A Glove-based Virtual Hand Rehabilitation System for Patients with Post-traumatic Hand Injuries.

Recent studies have shown that virtual gamified therapy can be a potential adjunct to conventional orthopedic rehabilitation. However, the off-the-shelf gaming consoles used for virtual rehabilitation pose several practical challenges in deploying them in clinical settings. In this paper, we present the design of a portable glove-based virtual hand rehabilitation system (RehabRelive Glove) that can be used at both clinics and homes for physiotherapy. We also evaluate the system's efficacy on patients with post-traumatic hand injuries. Thirty patients were randomly categorized into groups A (virtual rehabilitation) and B (conventional physiotherapy). Both groups received fifteen 25-minute sessions of respective therapy over three weeks. The wrist and finger joints' range of motion (ROM) and grip strength were measured every seven sessions to compare the efficacy. Group A showed about 1.5 times greater improvement in flexion/extension ROM of the wrist compared to Group B. While both groups improved finger ROM and grip strength with time, no significant difference was observed between the groups. The results suggest that the proposed virtual rehabilitation system effectively enables patients with hand injuries to recover ROM faster.

Pain and participation in social activities in people with relapsing remitting and progressive multiple sclerosis.

Background: Differences in pain between subtypes of multiple sclerosis are understudied. Objective: To compare the prevalence of pain, and the association between pain and: (a) pain interference and (b) social participation in people with relapsing-remitting multiple sclerosis and progressive multiple sclerosis. Methods: Participants completed the McGill Pain Questionnaire Short-Form-2, Pain Effects Scale and Ability to Participate in Social Roles and Activities-V2.0 questionnaires. We tested the association between multiple sclerosis subtype, pain severity, and pain interference/social participation using quantile regression. Results: Of 231 participants (relapsing-remitting multiple sclerosis: 161, progressive multiple sclerosis: 70), 82.3% were women. The prevalence of pain was 95.2%, of more than mild pain was 38.1%, and of pain-related limitations was 87%; there were no differences between multiple sclerosis subtypes. Compared to participants with relapsing-remitting multiple sclerosis, those with progressive multiple sclerosis reported higher pain interference (mean (standard deviation) Pain Effects Scale; progressive multiple sclerosis: 15[6.0] vs relapsing-remitting multiple sclerosis: 13[5], p = 0.039) and lower social participation (Ability to Participate in Social Roles and Activities T-scores 45[9.0] vs 48.3[8.9], p = 0.011). However, on multivariable analysis accounting for age, physical disability, mood/anxiety and fatigue, multiple sclerosis subtype was not associated with differences in pain interference or social participation. Conclusions: Pain was nearly ubiquitous. Over one-third of individuals with relapsing-remitting multiple sclerosis and progressive multiple sclerosis reported pronounced pain, although this did not differ by multiple sclerosis subtype.

Effect of N95 Filtering Facepiece Respirator on Venous Blood Carbon Dioxide Levels and Hemodynamic Changes in Health Care Workers.

Background: N95 filtering facepiece respirators (FFR) are used by health care workers for prevention of airborne infection, and its use has increased manifolds during COVID-19 pandemic. Prolonged use may result in carbon dioxide (CO2) accumulation, affect hemodynamics, and blood gas values. Although arterial blood gas values accurately measure the blood CO2 levels, venous blood gas values also show acceptable correlation. Aim: To evaluate the physiological impact of N95 FFRs on health care workers, including hemodynamic changes and venous blood levels of CO2 during a period of 6 h. Settings and Design: Prospective observational study in a tertiary care hospital. Methods: The study was conducted on 30 health care workers who performed routine duties while wearing N95 FFR. Venous blood gas values (CO2, pH, and bicarbonate) and vitals (respiratory rate, heart rate, blood pressure, and saturation) were noted at baseline, 2 (T2), and 6 h (T6) after wearing the mask. Discomfort level was also measured on a Visual Analogue Scale (VAS) of 1-10. Statistical Analysis: Repeated measures analysis was done using repeated measures ANOVA or Friedman's test. Group comparisons for continuously distributed data were made using independent sample "t" test or Wilcoxon test. Results and Conclusion: Hemodynamic and blood gas values did not change over time. The VAS for discomfort because of respirator use was 1.33 (1.42) at T2 and 2.77 (1.91) at T6. This was a significant increase in discomfort over time (P = 0.001). About 80% of participants experienced discomfort during this period. N95 FFR did not lead to significant alteration in hemodynamics or change in blood gas values after 6 h of continuous usage. However, discomfort significantly increased over time.

