Association of Chest Pain with Rate Pressure Product and ST-segment Changes after Sub Arachnoid Block in Caesarean Section.

When healthy women undergo caesarean section (CS) under sub arachnoid anaesthesia, transient electrocardiographic changes, such as ST-segment depression and T-wave abnormalities, are observed. During an elective caesarean section under sub arachnoid anaesthesia, about one-third of healthy parturient experience chest pain and ECG changes suggestive of myocardial ischemia. To assess the ST-segment and Rate Pressure Product changes with chest pain in patients with elective caesarean section under subarachnoid block. The Department of Anesthesia, Analgesia and Intensive Care Medicine at Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh was the site of this prospective observational study. The study included 86 healthy women between the ages of 20 and 35 who needed an elective caesarean section under a single shot sub arachnoid block and who visited the Department of Anesthesia, Analgesia, and Intensive Care Medicine at BSMMU in Shahbagh, Dhaka from January 2019 to June 2019. In comparison to the no chest pain group, ST-segment changes among the chest pain group at delivery, 5 minute, 10 minute after delivery and at the end of the surgery were highly significant (p=0.001). Comparatively, Rate Pressure Product changes were found to be significantly higher in the group with chest pain than in the group without chest pain (p=0.001). It is concluded that there is a substantial association of chest pain with rate pressure product and ST-segment changes after subarachroid block in caesarean section.

Dexmedetomidine as an Adjuvant to Bupivacaine in Caudal Analgesia in Children Undergoing Infra-Umbilical Surgery.

When performing infra-umbilical procedures, caudal epidural analgesia with bupivacaine is frequently used to provide both intra- and post-operative analgesia. Dexmedetomidine, an alpha 2 agonistsare extensively used in neuraxial blocks and peripheral nerve blocks to prolong the action of bupivacaine. To find out the effects of dexmedetomidine as an adjuvant to bupivacaine for caudal analgesia in children undergoing infra-umbilical surgery. This was a randomized, controlled double-blinded prospective observational study and was performed from July 2019 to December 2019. A total of 60 (Sixty) patients with different infra-umbilical surgical problems underwent different procedure under caudal anaesthesia in different operation theatre in Bangabandhu Sheikh Mujib Medical University, Dhaka were enrolled in this study. Elaborate personal history, meticulous clinical examinations and relevant laboratory investigations was done. Post-operative adverse effects also were monitored. All information from history of illness, clinical, laboratory findings, duration of analgesia and post-operative adverse effects were recorded in a preformed data sheet (Appendix-I) and statistical analysis was done by SPSS 22.0. Mean age of the children in Group A (dexmedetomidine + bupivacaine) was 5.50±2.61 years and in Group B (bupivacaine) was 5.66±2.75. Mean weight of the children in Group A was 19.22±8.58 kg and in Group B was 19.70±8.94 kg in this study. Mean duration of anaesthesia was 27.5±6.5 minute in Group A and 28.5±5.5 minute in Group B. The mean duration of analgesia was 4.32±0.54 hours for Group A and 2.12±0.32 hours in Group B. In Group A, 46.7% patients required 1 and 3.3% required 2 rescue analgesic but in Group B, 43.3% patients required single rescue analgesic and 33.3% required two rescue analgesics (p<0.05). In Group A, 6.7% patients had nausea/ vomiting and in Group B, 16.7% patients had nausea/ vomiting (p>0.05). It can be concluded that dexmedetomidine with bupivacaine for caudal analgesia in infra-umbilical surgery significantly prolongs the duration of postoperative analgesia when compared to bupivacaine alone without any side-effects.

Predicting Difficult Intubation by using Modified Mallampati (MMT) with or without Thyromental Height Test (TMHT).

Failed Tracheal Intubation with Subsequent inability to maintain an open airway and adequate oxygenation is the most frequent cause of brain damage or death during anesthesia. Recognizing before anesthesia the potential for difficult intubation allows time for optimal preparation. Proper Selection of equipment and techniques is needed to avoid unwanted situation. To find out difficulties associated with endotracheal intubation using Modified Mallampati Test (MMT) combined with Thyromental Height Test (TMHT) and MMT without TMHT. This prospective observational study was conducted at the Department of Anesthesia in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from April 2018 to September 2018. Two hundred two patients with different surgical procedures under general anaesthesia in different operation theaters of BSMMU, Dhaka were selected as study population. After taking written consents from each patient or his/her attendant elaborate history of illness, meticulous clinical examinations were performed and relevant laboratory investigations were done. All information was recorded in a preformed data sheet and statistical analysis was done by SPSS-22.0. Mean age ±SD of the study subjects was 42.49±14.29 years in MMT with TMHT group and 43.40±15.39 years in MMT without TMHT group. Females were enrolled more than males in both the groups. BMI was 28.75±3.59kg/m² in MMT with TMHT group and 29.44±8.64kg/m² in MMT without TMHT group. There were no significant differences in age, gender and BMI between the groups. Sensitivity, specificity, PPV, NPV and accuracy were 100.0%, 96.0%, 96.2%, 100.0% and 98.0% respectively of MMT with TMHT in predicting intubation difficulty. Sensitivity, specificity, PPV, NPV and accuracy were 100.0%, 96.0%, 96.2%, 100.0% and 98.0% respectively of MMT only in predicting intubation difficulty. MMT combined with TMHT is a better predictor of intubation difficulty than MMT alone.

