RESUMO
To assess the knowledge and attitude of practicing physicians and surgeons towards the use of pain medication according to the World Health Organisation cancer pain analgesic ladder, the current study was conducted at tertiary care hospitals of the four provinces of Pakistan. Professionals having experience of treating cancer patients for >2 years were included. Data was collected using a self-administered questionnaire sent to each participant using Google Forms. Of the 630 physicians approached, 133(21%) responded. Of them, 74(55.64%) participants were familiar with the World Health Organisation analgesic ladder. There was a significant difference in the frequency of using the ladder based on age (p<0.05). Most participants 31(23%) reported the nonavailability of the recommended drugs as the reason for not following the analgesic ladder. There is a strong need to educate physicians and surgeons about the World Health Organisation analgesic ladder, and to make strategies to improve opioid availability in Pakistan.
Assuntos
Atitude do Pessoal de Saúde , Dor do Câncer , Conhecimentos, Atitudes e Prática em Saúde , Centros de Atenção Terciária , Organização Mundial da Saúde , Humanos , Paquistão , Dor do Câncer/tratamento farmacológico , Masculino , Feminino , Adulto , Padrões de Prática Médica/estatística & dados numéricos , Analgésicos Opioides/uso terapêutico , Pessoa de Meia-Idade , Inquéritos e Questionários , Analgésicos/uso terapêutico , Manejo da Dor/métodos , Estudos Transversais , Cirurgiões , Médicos/psicologia , Médicos/estatística & dados numéricosRESUMO
BACKGROUND: Patients admitted to ICU usually have moderate-to-severe pain at rest and during care-related activities. The "Critical Care Pain Observation Tool (CPOT)" is a reliable and validated objective assessment tool for those patients who cannot self-report pain in ICU. The objectives of the educational course were to assess the baseline knowledge, and practice of pain assessment in critically ill patients and reassess the same in all participants of the course by comparing the results of pre and post-test. METHODS: The educational course of six hours of contact time on the use of CPOT for pain assessment in ICU patients was designed and conducted by the authors after approval from the Ethics Review Committee, Aga Khan University. This educational course was delivered at five different tertiary care hospitals in the Sindh province of Pakistan. A pre-test consisting of 25 true/false multiple-choice questions was conducted at the beginning of the course to assess the baseline knowledge, and practice of participants regarding pain assessment in critically ill patients and the same test was taken at the end of the course. RESULTS: A total of 205 critical care physicians and nursing staff attended the courses. Both pre-test and post-test were completed by 149 (72.6%) participants, of which 53 (35.6%) were female and 96 (64.4%) were male. The mean pre-test score of participants was 57.83 ± 11.86 and the mean post-test score of participants was 67.43 ± 12.96 and this was statistically significant (p = < 0.01). In univariate analysis, the effect of training was significantly higher in the female gender (p = 0.0005) and in those participants, who belong to the metropolitan city (p = 0.010). In multivariate analysis, participants from non-metropolitan cities showed less improvement in post-test scores compared to those who come from the metropolitan city (p = 0.038). CONCLUSIONS: The participating physicians and nurses showed a positive impact on the knowledge and clinical skills regarding pain assessment in CIPs. The participants from hospitals in metropolitan cities showed a significant improvement over those who were from non-metropolitan cities.
Assuntos
Estado Terminal , Países em Desenvolvimento , Humanos , Masculino , Feminino , Medição da Dor , Unidades de Terapia Intensiva , Cuidados Críticos , DorRESUMO
BACKGROUND: Unrelieved postoperative pain afflicts millions each year in low and middle income countries (LMIC). Despite substantial advances in the study of pain, this area remains neglected. Current systematic review was designed to ascertain the types of clinical trials conducted in LMIC on postoperative pain management modalities over the last decade. METHODS: A comprehensive search was performed in June 2019 on PubMed, Cochrane Library, CINAHL Plus, and Web of Science databases to identify relevant trials on the management of postoperative pain in LMIC. Out of 1450 RCTs, 108 studies were reviewed for quality evidence using structured form of critical appraisal skill program. Total of 51 clinical trials were included after applying inclusion/exclusion criteria. RESULTS: Results are charted according to the type of surgery. Eleven trials on laparoscopic cholecystectomy used multimodal analgesia including some form of regional analgesia. Different analgesic modalities were studied in 4 trials on thoracotomy, but none used multimodal approach. In 11 trials on laparotomy, multimodal analgesia was employed along with the studied modalities. In 2 trials on hysterectomy, preemptive pregabalin or gabapentin were used for reduction in rescue analgesia. In 13 trials on breast surgical procedures and 10 on orthopaedic surgery, multimodal analgesia was used with some form of regional analgesia. CONCLUSION: We found that over the past 10 years, clinical trials for postoperative pain modalities have evolved in LMIC according to the current postoperative pain management guidelines i.e. multi-modal approach with some form of regional analgesia. The current review shows that clinical trials were conducted using multimodal analgesia including but not limited to some form of regional analgesia for postoperative pain in LMIC however this research snapshot (of only three countries) may not exactly reflect the clinical practices in all 47 countries. Post Operative Pain Management Modalities Employed in Clinical Trials for Adult Patients in LMIC; A Systematic Review.