Current practice of Rapid Sequence Induction (RSI) in pediatric anesthesia: A survey from India.

Background and Aims: Rapid Sequence Induction (RSI) is an established technique to secure the airway in patients who are at risk of aspiration. The practice of RSI in the pediatric population is highly variable due to numerous patient factors. We conducted a survey to find the prevalent practices and adherence of anesthesiologists to the practice of RSI in different pediatric age groups and whether it differs with the experience of the anesthesiologist or the age of the child. Material and Methods: The survey was conducted among residents and consultants attending the pediatric national anesthesia conference. The questionnaire consisted of 17 questions on anesthesiologist's experience, adherence, conduct of pediatric RSI, and the reason for nonadherence. Results: The response rate was 75% (192/256). Anesthetists having less than 10 years of experience adhered to RSI more often as compared to respondents with more experience. Succinylcholine was the most commonly used muscle relaxant for induction, with use increasing in higher age groups. The application of cricoid pressure increased with increasing age groups. Anesthetists with >10 years of experience used cricoid pressure more often in age groups of <1 year (P < 0.05). In a scenario of intestinal obstruction, adherence to RSI was low in pediatrics as compared to adults, with 82% of respondents agreeing to this. Conclusion: This survey on the practice of RSI in the pediatric population demonstrates wide variation in the practice among individuals and the reasons for nonadherence as compared to adults. It highlights the need felt by almost all the participants for more research and protocol in the practice of pediatric RSI.

Analgesic efficacy of superficial versus deep serratus plane block for modified radical mastectomy under general anaesthesia: A randomised comparative study.

Background and Aims: Serratus anterior plane (SAP) blocks can be given either superficial or deep to the serratus anterior muscle to block the branches of intercostal nerves providing analgesia to the anterolateral chest wall. This prospective randomised comparative study aimed to compare the analgesic efficacy of superficial and deep SAP block in breast surgeries. Methods: Forty female patients scheduled to undergo elective modified radical mastectomy under general anaesthesia (GA) were randomly assigned to receive ultrasound guided SAP block with 30 ml 0.375% ropivacaine either superficial (group S, n = 20) or deep (group D, n = 20) to the serratus anterior muscle, before the induction of GA. The primary outcome was post operative fentanyl requirement over 24 hours and secondary outcomes were comparison of numerical rating scale (NRS) scores for pain, sensory block mapping, time to perform the block, number of needle attempts, etc. Results: The post operative 24-hour fentanyl requirement was comparable between group S and D (318.75 ± 80.65 versus 272.5 ± 80.25 µg, P = 0.07). NRS pain scores were comparable between the groups. Sensory block mapping done at various levels showed T3-T7 block in most of the patients with no difference between the groups. Block performance time (6.05 ± 3.27 versus 8.35 ± 3.26 minutes, P = 0.034) and number of needle attempts was significantly lesser in group D. Conclusion: There was no difference in analgesic efficacy when SAP block was given superficial or deep to serratus anterior muscle for modified radical mastectomies. However, deep SAP block required less time and number of attempts to perform than superficial technique.

Nalbuphine as an Intrathecal Adjuvant to 0.5% Hyperbaric Bupivacaine in Two Different Doses for Postoperative Analgesia After Abdominal Hysterectomy: A Prospective, Randomized, Double-Blind Control Study.