Association of Modified Sequential Organ Failure Assessment (MSOFA) Score and C-reactive protein (CRP) With the Outcome of Patients under Mechanical Ventilation.

Different scoring systems has been discovered in medical practice, more specifically for ICU treatment, are designed to objectively quantify physiologic derangements and comorbid conditions for estimating mortality, length of stay and ICU resource use. This observational and descriptive study was carried out in the ICU, BSMMU, Dhaka, during March 2014 to May 2016, to determine the association of MSOFA score, CRP level with the outcome of patients on mechanical ventilation as well as compare the MSOFA and CRP combined with MSOFA alone. For this purpose, a total of 60 critically ill patients admitted in the above hospital were included in this study. Patients with an ICU stay of less than 48 hours, readmissions not considered, known case of neuromuscular disease, connective tissue disorder, renal disease and pregnancy and Patients refused to give written consent were excluded from the study. Patients who had MSOFA ≥7, their mean duration of ICU stay were 10.9±6.7 days and mean duration of mechanical ventilation 7.63±5.2 days. Patients who had CRP >11mg/L, their mean duration of ICU stay was 10.8±7.2 days and mean duration of mechanical ventilation was 7.35±5.1 days. Patients who had MSOFA score ≥7 and CRP ≥11mg/L with mean duration of ICU stay was 10.82±7.2 days and mean duration of mechanical ventilation was 7.12±5.2 days. 69.2% patients were CRP status positive (≥11) in death group and 33.3% had alive group. 92.3% patients were Positive (CRP ≥7 or MSOFA ≥11) in death group and 14.3% had alive group. MSOFA identified true positive 32 cases for death, false positive 5 cases, false negative 7 cases and true negative 16 cases confirmed by patient's outcome. CRP level identified true positive 27 cases for death, false positive 7 cases, false negative 12 cases and true negative 14 cases confirmed by patients outcome. Combined (CRP ≥11mg/L and MSOFA score ≥7) identified true positive 33 cases for death, false positive 1 case, false negative 6 cases and true negative 20 cases confirmed by patient's outcome. We concluded that there is a positive correlation (r=0.323; p=0.014) between CRP status with MSOFA score, positive correlation (r=0.402; p=0.002) between MSOFA score with MSOFA score and CRP combined and a positive correlation (r=0.999; p=0.001) between CRP level with MSOFA score and CRP combined.

Demographic and Clinical Profile of COVID-19 ICU Patients of Bangabandhu Sheikh Mujib Medical University, Bangladesh.

Corona viruses are a group of RNA viruses that cause infection in humans and animals. In human Corona viruses cause respiratory tract infections ranging from mild to critical illness. Corona virus disease 2019 (COVID-19) is caused by strain of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). The disease was first identified in Wuhan city, of China, in December 2019 and since spread all around the world. In Bangladesh first case has been declared by Institute of Epidemiology, Disease Control and Research (IEDCR) in 8th March, 2020 and first death on 18th march in an ICU and by 13th December total 489,178 cases and 7,020 deaths occurred in this country. The main objective of this study was to determine the Demographic and Clinical Profile of COVID-19 ICU patients in Bangladesh. This retrospective descriptive study on clinical profile along with short term treatment outcomes of COVID-19 patients conducted from COVID-19 dedicated Intensive care unit of Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh during July 2020 to November 2020. Total 300 ICU patients was included in this study. The age range of the patients was from 15 to 91 years. The highest percentage of patients about 49.00%, which was 147 patients were belonged to 61-75 years age group. The patients mean age was 62.80 years. Regarding gender distribution, among those 300 patients; 77.00% which is 231 were male and only 23.00% which is 69 were female. Patients admitted with symptoms like, respiratory distress/shortness of breath (100.00%), persistent worsening cough (60.00%), fatigue (55.00%) and fever (40.00%). Patients were also present with sore throat (35.00%), rhinorrhea (30.00%), altered mental status (20.00%), diarrhoea (10.00%) and chest pain (5.00%). Regarding co-morbidities, around half of the patients were suffering from Diabetes (60.22%) and Hypertension (53.44%). Significant amount of patients were also suffering from chronic obstructive pulmonary disease (27.00%) and bronchial asthma (16.78%). Ischemic heart disease was (10.33%), chronic kidney disease (10.89%), hypothyroidism (9.78%) and multiple co-morbidities (15.12%) at the time of admission. Mortality rate in this case were 71.00% and most of the death cases were in between 61 to 75 years of age group (40.00%). After improvement 27.00% patients were transferred to cabin for further management. We could discharge to home directly only 2.00% of patients.

