparable first-attempt success rate, mean insertion time, fibre-optic view, and gastric tube insertion as compared to LMA ProSeal.

A study to evaluate the change in perfusion index as an indicator of successful ultrasound-guided supraclavicular block.

BACKGROUND AND AIMS: Perfusion index (PI) is a new simple, objective and non-invasive method for evaluation of the success of central neuraxial and peripheral nerve blocks. So, we conducted a study with an aim to evaluate PI as an indicator for success of ultrasound-guided supraclavicular block (SCB). METHODS: 65 patients of either sex, age 18-60 years, American Society of Anesthesiologists physical status I and II posted for upper limb surgery under ultrasound (US)-guided SCB were included. PI was recorded at baseline every 2 minutes till 10 minutes and then every 5 minutes till 30 minutes after block. PI ratio was calculated as the ratio between PI at 10 minutes and baseline PI. Sensory and motor blocks were assessed at 5-minutes intervals up to 30 minutes. Descriptive analysis was applied by mean and standard deviation for quantitative, frequency and proportion for categorical variables. RESULTS: Mean PI increased continuously from baseline and reached the maximum at 10 minutes and then slightly decreased up to 30 minutes, but values at subsequent time intervals were quite high as compared to baseline. In case of successful blocks, median PI started increasing 2 minutes after the block and then increased in a linear fashion till 10 minutes, whereas in case of failed blocks, it only increased minimally. CONCLUSION: PI is an objective and faster indicator for evaluating success of US-guided SCB. A cut-off value of 3.25 for PI and 3.03 for PI ratio showed a fairly good ability with high sensitivity and specificity for predicting the success of SCB.

JASMONATE ZIM-DOMAIN Family Proteins: Important Nodes in Jasmonic Acid-Abscisic Acid Crosstalk for Regulating Plant Response to Drought.

Plants modulate the metabolism of phytohormones and their signaling pathways under drought to regulate physiological and adaptive responses. Jasmonic acid (JA) is one of the major classes of phytohormones and has been found to potentially enhance plant tolerance to various abiotic stresses, including drought. The JASMONATE ZINC FINGER INFLORESCENCE MERISTEM (ZIM)-DOMAIN (JAZ) proteins are the negative regulators in the JA-signaling pathway. The JAZ protein family is explicit to plants and involved in the regulation of numerous biological processes, including drought-responsive mechanisms. In this review, we synthesize the mechanistic insight into the roles of JAZ proteins in the regulation of drought responses by connecting the JA-signaling with abscisic acid-signaling.

A study to evaluate ocular changes in patients undergoing spine surgery in the prone position.

Background and Aims: AA present prospective study was conducted to evaluate ocular changes occurring in patients undergoing spine surgery in the prone position. Material and Methods: A total of 44 patients of either sex, belonging to American society of Anaesthesiology I and II (aged 18-60 years) scheduled for elective spine surgery in prone position were enrolled in the study. Baseline IOP and MAP measurement were taken prior to induction. After induction of anaesthesia patients were intubated using flexo-metallic tube of appropriate size. IOP and MAP were recorded after induction of anaesthesia, following completion of surgery and immediately after turning the patient supine and 30 min following extubation. Blood loss and duration of surgery was also noted. The OPP was derived using the formula (OPP = MAP-IOP). Ophthalmic examination was also performed using direct and indirect ophthalmoscopy on the day prior to surgery and on first post-operative day to rule out anterior ischemic optic neuropathy (AION), posterior ischemic optic neuropathy (PION), and retinal ischemia. Results: Mean IOP significantly increased (18.91 ± 3.56 mm Hg) (P < 0.001) at the end of surgery as compared to baseline value 12.85 ± 3.07 mm Hg. As a result mean OPP significantly reduced (75.12 ± 16.45) (P = 0.0018) at the end of the procedure. Conclusion: In patient's undergoing spine surgery in the prone position, careful patient positioning with no extrinsic pressure on the eyes, minimal surgical time and blood loss, and prevention of intraoperative hypotension, should be ensured to prevent the IOP rise and a reduction in OPP which can further prevent post-operative visual disturbance.

A randomised controlled trial to study Bispectral guided induction of general anaesthesia using propofol and etomidate infusion.