Assuntos
Países em Desenvolvimento , Disparidades em Assistência à Saúde , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Adulto , Comorbidade , Humanos , PobrezaRESUMO
Abdominal pain, due to pancreatic diseases like idiopathic recurrent pancreatitis and chronic pancreatitis, is difficult to manage with medications alone in some patients. The Coeliac plexus innervates abdominal organs including the liver, gallbladder, pancreas, etc. We are presenting a case of the successful pain man-agement of a 13-year-old boy with recurrent pancreatitis, by the application of coeliac plexus block. The patient was admitted to the hospital with severe abdominal pain in August 2019. Multimodal analgesia was provided to manage his pain, but he continued to have moderate to severe pain in the abdomen. So, he was scheduled for coeliac plexus block under fluoroscopy in the operating room. Block Procedure was performed with standard monitoring and under conscious sedation bilaterally, via paramedian technique at the level of L1 using 22G Chiba needle. The injection Ropivicaine 0.25% with dexamethasone was injected on each side. After the procedure, his pain was significantly reduced and he was discharged on oral medications after two days.
Assuntos
Bloqueio Nervoso Autônomo , Plexo Celíaco , Pancreatite Crônica , Dor Abdominal/etiologia , Adolescente , Criança , Humanos , Masculino , Manejo da Dor , Pancreatite Crônica/complicaçõesRESUMO
OBJECTIVE: To determine the frequency of persistent pain in patients after breast cancer surgery, and to assess the distribution and characteristics of pain in such patients. METHODS: The prospective observational single cohort study was conducted at the Department of Anaesthesiology and in the Breast Clinic of the Department of Surgery, Aga Khan University Hospital, Karachi, from August 2016 to January 2017, and comprised adult female patients with biopsy-proven carcinoma of breast who were scheduled for elective definitive breast cancer surgery. The patients were followed up for up to three months post-surgery and those with persistent pain were followed up for six months post-operation. Data was analysed using SPSS 19. RESULTS: Of the 120 patients, 26(21.7%) developed persistent post-surgical pain for up to three months, while in 17(14.2%) patients, the pain continued for up to six months after the operation. Among those with persistent post-surgical pain, 11(42.3%) had burning pain, 10(38.5%) had throbbing pain, 3(11.5%) had numbness and 2(7.7%)had mixed character of pain. Also, 11(42.3%)patients developed pain at more than one site including axilla, chest wall, upper arm and surgical scar area, and the site of pain in majority patients 15(57.7%) was axilla. CONCLUSION: The incidence of persistent pain following breast cancer surgery was found to be 21.7%.
Assuntos
Neoplasias da Mama , Adulto , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/cirurgia , Estudos de Coortes , Feminino , Humanos , Mastectomia , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Centros de Atenção TerciáriaRESUMO
BACKGROUND AND AIMS: General anesthesia and airway management of patients for head and neck cancer surgery is a challenge for the anesthesiologist. Appropriate assessment and planning are essential for successful airway management. Our objectives were to review airway management strategies in patients undergoing head and neck cancer surgery in our tertiary care institution and also to observe the effect of airway management techniques on postoperative length of hospital stay (PLOS). MATERIAL AND METHODS: A retrospective medical record review of 400 patients who underwent major head and neck cancer surgery in our institution was conducted. A special form was used, and records were searched for airway and anesthetic management in the operating room and recovery room, and for PLOS. RESULTS: 289 (72.25%) of the patients were male, and 111 (27.75%) female. 49.8% of patients had Mallampati score of 3 and 4. Airway was managed with tracheostomy in 81 (20.25%) patients; nasal intubation was performed in 177 (44.25%) and oral intubation in 142 (35.5%) patients. Postoperative emergency tracheostomy was not done in any of the patients. CONCLUSION: Median postoperative hospital stay was significantly longer (P = 0.0005) in patients who had a tracheostomy performed compared with those where the airway was managed without it.