National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI).

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Nitrous Oxide versus Medical Air Using in General Anaesthesia During Laparoscopic Cholecystectomy: A Comparative Study.

This study was designed to observe the haemodynamic changes, recovery status and cost effectiveness during anaesthesia in laparoscopic cholecystectomy with medical air in comparison to anaesthesia with nitrous oxide associated with maintain of adequate analgesia and was conducted in the department of Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2017 to June 2017. Nitrous oxide is popularly using as an analgesic in current balanced general anesthesia in addition carrier agent for anesthetic. Intraoperative pain intensity depends on many variables including, type of surgery, surgical stimulation and surgical incision. It is difficult to measure intraoperative pain properly under general anesthesia therefore anesthetist depends on the surrogate marker of inadequate analgesia like raised heart rate, blood pressure, sweating and lacrimation. However, unfortunately, these parameters may changes in same direction with light plane of anesthesia, hypercarbia and ongoing procedural status of the patient.

Role of Oral Clonidine Premedication on Intra-operative Haemodynamics and PONV in Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy is a gold standard surgical procedure for gallbladder operation. It causes altered haemodynamic responses due to pneumoperitoneum and surgical procedure also causes high incidence of postoperative nausea &vomiting. Clonidine has been shown to reduce intraoperative haemodynamic instability. This randomized prospective single blind clinical study was designed to evaluate the efficacy of oral clonidine premedication for attenuation of haemodynamic responses associated with pneumoperitoneum & also reduce the incidence of postoperative nausea & vomiting and carried out in the department of Anaesthesia Analgesia and Intensive care Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2010 to June 2010. Sixty adult patients of ASA physical status I & II scheduled for elective laparoscopic cholecystecomy were recruited for a prospective randomized single blind study. They were selected randomized into two equal groups, thirty in each group. Group A received no premedication & Group B (Clonidine) received clonidine (100µgm) orally 60 minutes before induction of anaesthesia. Pulse rate, mean arterial pressure were recorded prior to induction, 2 minutes after endotracheal intubation, before pneumoperitoneum, 10 minutes & 20 minutes after pneumoperitoneum, 10 minutes after release of carbon dioxide & 10 minutes after extubation. Patients in Group B (Clonidine) maintained greater haemodynamic stability intraoperatively compare to Group A after intubation, during pneumoperitoneum and also extubation. Pulse rate & mean arterial pressure significantly varies in Group A compare with Group B (Clonidine) at different times of intraoperative period (p<0.05). Postoperative nausea & vomiting was significantly less in Group B (Clonidine). Premedication with oral clonidine attenuates the haemodynamic responses produced by pneumoperitoneum during laparoscopic cholecystectomy and also significantly nausea and vomiting, results better patient satisfaction and cost effective.

Assessment of Difficulties Associated with Endotracheal Intubation using Modified Mallampati and Upper Lip Bite Test.

This study was aimed at finding the parameters for prediction of difficulty in endotracheal intubation, that are easy to examine and that could better predict difficulty. The current observational prospective, cross sectional study was conducted in the department of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from March 2015 to September 2015 comprising 180 patient of both sexes requiring endotracheal intubation were arranged into two groups, Group A: Modified Mallampati test Group and Group B: Modified Mallampati & upper lip bite test group (combined) Assessment of difficulty in intubation was done by Cormack & Lehane direct Laryngoscopic grading. Outcome was measured as no difficulty or difficulty in intubation. In Group A 33 cases were true positive, 15 false negative, 26 false positive, 16 true negative. In Group B 53 cases were true positive, 1 false positive, 8 false negative, 28 true negative. The validity tests for Group A for evaluation of difficult intubation were indicated by sensitivity 55.9%, Specificity 51.6%, Accuracy 54.41%, Positive predictive value 68.8% and Negative predictive value 38.1%. The values for Group-B were 86.9%, 96.6%, 90.0%, 98.1% and 77.8% respectively. Combined modified Mallampati & Upper Lip Bite Test has definite value in the diagnosis of difficulty in intubation and can be regarded as sensitive & specific test for operative discrimination of the patient.

