Child health nursing in the Solomon Islands: A qualitative evaluation of the impact of the 'Bachelor of nursing - Child health'.

AIM: To explore graduates' perceptions of the impact on nursing practice of a new postgraduate course in child health, developed and implemented in the Solomon Islands in 2016. BACKGROUND: The Bachelor of Nursing - Child Health was implemented in 2016 to develop nurses' knowledge and skills in child health and paediatric care with the intent to improve national child health outcomes. DESIGN: A qualitative exploratory, descriptive design was used to evaluate the impact of the Bachelor of Nursing - Child Health on graduates' nursing practice. METHODS: Fourteen nurses who graduated from the first cohort of students enrolled in the child health course were purposively selected to participate. Participants engaged in individual semi-structured interviews, conducted between August and December 2018. A thematic analysis was undertaken following Braun and Clarke's six-phase process. RESULTS: Findings from the study demonstrate positive impacts of the course on graduates' nursing practice. These include a perceived enhanced quality of care through their commitment to evidence-based practice, the ability to contribute to capacity building of colleagues, the reinforcement of provincial public health programmes and expanded participation in managerial activities. Following graduation, most alumni took on senior roles and greater responsibilities, felt more confident in managing unwell children, felt there was better access to and quality of child health care at the community and broader country levels and felt recognised by colleagues and communities. Some graduates faced resistance from colleagues to change practice and felt that despite being given greater responsibilities, nursing levels and salaries remained unchanged. This reflected a potential lack of recognition from hospital or provincial managers, the Nursing Council as the regulatory body for the nursing profession, and the Ministry of Health and Medical Services. A lack of human and material resources also impacted quality of care. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Findings from this study underline the need for the Solomon Islands National University, the Nursing Council, the Public Service and the Ministry of Health and Medical Services to concord and delineate formal accreditation standards for child health nurses. Overall, collaborative efforts and commitments at local, regional and global levels are required to support child health nurses in their ability and ambition to improve national child health outcomes. CONCLUSIONS: Findings from this study demonstrate positive impacts of the course on graduates' nursing practice. The impact of increasing nurses' knowledge and skills on national child health outcomes could be significant. Ongoing implementation and recognition of this course in the Solomon Islands, as well as more broadly across the Pacific region, are recommended.

Supplementation of nano-selenium (SeNPs) improved growth, immunity, antioxidant enzyme activity, and selenium retention in broiler chicken during summer season.

The present experiment was aimed at finding the optimal supplemental dose of nano-selenium in broiler chicken during the summer season for better performance in terms of growth, blood metabolites, immune response, antioxidant status, and selenium concentration in vital organs. Three-hundred-day-old Vencobb broiler chicks were randomly distributed into five dietary treatment groups with six replicates of 10 chicks each. The dietary treatments were as follows: T1 (control group), basal diet; T2, basal diet with 0.0375 ppm of nano-Se; T3, basal diet with 0.075 ppm of nano-Se; T4, basal diet with 0.15 ppm of nano-Se; T5, basal diet with 0.3 ppm of nano-Se. The experiment was carried out for 35 days. The average gain and feed conversion ratio were best observed in T4 and T5. The antibody titres were significantly higher (P < 0.05) in the treated birds. At the 5th week, erythrocytic glutathione peroxidase, catalase, and superoxide dismutase activities were significantly (P < 0.05) higher and lipid peroxidation values were significantly (P < 0.05) lower in all the nano-Se-treated groups. The Se levels in the liver, breast muscle, kidney, brain, and gizzard were significantly (P < 0.05) increased with increased dietary nano-Se. Histological studies of the liver and kidney in the highest nano-Se-treated groups (T4 and T5) did not show any abnormal changes. It is concluded that supplementation of nano-selenium at 0.15 ppm over and above the basal level improved the performance and protect the birds from summer stress without any adverse effect on the vital organs of chicken.

The Lifebox Surgical Headlight Project: engineering, testing, and field assessment in a resource-constrained setting.

BACKGROUND: Poor surgical lighting represents a major patient safety issue in low-income countries. This study evaluated device performance and undertook field assessment of high-quality headlights in Ethiopia to identify critical attributes that might improve safety and encourage local use. METHODS: Following an open call for submissions (December 2018 to January 2019), medical and technical (non-medical) headlights were identified for controlled specification testing on 14 prespecified parameters related to light quality/intensity, mounting and battery performance, including standardized illuminance measurements over time. The five highest-performing devices (differential illumination, colour rendering, spot size, mounting and battery duration) were distributed to eight Ethiopian surgeons working in resource-constrained facilities. Surgeons evaluated the devices in operating rooms, and in a comparative session rated each headlight in terms of performance and willingness to purchase. RESULTS: Of 25 submissions, eight headlights (6 surgical and 2 technical) met the criteria for full specification testing. Scores ranged from 8 to 12 (of 14), with differential performance in lighting, mounting and battery domains. Only two headlights met the illuminance parameters of more than 35 000 lux during initial testing, and no headlight satisfied all minimum specifications. Of the five headlights evaluated in Ethiopia, daily operation logbooks noted variability in surgeons' opinions of lighting quality (6-92 per cent) and spot size (0-92 per cent). Qualitative interviews also yielded important feedback, including preference for easy transport. Surgeons sought high quality with price sensitivity (using out-of-pocket funds) and identified the least expensive but high-functioning device as their first choice. CONCLUSION: No device satisfied all the predetermined specifications, and large price discrepancies were critical factors leading surgeons' choices. The favoured device is undergoing modification by the manufacturer based on design feedback so an affordable, high-quality surgical headlight crafted specifically for the needs of resource-constrained settings can be used to improve surgical safety.