RESUMO
OBJECTIVE: To determine the frequency of appropriate epidural catheter-incision congruency in adult patients undergoing major abdominal surgeries, as well as the frequency of ineffective postoperative analgesia with continuous epidural infusion, side effects, and complications of epidural insertion and epidural catheter infusion. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan, from September to November 2022. METHODOLOGY: All adult patients who underwent elective major abdominal surgery under general anaesthesia with epidural analgesia were included in this study. Data were collected by chart review of the patients enrolled in Acute Pain Service for the study period. Intraoperative anaesthesia form, epidural infusion form and all records of acute pain service for the postoperative period were reviewed and recorded. RESULTS: One hundred and eighty-two patients were included in this study. The epidural catheter was inserted congruent to the surgical incision i.e. T10-T11 level or above in 43 (23.6%) patients only. In the postoperative period, overall effective epidural analgesia was observed in 79 (43.4%) of the patients. Motor block in lower limbs was observed in 66 (36.26%) of patients in the immediate postoperative period. CONCLUSION: The present study shows appropriate epidural catheter-incision congruency in only 23.6% of the patients. This could be one of the common reasons for ineffective postoperative pain relief via epidural analgesia in 56.6% of patients. KEY WORDS: Epidural catheter insertion site, Major abdominal surgeries, Postoperative analgesia.
Assuntos
Abdome , Analgesia Epidural , Hospitais de Ensino , Dor Pós-Operatória , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Feminino , Masculino , Analgesia Epidural/métodos , Pessoa de Meia-Idade , Adulto , Paquistão , Abdome/cirurgia , Idoso , Anestésicos Locais/administração & dosagem , Cateterismo/métodosRESUMO
BACKGROUND: Endotracheal tube (ETT) is inserted into the trachea to maintain airway patency. Maintaining adequate ETT cuff pressure is important to ensure a proper seal to lower the risk of aspiration and tracheal trauma. This study was designed to assess the frequency of inappropriate ETT cuff pressure at the time of intubation and variation in ETT pressure at the end of a prolonged surgery. METHODS: This study was conducted in the Department of Anaesthesiology, Aga Khan University from October 2019 to March 2020. All adult patients of both genders, undergoing prolonged surgery under general anaesthesia were included. Patients were intubated with an appropriate size ETT, and the cuff was inflated with air. ETT cuff pressure was measured after intubation and, at the end of prolonged surgery to assess any variation. RESULTS: Fifty-eight patients were included, of which 37 (63.8%) were female. The mean age was 47.36 years. The frequency of inappropriate ETT cuff pressure at the time of intubation was found in thirty-five (60.3%) patients, which was corrected to 25 cm H2O before the start of surgery. At the end of the surgery, forty-one (70.7%) patients showed an increase in ETT cuff pressures with the majority (33%) having a variation of 51-70 (81-100 cm H2O). CONCLUSIONS: The frequency of inappropriate ETT cuff pressure at the time of intubation was found in thirty-five (60.3%) patients. In six (10.3%) patients, ETT cuff pressure was below 20 cm H2O while in twenty-nine (50%) patients, ETT cuff pressure was above 30 cm H2O. In forty-one (70.7%) patients ETT cuff pressure was abnormally high that is >30 cm H2O at the end of prolonged surgical procedures.
Assuntos
Intubação Intratraqueal , Traqueia , Adulto , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Intubação Intratraqueal/métodos , Estudos Prospectivos , Anestesia Geral , Desenho de EquipamentoRESUMO
This review article attempts to provide a comprehensive review of the recent progress in cerium oxide (CeO2)-based resistive random-access memories (RRAMs). CeO2 is considered the most promising candidate because of its multiple oxidation states (Ce3+ and Ce4+), remarkable resistive-switching (RS) uniformity in DC mode, gradual resistance transition, cycling endurance, long data-retention period, and utilization of the RS mechanism as a dielectric layer, thereby exhibiting potential for neuromorphic computing. In this context, a detailed study of the filamentary mechanisms and their types is required. Accordingly, extensive studies on unipolar, bipolar, and threshold memristive behaviors are reviewed in this work. Furthermore, electrode-based (both symmetric and asymmetric) engineering is focused for the memristor's structures such as single-layer, bilayer (as an oxygen barrier layer), and doped switching-layer-based memristors have been proved to be unique CeO2-based synaptic devices. Hence, neuromorphic applications comprising spike-based learning processes, potentiation and depression characteristics, potentiation motion and synaptic weight decay process, short-term plasticity, and long-term plasticity are intensively studied. More recently, because learning based on Pavlov's dog experiment has been adopted as an advanced synoptic study, it is one of the primary topics of this review. Finally, CeO2-based memristors are considered promising compared to previously reported memristors for advanced synaptic study in the future, particularly by utilizing high-dielectric-constant oxide memristors.