Prolonged analgesia by adding midazolam and hyperbaric bupivacaine in subarachnoid block for lower uterine caesarian section.

Antinociceptive effect and safety of sub-arachnoid (SAB) midazolam is well established in animals and human beings. In this randomized, prospective placebo control clinical study, we investigated the addition of 2.5mg midazolam to bupivacaine on the quality of surgical anaesthesia and duration of first analgesic in the post operative period after lower uterine caesarean section (LUCS). Sixty ASA I or II pregnant women scheduled for elective lower uterine caesarean section were selected for the study. The patients were randomly allocated to receive 2ml of 0.5% hyperbaric bupivacaine with either 0.5ml of 5% dextrose in aqua or 2.5 mg (0.5ml) midazolam. The duration of first analgesic demand, quality of anaesthesia, haemodynamic changes and neonatal condition were assessed. The duration of analgesia (the time interval in minutes between the sub-arachnoid injection and the first analgesic demand by the patient) was significantly longer in the Group II than Group I (197min vs. 112min; p<0.001). The quality of surgical anaesthesia was excellent or good throughout the surgical procedure in 90% (n = 27) of the patients in Group II (p = 0.01). Systolic Blood pressure was significantly lower in the group I at 10 min and 20 min after administration of SAB than group II (p = 0.005 and p = 0.007) but comparable at other times. Sedation level, Apgar score was comparable in both groups. No neurological deficit or other significant adverse effects were recorded. The addition of midazolam with hyperbaric low dose bupivacaine in SAB significantly improves the quality of surgical anaesthesia and prolongs the duration of analgesia without any adverse effects.

Intrathecal neostigmine for postoperatrive analgesia in caesarean section.

This study was done for intrathecal adjuncts often are used to enhance small dose spinal bupivacaine anaesthesia. We designed this study to evaluate the postoperative analgesic efficacy and safety of intrathecal neostigmine. A randomized, double-blind prospective study was conducted in 90 healthy term pregnant patients scheduled to undergoing elective caesarean section using spinal anaesthesia. Women were administered 12.5 mg bupivacaine alone or with 75 microgram and 150 microgram of neostigmine as intrathecal drug. Parametric data were analyzed using ANOVA. Chi-square test was used to analyze the incidence data. Neostigmine significantly increased the duration sensory and motor block (p<0.05) and the time until for achieving discharge criteria. The addition of neostigmine produced dose-dependent nausea and vomiting and had no significant effect on haemodynamic or respiratory parameters. Addition of neostigmine to intrathecal bupivacaine extends the duration of postoperative analgesia with fewer side-effects without adverse effects on fetus following caesarean section.

Hard x-ray correlation analysis as a diagnostic tool for the measurement of magnetic turbulence in tokamaks.

A diagnostic has been developed for the measurement and characterization of the magnetic turbulence occurring in the core region of a tokamak. A specially shielded detector looking in the tangential direction has been employed to measure the thin target bremsstrahlung from the core plasma. The thick target bremsstrahlung from the limiter is also recorded at the same time. Auto- and cross-correlation analyses have been shown to yield, respectively, the stochasticity of the magnetic fluctuations in the core region and the consequent diffusion coefficient of the nonthermal electrons. The measured stochasticity bears a relationship with the diffusion coefficient. Data obtained from internal magnetic probes corroborate the above trend but the hard x-ray measurement data are shown to be more reliable than those obtained from magnetic probes.

Psychosocial adjustment of patients and caregivers prior to allogeneic bone marrow transplantation.

There are many studies that examine the psychosocial adjustment of survivors of bone marrow transplantation (BMT). On the other hand, there are relatively few studies that examine the psychosocial adjustment of patients prior to BMT, and even fewer that focus on the psychosocial adjustment of the patient's caregiver. The purpose of the present study was to assess performance status and psychosocial adjustment to illness, mood and stress response of patients and caregivers prior to admission for allogeneic BMT. Forty patients and their 39 caregivers were assessed using standardized measures. One-fourth of the patients reported clinical levels of psychosocial maladjustment on the Psychosocial Adjustment to Illness Scale and had greater adjustment problems than BMT survivors. Approximately one-third (35%) and one-quarter (23%) of the patients reported significant symptoms of intrusive and avoidance stress responses, respectively on the Impact of Events Scale. Caregivers reported more impairments in family relationships than patients, but overall reported similar distress to that of patients. Information about the pre-BMT process appears to be critical to understanding the psychosocial impact that BMT can have on patients and their caregivers.