BACKGROUND AND AIMS: The present prospective, randomised study was done to evaluate induction characteristics with bispectral (BIS) index guided infusion of propofol and etomidate. MATERIALS AND METHODS: After institutional ethical committee approval, 70 patients, aged 18-60 years, American Society of Anaesthesiologists (ASA) I and II scheduled for elective surgery were included. Patients were randomly allocated into one of the two groups. In Group E, patients received etomidate infusion at a rate of 0.07 mg kg-1 min-1 and in Group P, received propofol infusion of 0.7 mg kg-1 min-1. Time from start of infusion to loss of palpebral reflex (TP), loss of verbal command (TV), BIS to reach 50 (TBIS50), mean induction dose and incremental dose of each drug required to keep BIS50., haemodynamic parameters and adverse effects like pain, myoclonus, apnoea and postoperative nausea and vomiting (PONV) were also noted. RESULTS: TP,TV, and TBIS 50 was faster in E as compared to P group and was statistically significant for all parameters. Mean induction dose of drug required till BIS 50 was 2.68 ± 0.56 mg kg-1 and 0.242 ± 0.11 mg kg-1 in group P and E, respectively. There was a significant difference between the groups with group E requiring incremental dose in a significant proportion of patients (P = 0.004). There was a significant decrease in MAP in P group as compared to E. In group P, more number of patients experienced pain and had apnoea episode as compared to group E. (P < 0.001). Myoclonus was observed in group E only (P = 0.016). CONCLUSION: BIS-guided titration of propofol and etomidate infusion for induction did not result in reduction of the dose, haemodynamic variations and other effects.

Jasmonic Acid at the Crossroads of Plant Immunity and Pseudomonas syringae Virulence.

Sensing of pathogen infection by plants elicits early signals that are transduced to affect defense mechanisms, such as effective blockage of pathogen entry by regulation of stomatal closure, cuticle, or callose deposition, change in water potential, and resource acquisition among many others. Pathogens, on the other hand, interfere with plant physiology and protein functioning to counteract plant defense responses. In plants, hormonal homeostasis and signaling are tightly regulated; thus, the phytohormones are qualified as a major group of signaling molecules controlling the most widely tinkered regulatory networks of defense and counter-defense strategies. Notably, the phytohormone jasmonic acid mediates plant defense responses to a wide array of pathogens. In this review, we present the synopsis on the jasmonic acid metabolism and signaling, and the regulatory roles of this hormone in plant defense against the hemibiotrophic bacterial pathogen Pseudomonas syringae. We also elaborate on how this pathogen releases virulence factors and effectors to gain control over plant jasmonic acid signaling to effectively cause disease. The findings discussed in this review may lead to ideas for the development of crop cultivars with enhanced disease resistance by genetic manipulation.

A prospective randomised trial to compare three insertion techniques for i-gel™ placement: Standard, reverse, and rotation.

BACKGROUND AND AIMS: This prospective randomised study was done to compare standard, reverse, and rotation techniques of i-gel™ placement in terms of insertion characteristics and success rate. MATERIAL AND METHODS: After institutional ethics committee approval, 135 patients aged 18-50 years, ASA I and II undergoing elective surgery under general anesthesia were included. After induction of anesthesia, i-gel™ was inserted by standard, reverse, and rotation technique in Groups I, II, and III, respectively. The primary objective was mean time of insertion. Secondary variables included ease of insertion, first attempt success rate, manoeuvres required, fiberoptic view of placement, oropharyngeal leak pressure, ease of placement of nasogastric tube, and complications if any. RESULTS: Mean time of insertion was 18.04 ± 5.65 s, 15.00 ± 5.72 s and 16.12 ± 5.84 s for groups I, II, and III, respectively. Time taken for insertion was shortest and significantly lower (P = 0.048) for group II compared to group I. Insertion time was comparable between rest of groups. The overall success rate in groups I, II, and III were 91.1%, 95.6%, and 93.3% respectively (P = 0.7). The first attempt success rate was 82.2%, 89%, and 84.4% in groups I, II and III, respectively (P = 0.07). Manoeuvres were required in five (12.19%) patients in group I, four (9.30%) patients in group II, and three (7.14%) patients in group III (P = 0.602). Complications occurred in eight, three, and three patients in groups I, II, and III, respectively. CONCLUSION: All techniques of i-gel insertion are equally good and choice of technique depends upon the experience and comfort of the investigator with the particular technique.

A prospective, randomised, comparative study to evaluate long axis, short axis and medial oblique axis approach for ultrasound-guided internal jugular vein cannulation.

BACKGROUND AND AIMS: The Ultrasound (USG)-guided internal jugular vein (IJV) cannulation can be performed using different approaches like short axis (SAX), long axis (LAX), oblique axis (OAX) or medial oblique axis (M-OAX). We aimed to determine which view was optimal for IJV cannulation. METHODS: After ethical committee approval and written informed consent, this prospective, randomised, controlled trial was conducted on 108 patients. Patients were allocated into one of the three groups: A (SAX), B (LAX) and C (M-OAX approach) for USG-guided IJV cannulation. The number of needle passes, the success of IJV cannulation and its diameter, venous access time, guidewire time, catheterisation time and complications if any were recorded. Statistical analysis was performed by SPSS version 17.0. RESULTS: First needle pass success rate was highest in M-OAX (97.2%) followed by SAX (88.9%) and then LAX (77.8%) but it was statistically insignificant among the groups. Mean venous access, guidewire insertion and catheterisation time were shortest in M-OAX followed by SAX and then LAX approach. It was statistically significant between LAX and SAX and between LAX and M-OAX group. (P < 0.001). The carotid puncture was noticed in two patients in the LAX group. The overall success rate and the number of needle passes were comparable among the groups. CONCLUSION: The M-OAX approach is a safe and effective technique for USG-guided IJV cannulation when compared to SAX and LAX approaches.