RESUMO
In recent years, energy storage and conversion tools have evolved significantly in response to rising energy demands. Owing to their large surface area, superior electric and chemical stabilities, and thermal conductivities, barium copper phosphate (BaCuPO4) materials are promising electrode materials for electrochemical energy storage systems. In this study, the synthesis of nanostructures (NSs) using hydrothermal and chemical precipitation methods and exploring the electrochemical characteristics of BaCuPO4 in asymmetric supercapacitors provides a comparative investigation. Systematic characterization shows that nanomaterials prepared by applying the hydrothermal method have a more crystalline and large surface area than chemical precipitation. In the three cell arrangements, the hydrothermally prepared BaCuPO4 NSs delivered a high specific capacity (764.4 C g-1) compared to the chemical precipitation route (660 C g-1). Additionally, the supercapattery associated with the two electrode assemblages delivers an optimum specific capacity of 77 C g-1. The energy and power density of BaCuPO4//AC NSs were 52.13 W h kg-1 and 950 W kg-1, respectively. A durability test was also performed with BaCuPO4//AC NSs for 5000 consecutive cycles. Further, the coulombic efficiency and capacity retention of BaCuPO4//AC after 5000 cycles were 81% and 92%, respectively. Bimetallic phosphate is comparatively suggested for future perspectives towards HER to overcome the performance of single metal phosphate materials. This is the first approach, we are aware of, for investigating the electrochemical behavior of BaCuPO4, and our results suggest that it may be useful as an electrode material in electrochemical systems requiring high energy and rate capabilities.
RESUMO
Background: Cricoid pressure (CP) is applied to occlude the esophagus during endotracheal intubation in patients at an increased risk of aspiration of gastric contents. Evidence shows marked deficiencies in knowledge and skills for CP application among personnel responsible for this task. This study evaluated the effectiveness of CP training in improving knowledge and skills regarding CP application among anesthesiology technicians and critical care nurses and assessed the retention of skills after 2 months. Methods: Five workshops were conducted on effective application of CP. Indications, relevant anatomy, physiology, and correct technique were taught using interactive sessions and videos and hands-on practice on a weighing scale, 50-mL syringe, and trainer model. Pre- and postworkshop tests were conducted for knowledge and skill. An assessment was repeated after 2 months to assess skill retention. Results: Five workshops were conducted for 102 participants. Statistically significant improvements were seen in mean scores for knowledge in postworkshop assessments (12.32 ± 2.12 versus 7.12 ± 2.32; P < .01). Similarly, posttraining mean scores for skill assessment were significantly higher than pretraining scores (6.31 ± 0.96 versus 2.72 ± 2.00; P < .0005), indicating an overall 131% improvement. Seventy-four participants appeared for assessment of the retention of skills. A 20% decrement was observed compared with posttraining scores (5.15 ± 1.71 versus 6.45 ± 0.86; P < .0005). Conclusions: A significant improvement was observed in both knowledge and skills immediately following training. However, this does not ensure long-term retention of clinical skills, as a 20% decrement was observed 2 months after the workshops. Formal training and regular practice are recommended to enable clinicians to perform CP effectively.
RESUMO
BACKGROUND: Obesity is a growing public health concern and is one of the leading causes of human suffering and disability worldwide. The number of overweight and obese people is dramatically increasing, and local data showed that low back pain (LBP) is more common in people with obesity, prolonged sitting jobs, psychological disorders, and lack of exercise. METHODS: This study was conducted in a cohort of 300 adult patients of either gender who visited a pain management clinic with LBP. Patient data were retrieved from the hospital software program and recorded in a pre-designed proforma. The data included the patient's age, gender, weight, height, BMI, comorbidities, site of pain, duration of pain, distribution of pain, severity of pain, history of spinal trauma, previous spinal surgery, and working diagnosis. RESULTS: Out of 300 patients with LBP, 185 (61.7 %) were female and 115 (38.3%) were male, of these, 224 (74.6%) were overweight or obese. One hundred and three (34.3%) had axial back pain and 197 (65.7%) patients had lumbar radicular pain. Linear regression analysis showed that 17% variability in pain scores in both genders can be explained by the increase in BMI. There is a statistically significant relationship, i.e. P=0.0005, exists between pain score and BMI. CONCLUSION: This study showed the strong association between obesity and LBP in the Pakistani population. Approximately, 75% were overweight or obese in our LBP population-based cohort and this association was stronger among women than men.
