Anesthetic Challenges Associated With Posterior Reversible Encephalopathy Syndrome in a Pregnant Woman Scheduled for a Caesarean Section.

Recently, there has been a rise in reports of posterior reversible encephalopathy syndrome (PRES), which is an uncommon neurologic illness. The precise cause of PRES syndrome is yet unknown, but there are certain illnesses that have been associated with it. Furthermore, because of advances in imaging methods and growing awareness, the connection between PRES and pre-eclampsia/eclampsia is becoming increasingly recognised. Pre-eclampsia/eclampsia by itself poses distinct perioperative difficulties; in addition, PRES makes anesthesia administration more difficult. Regretfully, there is a lack of knowledge regarding the anesthetic treatment provided to the extremely sick and medically complex patients, and it is uncertain whether the chosen anesthetic might exacerbate neurologic problems. Here, we discuss the implications for the anesthetic management of PRES presentations.

Anesthetic Challenges in an Infant With Tetralogy of Fallot Posted for Non-cardiac Surgery: A Case Report and Literature Review.

The goal of this article is to provide an up-to-date and comprehensive review of the current perioperative anesthetic management of pediatric patients with congenital heart disease (CHD) undergoing non-cardiac surgery. This report discusses a case of a nine-month-old female with Tetralogy of Fallot who was scheduled for non-cardiac surgery for anorectal malformation stage 1 and stage 2 repair. This case study discusses how to adjust perioperative anesthesia care in cases of left-to-right shunt, right-to-left shunt, and complex cardiac disease. In addition, the author discusses special considerations such as pulmonary hypertension, newborns with CHD undergoing extracardiac surgery, and the importance of regional anesthesia in children with CHD undergoing non-cardiac surgery.

Challenges in Anaesthetic Management in a Case of Facial Plexiform Neurofibromatosis Posted for Debulking Surgery.

A patient diagnosed with facial plexiform neurofibromatosis type 1 who is 18 years old and is scheduled for tumour resection and debulking surgery of his face is the subject of this study. The purpose of this paper is to describe the anaesthetic treatment that was administered to this patient. In addition, we analyze the relevant literature, with a particular emphasis on the implications of modifying neurofibromatosis to achieve anaesthesia. Our patient was found to have multiple huge tumours all over his face. When he first arrived, he experienced cervical instability as a result of the enormous mass on the back of his head and in the region of his scalp. He also expected to have difficulty maintaining an airway and breathing through a bag and mask. To protect the patient's airway, a video laryngoscopy was performed, and a difficult airway cart was maintained on standby in the event it was required. In conclusion, the purpose of this case study was to demonstrate the relevance of comprehending the one-of-a-kind anaesthetic requirements of persons diagnosed with neurofibromatosis type 1 who are about to undergo surgical procedures. Neurofibromatosis is an extremely uncommon kind of disease that requires the anesthesiologist's undivided attention in surgical settings. Careful pre-operative planning and competent intra-operative treatment are required when dealing with patients who are expected to have difficult airway management.

Period poverty and mental health of menstruators during COVID-19 pandemic: Lessons and implications for the future.

Menstruation is a naturally occurring phenomenon; however, millions of adolescent girls and women, as well as nonbinary persons who bleed every month, are deprived of menstruating safely and respectfully. Those belonging to marginalized sections face the brunt of lack of access to water, sanitation, and hygiene facilities; affordable menstrual supplies; and inequitable distribution of menstrual health education and are victims of period poverty. Their preexisting suffering was further exacerbated by the COVID-19 pandemic, which negatively affected the mental health of those menstruating. Adolescent girls and women in communities found it persistently challenging to access and afford menstrual products while deprived of menstrual hygiene education. These put them under immense stress and elevated financial liability, predisposing them to period poverty. Interventions addressing period poverty rely on mustering collective community voices and deploying adequate policy tools. All the efforts and solutions must provide social and financial protection nets and psychological aid through mental health support groups. It is core to drive menstrual health equity for all menstruators, irrespective of who they are, what they do, and where they live.

Anaesthetic Challenges in a Case of Oral Carcinoma With Anticipated Difficult Airway Posted for Tumour Excision and Reconstruction Surgery.