INTRODUCTION: Adding adjuvant drugs to intrathecal local anesthetics improves the quality and duration of the sensory blockade and prolongs postoperative analgesia. Intrathecal opioids are synergistic with local anesthetics, thereby intensifying the sensory block without increasing the sympathetic block. This study was designed to comparatively evaluate the two different dosages of nalbuphine as intrathecal adjuvants on subarachnoid block (SAB) characteristics of 0.5% hyperbaric bupivacaine. METHODS: A randomized, triple arm study was conducted on 60 adult female patients with American Society of Anesthesiologists physical status I and II, aged 30-60 years, scheduled for total abdominal hysterectomy under SAB. Patients were randomized into three groups: group I received 15 mg of 0.5% hyperbaric bupivacaine, group II received 15 mg of 0.5% hyperbaric bupivacaine with 1.6 mg of nalbuphine, and group III received 15 mg of 0.5% hyperbaric bupivacaine with 2.4 mg of nalbuphine. The primary outcome was the duration of analgesia, while secondary outcomes included onset, duration of sensory and motor block, maximum cephalic extension, and two dermatome segment regressions. RESULTS: The onset time of the sensory block was 3.2 ± 1.0 minutes, 3.5 ± 1.6 minutes, and 3.1 ± 1.1 minutes in groups I, II, and III, respectively. The onset time of the motor block was 8.5 ± 1.0 minutes, 8.5 ± 1.1 minutes, and 8.2 ± 1.1 minutes in groups I, II, and III, respectively. The onset of sensory and motor blocks was comparable among the three groups with no statistically significant difference (p > 0.05). The total duration of analgesia was 117.8 ± 23.3 minutes, 166.8 ± 27.8 minutes, and 181.8 ± 25.9 minutes in groups I, II, and III, respectively, with a statistically significant difference. Few incidences of manageable hypotension, but no incidences of bradycardia or respiratory insufficiency, occurred. Five patients of the control group shivered, which was managed well by tramadol 50 mg and ondansetron 4 mg. No patient suffered from pruritus, sedation, respiratory depression, nausea, and vomiting. CONCLUSION: The study concluded that intrathecal nalbuphine in a 1.6 mg dose is an effective adjuvant to 0.5% hyperbaric bupivacaine for SAB. It potentiated the SAB characteristics and enhanced the duration of analgesia with no effect on respiration. Nalbuphine in a dose of 2.4 mg did not offer any added advantage.

Sympathetic Blocks for Raynaud's Phenomena in Pediatric Rheumatological Disorders.

OBJECTIVE: Sympathetic blocks are invaluable to prevent morbidity from Raynaud's phenomenon (RP). RP may occur in children with rheumatological disorders and causes severe pain, discoloration of digits, gangrene, and auto-amputation. We describe the planning and execution of sympathectomy blocks in children with rheumatological disorders presenting with RP. METHODS: With upper-limb involvement, ultrasound-guided stellate ganglion block (USGB) was given with ropivacaine and clonidine. When all four limbs were involved, intrathecal block with bupivacaine and clonidine was also given. RESULTS: A total of 68 sympathectomy blocks were performed: 28 bilateral USGBs, two unilateral USGBs, and 10 intrathecal injections. Multiple interventions in a single day were frequently required. For safety, all USGBs were performed with an ultrasound with strict adherence to local anaesthetic volume was maintained, with periprocedure monitoring of 2-3 hours. All blocks were performed by an experienced specialist. All children reported immediate pain relief with prevention of major amputation. CONCLUSION: With meticulous planning, monitoring, and precautions, sympathectomy of limbs in pediatric rheumatological disorders with RP can be safely undertaken. Bilateral stellate ganglion block with ultrasound is safe in children, and clonidine is a useful adjunct for vasodilation and prolongation of the effect of sympathectomies in children.

Comparative evaluation of landmark technique and ultrasound-guided caudal epidural injection in pediatric population: A systematic review and meta-analysis.