RESUMO
C-reactive protein is produced in response to cytokines such as interleukin (IL)-6. It is known that increased plasma IL-6 levels induce increased hepatic and intratumoral production of C-reactive protein. Cyclooxygenase enzyme-2 is induced by various stimuli, including inflammation and various growth factors. Expression of these two markers has not been well studied in clear cell renal cell carcinoma. The objective of this study is to correlate the expression of C-reactive protein and cyclooxygenase enzyme-2 in clear cell renal cell carcinoma with pathologic parameters. A search of the surgical pathology and consultation files at our institution was performed for nephrectomy specimens with clear cell renal cell carcinoma from 2007 to 2008. Immunohistochemical stains for C-reactive protein and cyclooxygenase enzyme-2 were performed. Staining intensity was graded as 0, 1+, 2+, and 3+. The staining intensity was then correlated with pathologic stage and Fuhrman nuclear grade for each case. A total of 110 cases were identified. Strong expression of C-reactive protein was associated with higher Fuhrman nuclear grade and pathologic stage, and the strength of correlation was statistically significant (p = 0.01 and p = 0.001), respectively. However, cyclooxygenase enzyme-2 expression did not show statistically significant correlation with both pathologic stage and Fuhrman nuclear grade (p = 0.1 and p = 0.15), respectively. To our knowledge, this is the largest study to date correlating the expression of both C-reactive protein and cyclooxygenase enzyme-2 in tissue with pathologic parameters in patients with clear cell renal cell carcinoma, which could have significant prognostic and therapeutic implications.
Assuntos
Proteína C-Reativa/metabolismo , Carcinoma de Células Renais/metabolismo , Carcinoma de Células Renais/patologia , Ciclo-Oxigenase 2/metabolismo , Neoplasias Renais/metabolismo , Neoplasias Renais/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais/metabolismo , Carcinoma de Células Renais/cirurgia , Feminino , Humanos , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Nefrectomia , Prognóstico , Estudos RetrospectivosRESUMO
Adult granulosa cell tumor (GCT) of the ovary is mostly diagnosed in postmenopausal women. They typically secrete estrogen, which stimulates the endometrium to proliferate and cause abnormal bleeding. This study reviews the cytologic features of adult GCT of the ovary diagnosed by fine-needle aspiration (FNA). We reviewed slides from ten cases diagnosed by CT guided FNA from 1995 to 2007 at our institutions. Smears were stained with Diff-Quik and Papanicolaou stains. Patient's history and histologic diagnosis were also available and reviewed for all cases. The patients ranged in age from 39 to 83 yr. All 10 cases were hypercellular with both large and small overlapping cell clusters and individual cells. The cytologic features identified included: naked nuclei (10/10 cases), Call-Exner bodies (7/10 cases), blood vessels with prominent perivascular tumor cell growth (4/10 cases), spindle-shaped hyperchromatic stromal cells within cellular clusters (6/10 cases), mixed inflammation (3/10 cases), tumor cell necrosis (1/10 cases), and prominent metachromatic stroma seen in association with blood vessels (1/10 cases). Moderate to scant delicate cytoplasm was also seen (10/10 cases). Small, punctuate cytoplasmic vacuoles were also noted (7/10 cases) and were occasionally prominent (3/10 cases). In general nuclear to cytoplasmic ratios were high although lower than those typically seen in a lymphoma or small-cell carcinoma. Nuclei were generally centrally located although eccentrically located nuclei were consistently seen in a minority of cells. Nuclei were monotonous in size showing slightly convoluted (occasional rentiform and fetiform nuclei) to polygonal outlines. Prominent, central nucleoli were also seen (4/10 cases). Nuclear grooves were also seen (9/10 cases). No atypical mitotic activity was identified in any of the 10 cases (0/10 cases). In summary, the above cytologic features can also help in the cytologic diagnosis of adult GCTs.