Mandibular surgery, edentulous jaw, denture wear, and ageing are all risk factors for persistent mandibular ridge resorption and weakening. The tongue occludes the upper airway due to the mandible's edentulous condition. All of these factors contribute to the difficulties in regulating the airway. An adequate preoperative review assisted in classifying this index patient as having a high risk of difficult airway management, and appropriate actions were made to facilitate effective airway care. A 60-year-old male presented to casualty with a complaint of squamous cell carcinoma of the right buccal mucosa and was posted for wide local excision of the tumour, segmental mandibulectomy, bilateral modified radical neck dissection, and reconstruction with a fibular free flap. He had a restricted mouth opening and a heavy jaw, with Mallampati grade 4 and had an anticipated difficult airway. Hence, awake endotracheal intubation was done by flexible fibreoptic bronchoscope following airway blocks and an 8.0 mm cuffed flexometallic armoured tube was secured at 28 cm at the angle of the nose. Bilateral modified radical neck dissection and wide local excision of the tumour were done followed by mandibulectomy and its reconstruction by fibular free flap and anastomosis was performed. Tracheostomy was performed and the patient was shifted to the intensive care unit and kept knocked out with injection vecuronium and injection midazolam infusion. The patient was gradually weaned off the ventilator the following day and discharged on postoperative day 12 with minimal postoperative complications. A thorough pre-anaesthetic plan, simple and skilled anaesthetic management strategy, and well-organized teamwork aided in the effective anaesthetic care of this challenging airway patient.

Recommendations for maternal mental health policy in India.

Mental illnesses are a serious concern in India where every seventh person suffers from mental health problems-with women more affected than men. While the burden of perinatal mental illnesses grows, India lacks exclusive policies to address it. The COVID-19 pandemic has had an impact on routine antenatal care and institutional deliveries and has also affected the mental health of pregnant women and mothers. We evaluated existing policies. Policy options were evaluated against criteria like cost-benefit analysis, administrative feasibility, human resources, and equity along with the intended and unintended consequences. We propose three policy options: (1) strengthening and focused implementation of the existing national mental health program (NMHP), (2) integrating mental health in the ongoing Reproductive, Maternal, Newborn, Child and Adolescent Health Program, and (3) including a 'maternal' component in NMHP. We offered policy recommendations to fill the gap in addressing the maternal mental health challenge in India.

Serum Inflammatory Markers in Patients with Guillain Barre Syndrome.

Background: Guillain Barre syndrome (GBS) is an immune-mediated peripheral neuropathy characterized by the demyelination and axonal damage of the peripheral neurons. The pathogenesis of GBS involves the breakdown of the blood-brain barrier after which pro inflammatory cytokines attack the neurons in the peripheral nervous system. Aims: This study aims to evaluate five markers, namely matrix metalloproteinase (MMP)-2 and MMP-9, vascular endothelial growth factor (VEGF)-A, basic fibroblast growth factor (bFGF), and SFLT-1, which could have a role in the inflammatory response in patients with GBS and healthy controls. Settings and Design: In this prospective study, patients diagnosed with GBS at the department of neurology, Kasturba Medical College, Manipal, Karnataka were enrolled. Methods and Material: The markers selected for this study were analyzed using the ELISA method and expressed as given in the kit provided by the company. Ethical clearance was obtained from the Institutional Ethical Committee. Statistical Analysis: Results were evaluated using SPSS version 17.0 and expressed as mean ± SD. Error bars for each were drawn. Results: The levels of all five parameters showed a significant increase in patients as compared to controls. Conclusions: Disruption of the basement membrane of endoneurium by MMP-2 and MMP-9, recruitment and migration of macrophages and other cytokines by VEGF-A, bFGF, and soluble fms-like tyrosine kinase-1 (SFLT-1) are plausible, which leads to inflammation process and thus neuronal damage leading to the development of GBS.

Challenges in Anaesthesia Management of a 15-Year-Old Female With Ovarian Teratoma for Exploratory Laparotomy: A Case Report.

Rarely, an ovarian tumour will develop the growing teratoma syndrome. Growing teratoma syndrome of the cystic type has been linked to difficulties with anaesthesia because of the abdominal pressure the tumour exerts on the thorax. There haven't been any reports of this kind of ovarian tumour associated with ascites and bilateral pleural effusion in a paediatric age group. Here, we describe our anaesthetic experience in a case of developing solid-type ovarian teratoma syndrome with deranged lung status and haemodynamics. The patient was a 15-year-old female who was diagnosed with ovarian teratoma. She was scheduled for surgery when she arrived at our hospital with a 13 cm solid mass and respiratory distress. The patient's liver profile was abnormal; she had ascites, pleural effusion and a severely worsened lung condition. The patient was planned for an exploratory laparotomy and debulking surgery after preoperative optimisation. To prevent the re-expansion pulmonary oedema (RPO) following the excision of the tumour, a volume-restricted postoperative ventilation strategy was planned. Following enhanced recovery after surgery (ERAS) protocol and specific anaesthetic measures, we successfully managed the anaesthesia in a case of teratoma syndrome with a large abdominal tumour with successful recovery and early discharge from hospital.

