Ultrasound versus Nerve Stimulator Guided Obturator Nerve Block in Patients Undergoing Transurethral Resection of Bladder Tumor.

BACKGROUND: Urinary bladder cancer is more common in geriatric population. Transurethral resection of bladder tumor remains the mainstay of treatment. It is usually performed under subarachnoid block. However, obturator nerve is spared in subarachnoid block that can produce adductor jerk, which is associated with bladder injury, rupture, incomplete resection of tumor and hematoma. To overcome this jerk, selective obturator nerve block is commonly performed. Thus, we conducted this study to compare the efficacy of ultrasound and nerve stimulator-guided techniques for obturator nerve block. METHODS: This is a prospective, comparative study conducted at a tertiary care hospital in Nepal. Sixty patients, scheduled to undergo Transurethral Resection of Bladder Tumor for lateral and posterolateral wall bladder cancer under subarachnoid block were enrolled and divided into two group having thirty patients in each groups. Group I received 15 ml of 0.25% Bupivacaine to block obturator nerve by using peripheral nerve stimulator. Group II received the same amount of Bupivacaine to block obturator nerve under ultrasound guidance. We evaluated the success of the block, ease of the procedure and complications. RESULTS: The adductor reflex was present in 23.33% of cases with nerve stimulator guided obturator nerve block, whereas, it was16.66% in ultrasound guided technique (p=0.75). The success rate of obturator nerve block was 76.66% in nerve stimulator guided technique, whereas 83.33% in ultrasound guided technique (p= 0.21). 83.33% of obturator nerve block was found to be easy in nerve stimulator guided technique, whereas 66.66 % in ultrasound guided technique (p = 0.14). There were no major complications noted. CONCLUSIONS: The findings of this study conclude that both ultrasound and nerve stimulator guided techniques equally abolished the adductor reflexes. Both techniques are easy to perform and safe.

Clinical Characteristics and outcome analysis of SARS-CoV-2 patients admitted to different Critical Care Units in Nepal.

BACKGROUND: The clinical presentation, biochemical characteristics, and outcomes of patients infected with SARS-CoV-2 can vary in different populations. The purpose of the study is to assess the clinical presentation and identify predictors of mortality among patients with severe acute respiratory distress syndrome admitted to different critical care units in Nepal. METHODS: An observational study was conducted among the confirmed SARS-CoV-2 patients admitted to different critical care units in seven provinces of Nepal. Retrospective data was collected for the period of three months (April 14, 2021 to July 15, 2021) in relation to the peak of the second wave of COVID-19 pandemic in Nepal. Clinical, biochemical and mortality data were collected from the admitted patients of different critical care units. Univariate logistic regression analysis was done among the selected variables at 5% significance. Final predictor variables were identified after multiple regression analysis. RESULTS: Out of total of 646 patients admitted to critical care units of different provinces of Nepal, there was a male predominance 420 (65%). A total of 232(35.91 %) patients were non-survivors with the majority of mortality occurring in patients > 50 years of age. Cough (72.3 %), shortness of breath (70.9%) and fever (56 %) were the most common presenting clinical features. Increasing age, presence of comorbidity, critical COVID-19 cases, respiratory rate, temperature, serum urea and alanine aminotransferase were identified as predictors of mortality after multiple regression analysis. CONCLUSIONS: Approximately 36 % of the confirmed SARS-CoV-2 patient admitted to critical care units did not survive. There was a male preponderance with most casualties occurring in patients more than 50 years of age. Cough, shortness of breath and fever were the most common presenting features. After multiple regression analysis of the identified clinical and biochemical factors, age, presence of comorbidity, respiratory rate, temperature, severity grade as per the World Health Organization classification, serum urea and alanine aminotransferase were identified as the predictors of mortality.

Subarachnoid Block in Prone Position for lower limb surgery.

Subarachnoid block is a safe and effective regional anesthesia technique. It is usually carried out in sitting or lateral position but it can also be performed in prone position. Here we report two cases of flame burn over bilateral gluteal region extending to the posterior and lateral aspect of both thighs, who were planned for debridement and split skin grafting. Both patients had difficulty in siting and lying on either side of lateral position. We had administered subarachnoid block in prone position taking into consideration of patient's comfort and the nature of the procedure. Both patients remained hemodynamically stable throughout the procedure and their post-operative periods were uneventful. Keywords: Burn; prone position; subarachnoid block.

Evaluating the influence of temperature on proanthocyanidin biosynthesis in developing grape berries (Vitis vinifera L.).