Assuntos
Tumor de Células da Granulosa/patologia , Células da Granulosa/patologia , Neoplasias Ovarianas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha Fina , Núcleo Celular/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Pancreatic adenocarcinoma is a genetic disease showing somatic mutations of multiple genes, including SMAD4. SMAD4 is a tumor suppressor gene that is inactivated in a sub-set of pancreatic adenocarcinoma, either by the intragenic mutation of one allele in combination with the loss of the other allele or by homozygous deletion of both alleles. This study examines SMAD4 expression in fine-needle aspiration cell blocks from patients with pancreatic adenocarcinoma, as well as a variety of human cancers, in order to assess its viability as a tumor marker. A total of 100 patients with pancreatic adenocarcinoma, with diagnostic material from fine-needle aspiration cell blocks were selected for this study. In addition cancers from different sites were examined in multitumor tissue microarrays, which included two tissue cores from neoplastic surgical resection specimens. Cancers studied included endometrium (n = 100), colon (n = 100), ovary (n = 100), lung (n = 100), breast (n = 100), and malignant melanoma (n = 100). The sections were immunostained with SMAD4 using pressure cooker antigen retrieval labeled polymer horseradish peroxidase (DAKO), and the DAKO autostainer. Immunohistochemical expression was scored as negative, 1+, 2+, 3+. Only 2+ and 3+ staining was considered as positive staining. SMAD4 staining was nuclear and the results for tumor cell positivity for primary sites studied are as follows: Pancreas (80/100; 80%), endometrium (0/100; 0%), colon (0/100; 0%), ovary (3/100; 3%), lung (0/100; 0%), breast (2/100; 2%), and malignant melanoma (4/100; 4%). This study suggests that SMAD4 is an important marker for confirming a diagnosis of pancreatic adenocarcinoma as a primary tumor, as well as when it presents as a metastatic tumor on small fine-needle aspirate samples.
Assuntos
Adenocarcinoma/diagnóstico , Adenocarcinoma/metabolismo , Biomarcadores Tumorais/metabolismo , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/metabolismo , Proteína Smad4/metabolismo , Adenocarcinoma/patologia , Alelos , Biópsia por Agulha Fina , Feminino , Humanos , Mutação/genética , Neoplasias/metabolismo , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos , Proteína Smad4/genéticaRESUMO
BACKGROUND: A quarter of the world's neonatal deaths and 15% of maternal deaths happen in India. Few community-based strategies to improve maternal and newborn health have been tested through the country's government-approved Accredited Social Health Activists (ASHAs). We aimed to test the effect of participatory women's groups facilitated by ASHAs on birth outcomes, including neonatal mortality. METHODS: In this cluster-randomised controlled trial of a community intervention to improve maternal and newborn health, we randomly assigned (1:1) geographical clusters in rural Jharkhand and Odisha, eastern India to intervention (participatory women's groups) or control (no women's groups). Study participants were women of reproductive age (15-49 years) who gave birth between Sept 1, 2009, and Dec 31, 2012. In the intervention group, ASHAs supported women's groups through a participatory learning and action meeting cycle. Groups discussed and prioritised maternal and newborn health problems, identified strategies to address them, implemented the strategies, and assessed their progress. We identified births, stillbirths, and neonatal deaths, and interviewed mothers 6 weeks after delivery. The primary outcome was neonatal mortality over a 2 year follow up. Analyses were by intention to treat. This trial is registered with ISRCTN, number ISRCTN31567106. FINDINGS: Between September, 2009, and December, 2012, we randomly assigned 30 clusters (estimated population 156â519) to intervention (15 clusters, estimated population n=82â702) or control (15 clusters, n=73â817). During the follow-up period (Jan 1, 2011, to Dec 31, 2012), we identified 3700 births in the intervention group and 3519 in the control group. One intervention cluster was lost to follow up. The neonatal mortality rate during this period was 30 per 1000 livebirths in the intervention group and 44 per 1000 livebirths in the control group (odds ratio [OR] 0.69, 95% CI 0·53-0·89). INTERPRETATION: ASHAs can successfully reduce neonatal mortality through participatory meetings with women's groups. This is a scalable community-based approach to improving neonatal survival in rural, underserved areas of India. FUNDING: Big Lottery Fund (UK).