Clinical anatomy through gamification: a learning journey.

AIM: This study describes the developmental process of a series of anatomy games for medical students and analyses student participation and experiences around the gamification process. METHODS: Three diverse anatomy games were developed on the undergraduate medical curriculum. Based on students' playing and simultaneous learning experiences in each game, subsequent game contents were constructively modified. Students from three different universities participated in the study (total cohort=646); their experiences on the different games were documented and compared with each other. RESULTS: Feedback from 219 players showed that the games were fun (95%) and interesting (81%) and assisted their anatomy learning (97%); students' fun, interest and learning improved significantly in the two subsequent games (p<0.001). CONCLUSION: Carefully designed anatomy games create a fun-filled and interesting learning environment for undergraduate medical students. Learning experiences improved when students' feedback was appropriately addressed to constructively modify the subsequent learning resources.

Female Community Health Workers and Health System Navigation in a Conflict Zone: The Case of Afghanistan.

Afghanistan ranked 171st among 188 countries in the Gender Inequality Index of 2011 and has only 16% of its women participating in the labor force. The country has been mired in violence for decades which has resulted in the destruction of the social infrastructure including the health sector. Recently, Afghanistan has deployed community health workers (CHW) who make up majority of the health workforce in the remote areas of this country. This paper aims to bring the plight of the CHWs to the forefront of discussion and shed light on the challenges they face as they attempt to bring basic healthcare to people living in a conflict zone. The paper discusses the motivations of Afghani women to become CHWs, their status in the community and within the health system, the threatening situations under which they operate, and the challenges they face as working women in a deeply patriarchal society within a conflict zone. The paper argues that female CHWs should be provided proper accreditation for their work, should be allowed and encouraged to progress in their careers, and should be instilled at the heart of healthcare program planning because they have the field experience to make the most effective and community oriented programmatic decisions.

Telemedicine during COVID-19 in India-a new policy and its challenges.

During the COVID-19 pandemic, a countrywide lockdown of nearly twelve weeks in India reduced access to regular healthcare services. As a policy response, the Ministry of Health & Family Welfare which exercises jurisdiction over telemedicine in India, rapidly issued India's first guidelines for use of telemedicine. The authors argue that: guidelines must be expanded to address ethical concerns about the use of privacy, patient data and its storage; limited access to the internet and weaknesses in the telecom infrastructure challenge widespread adoption of telemedicine; only by simultaneously improving both will use of telemedicine become equitable; Indian medical education curricula should include telemedicine and India should rapidly extend training to practitioner. They determine that for low- and middle-income countries (LMIC), including India, positive externalities of investing in telemedicine are ample, thus use of this option can render healthcare more accessible and equitable in future.

Moral philosophy, pragmatism, and the larger cause: why "war" metaphors are needed during pandemics.

Coronavirus disease (Covid-19), which originated in China, is now a full-blown pandemic which has thrown governments and societies off-track in an unprecedented manner. War metaphors have been used widely to describe the scenario, but many critics decry them as harmful narratives. In this piece, we discuss the utility of the war metaphor to build solidarity and fraternity, which will be essential to get through the crisis. We also explain how concerns regarding increased authoritarianism and state excesses due to the use of these narratives are misplaced. We then tease out the colonial era concept of war that guides the arguments against the use of war metaphors in pandemics. We argue that in the post-modern world and in South Asian and African philosophies, wars are seen through the prism of the larger cause of dharma or ubuntu and that individual losses or gains in these contexts are part of a larger cause. The use of war metaphors reflects the need to get together for a societal cause. These metaphors are largely understood across societies while other alternatives are exclusionary, poetic and tangential in nature.

Keywords : Covid-19, pandemics, war metaphors, communication, philosophy, SARS-CoV-2

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Ethical challenges of digital health technologies: Aadhaar, India.