You're never too old: a cancer education and risk reduction program for the elderly.

BACKGROUND: Although age is the most significant risk factor for cancer, older adults are less likely to be informed about and to follow through with screening procedures. METHODS: The University of Chicago Cancer Research Center, working in collaboration with health educators and city elderly organizations, developed a carefully scripted, hour-long presentation on cancer awareness and screening, designed specifically for older adults. The program was designed to be delivered in the community by trained graduate students. Pre-post-program surveys were used to evaluate the program's effectiveness in increasing cancer awareness. RESULTS: The presentation was delivered 40 times at Chicago nutrition sites, regional senior centers, retirement homes, and community clinics, reaching close to 1,000 individuals. Responses to revised surveys showed improvements of an average of 22 (ranging from one to 41) percentage points per question. CONCLUSIONS: This program gives older adults the basic knowledge and tools they need to take more active roles in their health care, follow healthier lifestyles, and reduce cancer risk.

Study of cohort-specific consent and patient control in phase I cancer trials.

PURPOSE: To address the challenging ethical dilemmas created from the participation of advanced cancer patients in phase I trials, we assessed the feasibility of a clinical trial design that uses an interactive informed consent process in which patient-subjects can choose to become directly involved in decisions of dose escalation. PATIENTS AND METHODS: Subjects were advanced cancer patients in the Hematology/Oncology Clinics at the University of Chicago who were eligible to participate in a phase I trial in which they underwent a three-step informed consent process that used cohort-specific consent and allowed them the option to choose their own doses of the chemotherapeutic agents under study, vinorelbine (NVB) and paclitaxel (TAX), within predetermined limits. NVB and TAX were administered in conventional 21- to 28-day cycles for two cycles while on study. Dose escalation occurred when a patient-subject chose a higher untested dose after they received information on all previously assessable patient-subjects. In addition to the phase I trial itself, a survey that consisted of structured interviews, which sought to evaluate patients' experiences with the interactive subject-choice phase I trial design and consent process, was conducted with participating subjects. The phase I trial itself sought to determine the associated toxicities of the agents under study. The survey results were compared with a similar survey of a matched control population of subjects who participated in other concurrently active conventional phase I trials at our institution. RESULTS: Twenty-nine patient-subjects participated in the phase I trial, with 24 who agreed to and completed the survey interviews. Seventy-six percent of patient-subjects opted to choose their dose of the agents under study, and 28% chose the highest available doses. More than half of the patient-subjects (56%) felt some degree of comfort in being asked to choose their dose of chemotherapy, with 53% stating that being asked to choose their dose made them feel in control, fully informed, or content. However, there were no statistically significant improvements in objective measures of the informed consent process, which included surveyed subjects' stated understanding of either provided information about phase I trials and alternatives to trial participation or of the research purpose of phase I trials. By making choices, the group of patients in the interactive subject choice trial changed the size of the dose cohorts and modified the process of dose escalation in this phase I study. CONCLUSION: Although complex, our innovative phase I trial design is feasible. In addition to the use of cohort-specific consent, the trial design may reduce the magnitude of many of the commonly recognized ethical dilemmas associated with this form of clinical research, which include difficulties with information provision and the understanding of possible risks and benefits of phase I trial participation, through direct subject involvement in research decision making by otherwise potentially vulnerable cancer patients.

Novel and frequent mutations of hepatitis B virus coincide with a major histocompatibility complex class I-restricted T-cell epitope of the surface antigen.

We examined the full-length hepatitis B virus (HBV) envelope (surface antigen or HBV small surface antigen [HBsAg]) sequences of 12 different liver samples from 10 different hepatoma-containing chronic carriers. Surprisingly, novel and frequent mutations occurred predominantly at amino acids 40 and 47 of HBsAg, in addition to within a known protective B-cell epitope (so-called group a determinant of HBsAg 124-148). Approximately 58% of chronic carriers contain mutations at the group a determinant. The mutation frequency at the hotspot codons 40 and 47 is approximately 83%, 1 order of magnitude higher than at the known polymorphic sites of subtype-specific determinants at codons 122 and 160, which is approximately 4%. This new mutational domain is found to coincide with a major histocompatibility complex class I-restricted T-cell epitope. The potential biological significance of this novel mutation in the immunopathogenesis of HBV chronic carriers is discussed.

Nurse satisfaction with work in rural hospitals.

Little is written about retention and recruitment of nurses in small rural hospitals. The authors present findings of a nursing study that identified factors that encouraged and deterred nurses to practice in the rural environment.