Assuntos
Pessoal de Saúde , Promoção da Saúde/métodos , Saúde do Lactente , Saúde Materna , Serviços de Saúde Materno-Infantil , Resultado da Gravidez , População Rural , Acreditação , Adulto , Países em Desenvolvimento , Feminino , Humanos , Índia/epidemiologia , Lactente , Mortalidade Infantil , Razão de Chances , Morte Perinatal , Gravidez , Natimorto , Adulto JovemRESUMO
OBJECTIVE: To assess the efficacy of pre-incisional peritonsillar infiltration of two doses of ketamine on postoperative analgesia compared with peritonsillar normal saline in children undergoing tonsillectomy. STUDY DESIGN: Double blind, randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Anaesthesiology, Surgical Intensive Care and Pain Management, Civil Hospital, Karachi, Dow University of Health Sciences, from August 2008 to January 2009. METHODOLOGY: Seventy-five ASA physical status one patients, aged 5 - 12 years scheduled for tonsillectomy were enrolled in this study. Patients were divided into three groups of 25 each. Group-A received normal saline, Group-B, ketamine 0.5 mg/kg while group-C ketamine 1 mg/kg respectively. All medications were 2 ml and were applied 1 ml per tonsil; 3 minutes before tonsillectomy incision. Anaesthesia was induced and maintained with standard technique. All patients were monitored throughout surgery. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and Wilson sedation scale were used to evaluate pain levels and sedation respectively after operation. RESULTS: Mean duration of analgesia was significantly higher in group-C (17.28 ± 5.33 hours) as compared to group-B (11.36 ± 4.15 hours) and A (3.2 ± 0.71 hours) as well as group-B was also significantly higher than group-A (p < 0.05). Group-A had significantly higher pain scores than group-B and group-C. Both B and C groups had comparable pain scores, which were statistically significant at 6 and 8 hours. CONCLUSION: Single 0.5 or 1 mg/kg injection of ketamine given before surgical incision by peritonsillar infiltration provides efficient pain relief during postoperative period without significant side-effects in children undergoing tonsillectomy.
Assuntos
Anestésicos Dissociativos/administração & dosagem , Anestésicos Locais/administração & dosagem , Ketamina/administração & dosagem , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Tonsilectomia , Analgesia , Anestésicos Dissociativos/uso terapêutico , Anestésicos Locais/uso terapêutico , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Humanos , Ketamina/uso terapêutico , Masculino , Medição da Dor , Período Pós-Operatório , Cuidados Pré-Operatórios , Resultado do TratamentoRESUMO
BACKGROUND: Atherogenic risk in subjects with metabolic syndrome is partly mediated by increased oxidative stress and subsequent endothelial dysfunction. Clinical trials have demonstrated differences in outcomes between subjects receiving lipophilic statins (atorvastatin) compared with hydrophilic statins (pravastatin). However, whether these findings are attributable to differences in the doses administered or to nonlipid-lowering pleiotropic effects of statins on oxidative stress and vascular function remains unknown. We hypothesized that equipotent doses of these two statins will have divergent effects on markers of oxidative stress and endothelial function. METHODS: Thirty-six subjects with hyperlipidemia and metabolic syndrome and/or diabetes were randomized in a double-blind manner to either pravastatin 80 mg or atorvastatin 10 mg daily. Oxidative stress (dROMs assay that measures lipid hydroperoxides, plasma thiobarbituric acid reactive substances [TBARS], and aminothiol levels) and brachial artery flow-mediated dilation (FMD) were measured at baseline and after 12 weeks of statin therapy. RESULTS: Statin therapy reduced serum low-density lipoprotein cholesterol levels equally in both groups. Atorvastatin therapy was associated with a significant reduction in TBARS (P = .006) and dROMs levels (P = .02), which was not observed in subjects treated with pravastatin. Endothelial function improved with statin therapy (P = .02), but there was no difference between the statin groups. CONCLUSION: In hyperlipidemic subjects with metabolic syndrome, atorvastatin is associated with a greater reduction in lipid markers of oxidation compared with pravastatin. Whether these effects are responsible for the outcome differences in trials comparing these agents needs further investigation.