PROBLEM: The proliferation of information and communication technologies in India has enabled the emergence of health-related digital applications, from which important ethical issues arise. APPROACH: The Aadhaar identification system provides each resident in India with a 12-digit unique identification number, linked to demographic and biometric data. Identification by Aadhaar in welfare programmes has the important advantage of ensuring targeted benefits reach the intended recipients. LOCAL SETTING: Some of the major issues faced by the public health sector in India are inadequate funding and inefficient utilization of the funds allocated. The enhancement of currently available digital health records will greatly increase the efficiency of the health care services. RELEVANT CHANGES: The Aadhaar identification system has been linked to several health programmes since 2013. Success was achieved in a programme encouraging pregnant women to undergo delivery at a health facility, as use of Aadhaar number ensured that cash incentives reached the correct recipient. However, interruptions in the treatment of patients with tuberculosis and acquired immunodeficiency syndrome have been reported in other health programmes, due to patients fearing a breach of their confidentiality. LESSONS LEARNT: Although the proposed merging of the Aadhaar identification system with digital health care records could enable greater efficiency in monitoring public health and welfare programmes, important ethical issues of privacy and data ownership and use must be considered. In joining the digital revolution, low- and middle-income countries must also develop strict legal regulation to protect data and avoid information technology companies exploiting such databases for profit.

Ischemia-Modified Albumin, Creatinine, And Paraoxonase-1 Levels in Serum of Patients Undergoing Intravenous Contrast-Enhanced Computed Tomography and Its Association with Contrast-Induced Nephropathy.

BACKGROUND: Following contrast-enhanced computed tomography (CECT) contrast-induced nephropathy (CIN) may occur in patients with renal insufficiency or diabetes. Creatinine, the most common marker of CIN, may not be an accurate measure of damage and is affected by many non-renal factors. Our aim was to evaluate ischemia-modified albumin (IMA) as an early CIN marker and correlate it with paraoxonase-1 (PON-1) and creatinine before and after CECT. METHODS: Forty-eight adult patients scheduled for intravenous CECT, regardless of indication or body region for CECT, were included in this prospective study. Venous blood samples were obtained 12-24 hours before and after contrast media (CM) administration. Ischemia-modified albumin and PON-1 were estimated using methods described by Bar-Or et al. and Dantoine et.al., respectively. Creatinine was estimated on an automated analyzer. RESULTS: Significant differences in IMA (P < 0.001) and PON-1 (P < 0.001) levels were found between pre- and post-CECT samples, while the difference for creatinine was not significant (p = 0.073). No correlation was found between IMA and PON-1 or IMA and creatinine in either the pre- or post-CECT samples. CONCLUSION: After CM administration patients are subjected to oxidative stress and/or ischemia, as revealed by elevated IMA and decreased PON-1 levels; however, creatinine levels, most commonly estimated to assess reduced renal function, did not reflect the condition accurately. IMA may be a sensitive marker for CIN but further studies are required to confirm its usefulness.

Google classroom as a learning management system to teach biochemistry in a medical school.

Medical education has adopted various e-learning technologies to its aid. Addition of Google Classroom, introduced in 2014, as a Learning Management System (LMS) has provided a basic, easy to use platform. This study tested its efficacy in teaching a biochemistry module to first year MBBS students in an Indian medical school. Better access to learning material and supplementary teaching resources, helpfulness of immediate feedback, and learning outside of class environment were reported by students. Preference of mobile phone over laptop to access this LMS was reported. Use of this free to use LMS can be made, and especially in resource limited low and middle income countries, to encourage greater access to e-learning. © 2019 International Union of Biochemistry and Molecular Biology, 47(4):404-407, 2019.

Audio-visual aid in teaching "fatty liver".

Use of audio visual tools to aid in medical education is ever on a rise. Our study intends to find the efficacy of a video prepared on "fatty liver," a topic that is often a challenge for pre-clinical teachers, in enhancing cognitive processing and ultimately learning. We prepared a video presentation of 11:36 min, incorporating various concepts of the topic, while keeping in view Mayer's and Ellaway guidelines for multimedia presentation. A pre-post test study on subject knowledge was conducted for 100 students with the video shown as intervention. A retrospective pre study was conducted as a survey which inquired about students understanding of the key concepts of the topic and a feedback on our video was taken. Students performed significantly better in the post test (mean score 8.52 vs. 5.45 in pre-test), positively responded in the retrospective pre-test and gave a positive feedback for our video presentation. Well-designed multimedia tools can aid in cognitive processing and enhance working memory capacity as shown in our study. In times when "smart" device penetration is high, information and communication tools in medical education, which can act as essential aid and not as replacement for traditional curriculums, can be beneficial to the students. © 2015 by The International Union of Biochemistry and Molecular Biology, 44:241-245, 2016.