Experimental and modeling studies of the flow, dynamic and creep recovery properties of pearl millet starch as affected by concentration and cultivar type.

Starch from pearl millet varieties viz. ProAgro 9444 and HHB 67, selected on the basis of amylose content was studied for steady, dynamic and creep recovery characteristics as affected by concentration (3-15%). ProAgro 9444 and HHB 67 possess amylose content of 20.21% and 15.05%, respectively. Starch gel exhibited shear thinning behavior with flow behavior index <1, well described by Herschel Bulkley model (R2 > 0.969) at all the concentrations. The starch pastes were thixotropic and the extent increased with increasing concentration and amylose content. Dynamic shear properties obtained within the linear viscoelastic region suggested weak gel like behavior at all concentrations, except 3% starch from HHB 67 which was categorized as dilute solution. Weak gel like behavior at other concentrations was supported by tan δ < 1, and the gel from ProAgro 9444 was more elastic. Power law analysis of data from mechanical spectra also reflected weak gel behavior except for 3% HHB 67. High amylose and increasing concentration favored gel formation as magnitude of temperature at peak G' and G″ were lower. Creep compliance followed Burger model at higher concentrations whereas 3% HHB 67 exhibited Newtonian behavior. The strain recovery increased with increase in starch concentration and amylose content.

Amniotic fluid embolism.

Amniotic fluid embolism (AFE) is one of the catastrophic complications of pregnancy in which amniotic fluid, fetal cells, hair, or other debris enters into the maternal pulmonary circulation, causing cardiovascular collapse. Etiology largely remains unknown, but may occur in healthy women during labour, during cesarean section, after abnormal vaginal delivery, or during the second trimester of pregnancy. It may also occur up to 48 hours post-delivery. It can also occur during abortion, after abdominal trauma, and during amnio-infusion. The pathophysiology of AFE is not completely understood. Possible historical cause is that any breach of the barrier between maternal blood and amniotic fluid forces the entry of amniotic fluid into the systemic circulation and results in a physical obstruction of the pulmonary circulation. The presenting signs and symptoms of AFE involve many organ systems. Clinical signs and symptoms are acute dyspnea, cough, hypotension, cyanosis, fetal bradycardia, encephalopathy, acute pulmonary hypertension, coagulopathy etc. Besides basic investigations lung scan, serum tryptase levels, serum levels of C3 and C4 complements, zinc coproporphyrin, serum sialyl Tn etc are helpful in establishing the diagnosis. Treatment is mainly supportive, but exchange transfusion, extracorporeal membrane oxygenation, and uterine artery embolization have been tried from time to time. The maternal prognosis after amniotic fluid embolism is very poor though infant survival rate is around 70%.

Use of i-gel in magnetic resonance imaging.

Anesthesia for magnetic resonance imaging (MRI) requires special equipment that can be used in the presence of a magnetic field. Endotracheal tube and various laryngeal mask airway devices have a variable quantity of ferromagnetic material in the pilot balloon that could reduce image quality and result in artifacts. The i-gel is a reliable, easily inserted airway device, and causes minimal interference in image quality. We used i-gel in 10 anaesthetized adult patients undergoing MRI. The quality of image, evidence of airway, tongue, and dental trauma were assessed throughout the procedure. All scans were diagnostically adequate. Therefore, we concluded that i-gel causes the least ferromagnetic interference compared with other devices and improves the quality of imaging and produces minimal artifact while scanning.

Comparative evaluation of subclavian vein catheterisation using supraclavicular versus infraclavicular approach.

BACKGROUND AND AIMS: Infraclavicular (IC) approach of subclavian vein (SCV) catheterisation is widely used as compared to supraclavicular (SC) approach. The aim of the study was to compare the ease of catheterisation of SCV using SC versus IC approach and also record the incidence of complications related to either approach, if any. METHODS: In the study, 60 patients enrolled were randomly divided into two groups of 30 patients each. In Gp. SC right SCV catheterisation was performed using SC approach and in Gp. IC catheterisation was performed using IC approach. Access time, success rate of cannulation, number of attempts to cannulate vein, ease of guidewire and catheter insertion and length of catheter inserted and any associated complications were recorded. RESULTS: The mean access time in group SC for SCV catheterisation was 4.30 ± 1.02 min compared to 6.07 ± 2.14 min in group IC. The overall success rate in catheterisation of the right SCV using SC approach (29 out of 30) was better as compared with group IC (27 out of 30) using IC approach. First attempt success in the SC group was 75.6% as compared with 59.25% in the IC group. All successful subclavian vein  catheterisations in SC group and IC group were associated with smooth insertion of guidewire following subclavian venipuncture. CONCLUSION: The SC approach of SCV catheterisation is comparable to IC approach in terms of landmarks accessibility, success rate and rate of complications.