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.

Rhinocerebral zygomycosis in Pakistan: clinical spectrum, management, and outcome.

OBJECTIVE: To study the disease spectrum and salient management features of 36 patients with histopathologically-confirmed rhinocerebral zygomycosis seen at our academic center over a 16-year period. METHODS: Retrospective review of patients admitted to the Aga Khan University Hospital in Karachi, Pakistan from January 1991 to December 2006 with histopathologically-confirmed zygomycosis of the head and neck. RESULTS: Mean patient age was 40 +/- 5.0 years (range, 34-63 years), and 23 (64%) patients were male. Thirty-two (89%) patients were referred from clinical services other than otolaryngology. Underlying predisposing conditions included diabetes mellitus (21 patients), haematologic diseases (9), and renal failure (6). Twenty (55%) patients had limited sinonasal disease, ten (28%) had orbital involvement, and six (17%) had intracranial extension. All patients underwent rigid nasal endoscopy and biopsy, and black necrotic tissue was seen in 22 (61%) instances warranting endoscopic or open surgical debridement. Four of 6 patients undergoing open surgery required orbital exenteration. Overall patient survival was 56% (20/36 patients). Diabetic patients had improved survival (17/21, or 81%) compared to patients with haematologic disorders (3/9, or 33%) (p = 0.001). All six patients with intracerebral disease died. Eighteen of the 22 (82%) patients treated with surgery plus amphotericin B survived vs. two of 14 (14%) receiving amphotericin B alone (p < 0.001). CONCLUSIONS: In rhinocerebral zygomycosis, an aggressive, multidisciplinary, diagnostic and therapeutic approach that utilizes CT or MRI staging, and combines endoscopic or open surgical debridement with amphotericin B-based antifungal therapy offers the best chance of recovery.

Prevalence of allergic conjunctivitis in school children of Karachi.

OBJECTIVE: To determine the prevalence of allergic conjunctivitis in children in selected schools in Karachi, Pakistan. METHODS: This cross-sectional study was conducted in September and October 2008 as part of the School Eye Health Initiative launched by the Aga Khan University, Karachi and the Adamjee Eye Hospital, Karachi. Children in the selected schools underwent vision assessment and a slit lamp examination by an ophthalmologist. The main objective was to detect allergic conjunctivitis which was ascertained by the presence of papillae in the upper tarsal conjunctiva, redness of the eyes, and presence or history of itching and burning. RESULT: A total of 818 children aged 5-19 years were examined. Of these, 19.2% (95% CI 16.5% to 21.9%) had allergic conjunctivitis. There was a significant association between increasing age and allergic conjunctivitis (Odds ratio: 1.19, 95% CI: 1.12, 1.26; P < 0.001). Boys had a higher burden of allergic conjunctivitis than girls; however this difference was not statistically significant (Odds ratio: 1.31, 95% CI: 0.90, 1.91, p = 0.153). CONCLUSION: There is a very high prevalence of allergic conjunctivitis in children in the selected schools in Karachi. Further research is needed to identify factors that contribute to such a high burden of this condition and to assess whether a similar pattern is also observed elsewhere.

Central corneal thickness of Pakistani adults.

OBJECTIVE: To determine the average central corneal thickness (CCT) of healthy adults in the ophthalmology clinic of a tertiary care hospital of Pakistan. METHODS: This was a cross-sectional study conducted in the ophthalmology clinics of Aga Khan University Hospital, Karachi Pakistan. One hundred normal subjects (200 eyes) were studied. An ultrasound pachymeter was used to measure CCT. RESULTS: The mean (+/- SD) age of the study population was 44.29 +/- 15.18 years with a median of 47 years (range: 16-73). Twenty three percent of the subjects had diabetes mellitus, 29% hypertension and 6% had history of ischaemic heart disease. The mean (SD) CCT measurements were 531.08 +/- 33.37) and 531.29 +/- 33.33 micrometers in the right and left eyes respectively and were not significantly different from each other. There was no statistically significant correlation between CCT and IOP (r = 0.158, p = 0.12). We did not find a significant association between CCT and other independent variables like age, sex, presence of co-morbidity i.e. Diabetes Mellitus (DM), Hypertension (HTN), Ischaemic Heart Disease (IHD), myopia, hypermetropia, systemic and eye medication use. CONCLUSIONS: The average CCT values obtained in the hospital-based study closely match those of the African Americans. A population-based study would be needed to provide unbiased CCT estimate in Pakistani population.

Glaucoma admissions and surgery in public sector tertiary care hospitals in pakistan: results of a national study.

PURPOSE: To assess the annual number of glaucoma operations and admissions in the public sector tertiary care hospitals in Pakistan. METHODS: Eye departments in all 18 public tertiary care centers in the country were requested to provide data on the number of glaucoma operations and admissions during 1998. Of these, 13 hospitals agreed to participate. Eye departments' log books or patients' records were used to collect data retrospectively on the total number of eye admissions, the total number of glaucoma admissions, the type of glaucoma, and the total number and type of glaucoma operations. RESULTS: Glaucoma accounted for 8.1% (1,942/23,931) of all eye admissions. Open-angle glaucoma was responsible for 37.6% or 731 glaucoma admissions followed by secondary glaucoma (35.0%) and angle-closure glaucoma (18.2%). During 1998, 1,407 glaucoma-related operations were performed in the selected hospitals. The mean (+/-SD) and the median number of operations performed were 108.2 (+/-59.6) and 112 (range: 17-206), respectively. Trabeculectomies accounted for 1,043 (74.1 %) of all procedures. Their number ranged from 16 to 170 (median: 84) in the selected hospitals. CONCLUSIONS: We believe that the annual number of glaucoma operations performed in the public tertiary care hospitals in Pakistan is far less than required. In-depth research is therefore needed to explain if this is because of gaps in service provision or a genuine shift to medical management of glaucoma on an outpatient basis.