Assuntos
Anticolesterolemiantes/uso terapêutico , Endotélio Vascular/efeitos dos fármacos , Ácidos Heptanoicos/uso terapêutico , Hipercolesterolemia/tratamento farmacológico , Estresse Oxidativo/efeitos dos fármacos , Pravastatina/uso terapêutico , Pirróis/uso terapêutico , Adulto , Anticolesterolemiantes/farmacologia , Atorvastatina , Artéria Braquial/efeitos dos fármacos , Artéria Braquial/patologia , Artéria Braquial/fisiopatologia , Cistina/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Método Duplo-Cego , Endotélio Vascular/patologia , Feminino , Glutationa/sangue , Ácidos Heptanoicos/farmacologia , Humanos , Hipercolesterolemia/sangue , Hipercolesterolemia/complicações , Metabolismo dos Lipídeos/efeitos dos fármacos , Masculino , Síndrome Metabólica/sangue , Síndrome Metabólica/complicações , Pessoa de Meia-Idade , Pravastatina/farmacologia , Pirróis/farmacologia , Substâncias Reativas com Ácido Tiobarbitúrico/metabolismo , Resultado do Tratamento , VasodilataçãoRESUMO
OBJECTIVE: To assess ventilatory characteristics and airway complications associated with the use of I-gel in patients undergoing gynaecological surgeries. STUDY DESIGN: Experimental study. PLACE AND DURATION OF STUDY: Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Civil Hospital, Dow University of Health Sciences, Karachi, from July 2008 to June 2009. METHODOLOGY: One hundred adult female patients aged 15 - 75 years, ASA-I and II scheduled for elective gynaecologic surgical procedures under general anaesthesia with controlled ventilation were included in this study. After insertion of device, ease of insertion, time of insertion, peak airway pressure, leak pressure were noted. After proper placement of device, gastric tube was also passed in every patient. Pharyngolaryngeal morbidities (sore throat, dysphagia, dysphonia, neck pain and coughing at 1 hour and 24 hours postoperatively) were also noted. RESULTS: I-gel was inserted in the first attempt in 92% patients while second attempt was required in 8% of patients. Average time of insertion was 9.68 ± 2.69 seconds. Average leak pressure of 22.48 ± 2.07 cm H2O. After removal of I-gel no blood staining was found on any device. Coughing was noted in 6% patients after removal of device and mild sore throat was noted in only one patient after 24 hours of surgery. CONCLUSION: I-gel is a simple and easy to use supraglottic airway device. Its insertion do not require laryngoscopy and airway can be maintained in very short time in adult female patients.
Assuntos
Intubação Gastrointestinal/instrumentação , Intubação Intratraqueal/instrumentação , Máscaras Laríngeas , Adulto , Idoso , Anestesia Geral , Remoção de Dispositivo , Procedimentos Cirúrgicos Eletivos , Feminino , Géis , Procedimentos Cirúrgicos em Ginecologia , Hospitais de Ensino , Humanos , Intubação Gastrointestinal/métodos , Intubação Intratraqueal/métodos , Pessoa de Meia-Idade , Pressão , Respiração Artificial , Resultado do Tratamento , Adulto JovemRESUMO
AIMS: Arterial stiffening may lead to hypertension, greater left ventricular after-load and adverse clinical outcomes. The underlying mechanisms influencing arterial elasticity may involve oxidative injury to the vessel wall. We sought to examine the relationship between novel markers of oxidative stress and arterial elastic properties in healthy humans. METHODS AND RESULTS: We studied 169 subjects (mean age 42.6 ± 14 years, 51.6% male) free of traditional cardiovascular risk factors. Indices of arterial stiffness and wave reflections measured included carotid-femoral Pulse Wave Velocity (PWV), Augmentation Index (Aix) and Pulse Pressure Amplification (PPA). Non-free radical oxidative stress was assessed as plasma oxidized and reduced amino-thiol levels (cysteine/cystine, glutathione/GSSG) and their ratios (redox potentials), and free radical oxidative stress as derivatives of reactive oxygen metabolites (dROMs). Inflammation was assessed as hsCRP and interleukin-6 levels. The non-free radical marker of oxidative stress, cystine was significantly correlated with all arterial indices; PWV (r=0.38, p<0.001), Aix (r=0.35, p<0.001) and PPA (r=-0.30, p<0.001). Its redox potential, was also associated with PWV (r=0.22, p=0.01), while the free radical marker of oxidative stress dROMS was associated with Aix (r=0.25, p<0.01). After multivariate adjustment for age, gender, arterial pressure, height, weight, heart rate and CRP, of these oxidative stress markers, only cystine remained independently associated with PWV (p=0.03), Aix (p=0.01) and PPA (p=0.05). CONCLUSIONS: In healthy subjects without confounding risk factors or significant systemic inflammation, a high cystine level, reflecting extracellular oxidant burden, is associated with increased arterial stiffness and wave reflections. This has implications for understanding the role of oxidant burden in pre-clinical vascular dysfunction.