Pathophysiology and diagnosis of Guillain-Barré syndrome - challenges and needs.

Guillain-Barré syndrome (GBS) is an autoimmune polyneuropathy which presents with acute onset and rapid progression of flaccid, hyporeflexi quadriparesis. Both sensory and autonomic nerve involvement is seen. GBS has various subtypes that vary in their pathophysiology. The pathogenesis involves an immune response triggered by a preceding event which may be an infection, immunisation or surgical procedure. Clinical diagnosis has been largely the primary diagnosing criterion for GBS along with electrodiagnosis, which has several pitfalls and is supported by ancillary testing of cerebrospinal fluid (CSF) analysis and Nerve Conduction Studies. Measurement of anti-ganglioside antibodies is also an effective tool in its diagnosis. Further understanding of pathophysiology and better diagnostic methods are required for better management of GBS.

A Comparison of the Bleaching Effectiveness of Chlorine Dioxide and Hydrogen Peroxide on Dental Composite

This study was carried out to verify if composites could be bleached using chlorine dioxide as compared with hydrogen peroxide. 3M ESPE Filtek Z350 Universal Restorative discs were prepared (n=40), with dimensions 5 mm diameter x 2 mm thickness. The discs were divided into 4 groups of 10 discs each. Color assessment was performed by CIEDE2000. The discs were stained with coffee, tea, wine and distilled water (control) solutions for 14 days, 5 hours daily. Color assessment was repeated on stained discs and followed by bleaching of 5 discs from each group using chlorine dioxide and hydrogen peroxide in-office systems. Finally, a last color assessment was performed and compared statistically. DE2000 after bleaching was very close to baseline for both the bleaching agents, although chlorine dioxide showed better results than hydrogen peroxide. After staining, there was a clinically significant discoloration (∆E2000≥3.43) for the tea, coffee and wine groups, and discoloration (∆E2000) was seen more in the wine group as compared to tea and coffee. Overall, the control group (distilled water) had the least color change in the three intervals. After bleaching, the color in all specimens returned close to the baseline. The color differences between bleaching and baseline were less than 3.43 for all groups. The obtained results show that chlorine dioxide is slightly superior to hydrogen peroxide in the bleaching of composites, while maintaining the shade of the composite close to the baseline.

Este estudo foi realizado para verificar se resinas compostas podem ser clareadas com uso do dióxido de cloro, em comparação com peróxido de hidrogênio. Foram preparados discos com resina restauradora Filtek Z350 3M ESPE (n=40), com dimensões 5 mm de diâmetro × 2 mm de espessura. Os discos foram divididos em 4 grupos de 10 discos cada. A avaliação da cor foi realizada por meio do CIEDE2000. Os discos foram manchados com soluções de café, chá, vinho e água destilada (controle) por 5 h diárias durante 14 dias. A avaliação da cor foi repetida nos discos manchados e seguida por clareamento de 5 discos de cada grupo, utilizando dióxido de cloro ou peróxido de hidrogênio pela técnica de consultório. Finalmente, uma última avaliação da cor foi realizada e as técnicas comparadas estatisticamente. DE2000 após o clareamento foi muito próxima ao baseline, para ambos os agentes clareadores, embora o dióxido de cloro tenha mostrado melhores resultados do que o peróxido de hidrogênio. Após o manchamento, houve uma descoloração clinicamente significativa (ΔE2000≥3,43) para os grupos de chá, café e vinho, sendo que o clareamento (ΔE2000) foi melhor obtido com o grupo do vinho, em comparação com chá e café. No geral, o grupo controle (água destilada) teve a menor mudança de cor nos três intervalos. Após o clareamento, a cor em todos os espécimes voltou próxima ao baseline. As diferenças de cor entre o clareamento e o baseline foram inferiores a 3,43 para todos os grupos. Os resultados indicam que o dióxido de cloro é ligeiramente superior ao peróxido de hidrogênio no clareamento de resinas compostas, mantendo a cor próxima à escala do baseline.