BACKGROUND: Caudal block is a common regional anesthesia technique in pediatrics with landmark method predominantly being practiced. Ultrasound-guided technique provides real-time visualization of the structures and injection while performing caudal block. We performed this meta-analysis to determine the utility of ultrasound in caudal blocks in children over the landmark-based technique. METHODS: Randomized controlled trials comparing ultrasound-guided caudal blocks and landmark technique in pediatrics were searched from databases-PubMed, Embase, Scopus, and CENTRAL from inception until August 2020. The primary objective was success rate between the two techniques and secondary objectives included time to perform the block, first puncture success, and complications. RESULTS: Five trials with 904 participants were included for this meta-analysis. There was no difference in success rate between the two techniques (Risk ratio-1.07; 95% CI [0.97, 1.18]; p = .15). Time to perform the block was similar (Mean difference-8.88 s; 95% CI [-21.64, 39.40; p = .57) while first puncture success was higher with ultrasound-guided technique (Risk ratio-1.31; 95% CI [1.15, 1.49]; p = .0001). Complications like vascular puncture and needle misplacement were lower in the ultrasound group, and no serious complications were seen in any patient. Needle visualization and sacral canal distension were seen in 82% and 97.5% of the cases, respectively, in ultrasound group. CONCLUSION: Ultrasound-guided caudal injection does not improve the success rate or time to perform the block but results in higher first puncture success and lower incidence of complications compared to landmark technique.

The Role of Antibiotic Prophylaxis in Lichtenstein Repair of Primary Inguinal Hernia: A Prospective Double-Blind Randomized Placebo-Controlled Trial.

OBJECTIVE: The objective is to study the role of antibiotic prophylaxis, if any, in the prevention of wound infection after open mesh repair of primary inguinal hernias. MATERIALS AND METHODS: Patients coming to outpatient department for open mesh repair of inguinal hernia were randomized into the placebo group and antibiotic group, a total of 150 patients were enrolled in the study. Follow-up was done up to 1 month to look for any evidence of surgical site infection using the criteria of Centers for Disease Control on wound infection. RESULTS: Twelve patients in the antibiotic group and nine patients in the placebo group were found to have evidence of surgical site infection. This difference was found to be insignificant with P = 0.14. Three patients in the placebo group developed deep surgical site infection but on analysis, this difference was also found to be insignificant with P = 0.122.None of these patients required mesh removal. CONCLUSION: The result of the present study suggests that the use of prophylactic antibiotics during mesh repair of primary inguinal hernias does not give any extra protection from infections. Multicenter meta-analysis is required to give definite guidelines regarding the use of prophylactic antibiotics.

Sequential Supraclavicular Brachial Plexus and Stellate Ganglion Neurolysis for Upper Limb Pain in Metastatic Breast Cancer.

Neuropathic pain in cancer can result in severe debilitation to a patient with limited treatment options. Interventional modalities like nerve destruction can provide relief but at the expense of motor paralysis. Sympathetic pain is often an undiagnosed and undertreated condition that may accompany cases of chronic pain. We describe a case of severe neuropathic pain in brachial plexopathy in a middle-aged woman caused by metastatic breast cancer that was managed by chemical neurolysis of brachial plexus. Residual pain was treated by neurolysis of stellate ganglion due to the presence of sympathetic pain. This case report highlights the importance of the dual nature of pain and its management by chemical neurolysis in severe refractory neuropathic and sympathetic mediated pain.

Complementary and Alternative Modalities (CAM) for pain management in musculoskeletal diseases (MSDs).