The variability in grape (Vitis vinifera L.) proanthocyanidin content is largely attributable to viticultural and environmental conditions. However, the particular effect temperature has on proanthocyanidin biosynthesis is poorly understood. The aim of the present study was to ascertain the magnitude of the effect of temperature on proanthocyanidin biosynthesis in Cabernet Sauvignon grape berries cultured in vitro. In addition, the effects of temperature on global gene transcription were evaluated, and the microarray data were later validated by quantitative real-time PCR (qPCR). The grape berries used in this research were sampled 3-4 weeks after full bloom and cultured in vitro either under a low (20 °C) or high (30 °C) temperature treatment for 15 days (d) with sampling occurring every five days. The proanthocyanidin content was higher in the skin and seeds of grape berries cultured at a low temperature compared with a high temperature. However, overall proanthocyanidin composition between the treatments was not significantly affected. Microarray data revealed a total of 1298 genes with ≥ 3.5-fold expression differences under high temperature conditions. High temperature also inhibited the expression level of key genes involved in proanthocyanidin biosynthesis, anthocyanidin reductase (ANR) and leucoanthocyanidin reductase-1 (LAR-1) within the berry skin. However, the transcriptomic accumulation of transcription factors, such as VvMybPAs, VvMyb5a and VvMyb5b, was barely influenced during the peak expression of ANR and LAR-1. Thus, the present study revealed that temperature has a significant effect on proanthocyanidin biosynthesis in grape during berry development through enhancing the expression of key biosynthetic genes.

Comparison of Analgesic Efficacy of Ultrasound Guided Subcostal Transversus Abdominis Plane Block with Port Site Infiltration Following Laparoscopic Cholecystectomy.

BACKGROUND: Patients have significant pain following laparoscopic cholecystectomy. Several modalities have been used to manage this pain. Subcostal transversus abdominis plane (TAP) block is one of the components of multimodal analgesia and has been described as an effective technique for postoperative pain management. This study compares the impact of subcostal TAP block with port site local infiltration following laparoscopic cholecystectomy for postoperative pain and opioid consumption. METHODS: This is a prospective, randomized, interventional study. Sixty patients were enrolled and divided into two groups having 30 patients in each group. Group A received bilateral ultrasound guided subcostal TAP block with 10 mL of 0.25% bupivacaine after the completion of surgery. Group B received similar amount of local anesthetic infiltrated over all the laparoscopic port sites. Pain at rest and on movement was assessed using VAS scale in post-operative period at 0 min, 30 min, 2, 4, 6, 12 and 24 hours. Time of first rescue analgesic requirement and total opioid consumption over 24 hours were recorded. RESULTS: Patients receiving Subcostal TAP block had reduced postoperative pain as compared to port site infiltration and statistically significantly in first two hours after surgery. The 24 hours opioids consumption was significantly less (125mg ±25.42 versus 175mg ±25.42, p <0.001) in Subcostal TAP block group. Time for request of first rescue analgesic was prolonged in patients receiving the Subcostal TAP block (3.20±0.84 hours vs 1.70±0.65 hours, p <0.001). CONCLUSIONS: Ultrasound guided bilateral Subcostal TAP block provides effective post-operative analgesia and reduces opioid consumption in patients undergoing laparoscopic cholecystectomy.

Grade III bone cement implantation syndrome in malignant lung cancer patient: a case report.

BACKGROUND: Bone cement implantation syndrome is a known complication causing mortality during perioperative period particularly in patients with malignancy. With rise in aging population with malignancy in low income country, the syndrome is more likely to be encountered. CASE PRESENTATION: We present a case of 66 years old male patient with metastatic bronchogenic carcinoma of lung with pathological proximal femur fracture of left hip that underwent a cemented endoprosthesis under combined spinal epidural anesthesia who succumbed to intraoperative mortality due to grade III bone cement implantation syndrome even after aggressive fluid resuscitation, vasopressor use, and mechanical ventilation. CONCLUSIONS: Careful identification of risk factors with aggressive vigilance and intervention in part of surgeons and anesthesia both during intraoperative and postoperative period can mitigate the risk of bone cement implantation syndrome.

Light quality affects flavonoid biosynthesis in young berries of Cabernet Sauvignon grape.

Biosynthesis of phenolic compounds is known to be sensitive to light environments, which reflects the possible role of these compounds for photoprotection in plants. Herein, the effects of UV and visible light on biosynthesis of flavonoids was investigated, i.e., proanthocyanidins (PAs) and flavonols, in young berry skins of a red-wine grape, Vitis vinifera cv. Cabernet Sauvignon. Shading with light-proof boxes from the flowering stage until 49 days after treatment (DAT) partially decreased PA concentrations, and completely decreased flavonol concentrations in the berry skins. Shading decreased the transcript abundance of a flavonol-related gene more remarkably than those of PA-related genes. In addition, light exclusion influenced the composition of PAs, such as the decrease in the proportion of trihydroxylated subunits and the mean degree of polymerization (mDP) within PAs. However, solar UV exclusion did not affect the concentration and composition of PAs, whereas this exclusion remarkably decreased the flavonol concentration. Consistently, UV exclusion did not influence the transcript levels of PA-related genes, whereas it dramatically decreased that of flavonol-related genes. These findings indicated a different light regulation of the biosynthesis of these flavonoids in young berry skins of wine grape. Visible light primarily induces biosynthesis of PAs and affects their composition, whereas UV light specifically induces biosynthesis of flavonols. Distinct roles of members of a MYB transcription factor family for light regulation of flavonoid biosynthesis were proposed.