Musculoskeletal diseases are a group of clinical conditions affecting the body's movement and remain a common source of pain affecting the quality of life. The aetio-pathological reasons for pain associated with musculoskeletal diseases can be varied and complex. Conventional medicine can treat or modify pain due to musculoskeletal diseases; however, these may be associated with some side effects and at times may not be able to relieve pain completely. These treatment modalities also have ceiling effects like doses of analgesics, the number of nerve blocks, etc. Complementary and Alternative Medicine (CAM) provides a supplementary, unconventional modality to alleviate discomfort and disability associated with these mostly chronic conditions to manage activities of daily living. These modalities have been variedly combined with conventional management for symptom control and thus improve day-to-day activities. We assess the role of commonly used CAM modalities in the management of pain arising from Musculoskeletal diseases.

Intradiscal Platelet-Rich Plasma Injection for Discogenic Low Back Pain and Correlation with Platelet Concentration: A Prospective Clinical Trial.

OBJECTIVE: Discogenic pain is common cause of low back ache and may result in significant morbidity. Platelet-rich plasma (PRP) is an upcoming regenerative therapy that has treatment potential for this condition. The objective of this study was to correlate platelet concentration in intradiscal PRP injection with improvement in low back pain and functional status at three and six months. DESIGN: Prospective single-arm interventional study. SETTING: Outpatient pain clinic and operation theater. SUBJECTS: Twenty-five patients with discogenic pain diagnosed by clinical means and imaging with confirmation by provocative discography were recruited. METHODS: The patients received PRP injection at a single or multiple disc levels. Preprocedure numerical rating scale (NRS) pain scores and Oswestry Disability Index (ODI) scores were calculated. Platelet counts of patients and PRP samples were measured. At three and six months postprocedure, NRS and ODI scores were measured, and improvement in these scores was correlated with platelet concentrations in the PRP sample. RESULTS: Twenty patients completed the study. The improvement in NRS and ODI scores positively correlated with platelet concentrations in the PRP sample. We determined the correlation coefficient (r) of platelet concentrations with a reduction in NRS at three months (r = 0.65) and six months (r = 0.73) and in ODI score at three months (r = 0.72) and six months (r = 0.7). CONCLUSIONS: This study supports the use of intradiscal PRP for treatment of discogenic pain with preferably higher platelet counts to elicit a favorable response.

Analgesic efficacy and spread of local anesthetic in ultrasound-guided paravertebral, pectoralis II, and serratus anterior plane block for breast surgeries: A randomized controlled trial.

BACKGROUND: Thoracic paravertebral block (TPVB) has become the gold standard to provide postoperative analgesia in breast surgery. Recently, ultrasound-guided (USG) pectoralis (PECS) block and serratus anterior plane (SAP) block have been described as an alternative to TPVB. The objectives were to compare TPVB, PECS, and SAP block in terms of analgesic efficacy and the spread of local anesthetic by ultrasound imaging, correlating it with the sensory blockade. MATERIALS AND METHODS: Prospective randomized interventional study conducted in 45 ASA grades I-II patients scheduled for the elective breast surgery. Patients were randomly allocated into three groups, i.e., Gr.1 (USG -TPVB) (ropivacaine 0.375% 20 ml), Gr.2 (USG-PECS II) block (ropivacaine 0.375% 30 ml), and Gr.3 (USG-SAP) (ropivacaine 0.375% 30 ml). Spread of the local anesthetics was seen with ultrasound imaging. Onset of sensory blockade, postoperative fentanyl consumption, and pain scores was measured. RESULTS: TPVB and SAP group had comparatively higher spread and sensory block compared to PECS group. Postoperative fentanyl requirement (mean ± SD) was 428.33 ± 243.1 µg, 644.67 ± 260.15 µg, and 415 ± 182.44 µg in the TPVB group, PECS II group, and SAP group, respectively. SAP group had significantly lesser requirement than PECS II group (P = 0.028) but similar requirement as in TPVB group (P = 1.0). Pain scores were not significantly different among the group in the postoperative period. CONCLUSION: TPVB and SAP group result in a greater spread of the drug and provide equivalent analgesia and are superior to the PECS II block in providing analgesia for breast surgeries. SAP block is easier to perform than TPVB with lesser chances of complications and results in faster onset.