ANTECEDENTES: Una iluminación quirúrgica deficiente conlleva importantes problemas de seguridad para los pacientes en países de bajos ingresos. En Etiopía, se evaluó el rendimiento y la capacidad de iluminar el campo quirúrgico de varias lámparas de alta calidad para identificar aspectos esenciales que podrían mejorar la seguridad y fomentar su uso local. MÉTODOS: Tras una convocatoria abierta (diciembre de 2018-enero de 2019), se identificaron lamparás médicas y técnicas (no médicas) para realizar un análisis de 14 variables previamente definidas en relación con la calidad/intensidad de la luz, montaje y rendimiento de la batería, además de mediciones estandarizadas de iluminancia a largo plazo. Los cinco dispositivos de mayor rendimiento (iluminación diferencial, reproducción del color, tamaño del foco, montaje y duración de la batería) se distribuyeron entre 8 cirujanos etíopes que trabajaban en instalaciones con recursos limitados. Los cirujanos evaluaron los dispositivos en quirófano y en sesiones comparativas calificaron el rendimiento de cada lámpara y la disposición para su compra. RESULTADOS: De las 25 propuestas presentadas, 8 lámparas (6 quirúrgicas y 2 técnicas) cumplieron los criterios para realizar las pruebas de especificación completas. Las puntuaciones oscilaron entre 8 y 12 (de un total de 14), con diferencias en los ámbitos de iluminación, montaje y batería. Solo 2 lámparas proporcionaron > 35000 lux de iluminancia durante la prueba inicial, y ninguna lámpara cumplió con todas las especificaciones mínimas. De las cinco lámparas evaluadas en Etiopía, hubo una gran variabilidad en las opiniones de los cirujanos anotadas en los registros realizados, tanto sobre la calidad de la iluminación (21-92%), como del tamaño del foco (0-92%). En las entrevistas cualitativas surgieron comentarios importantes como la preferencia por un transporte fácil. Los cirujanos buscaban la mejor calidad al precio más razonable (dado que se utilizaban fondos propios para su adquisición) e identificaron el dispositivo menos costoso pero con alto funcionamiento como primera opción. CONCLUSIÓN: El hecho de que ningún dispositivo satisfizo todas las especificaciones predeterminadas y la gran variabilidad de precios fueron los aspectos esenciales que determinaron la elección de los cirujanos. El dispositivo mejor valorado está siendo modificado por el fabricante en función de los comentarios de diseño, para lograr una lámpara quirúrgica asequible y de alta calidad diseñada específicamente para satisfacer las necesidades de entornos con recursos limitados en la mejora la seguridad quirúrgica.

Variation in global uptake of the Surgical Safety Checklist.

BACKGROUND: The Surgical Safety Checklist (SSC) is a patient safety tool shown to reduce mortality and to improve teamwork and adherence with perioperative safety practices. The results of the original pilot work were published 10 years ago. This study aimed to determine the contemporary prevalence and predictors of SSC use globally. METHODS: Pooled data from the GlobalSurg and Surgical Outcomes studies were analysed to describe SSC use in 2014-2016. The primary exposure was the Human Development Index (HDI) of the reporting country, and the primary outcome was reported SSC use. A generalized estimating equation, clustering by facility, was used to determine differences in SSC use by patient, facility and national characteristics. RESULTS: A total of 85 957 patients from 1464 facilities in 94 countries were included. On average, facilities used the SSC in 75·4 per cent of operations. Compared with very high HDI, SSC use was less in low HDI countries (odds ratio (OR) 0·08, 95 per cent c.i. 0·05 to 0·12). The SSC was used less in urgent compared with elective operations in low HDI countries (OR 0·68, 0·53 to 0·86), but used equally for urgent and elective operations in very high HDI countries (OR 0·96, 0·87 to 1·06). SSC use was lower for obstetrics and gynaecology versus abdominal surgery (OR 0·91, 0·85 to 0·98) and where the common or official language was not one of the WHO official languages (OR 0·30, 0·23 to 0·39). CONCLUSION: Worldwide, SSC use is generally high, but significant variability exists. Implementation and dissemination strategies must be developed to address this variability.

ANTECEDENTES: Se ha demostrado que la utilización de la lista de verificación de seguridad quirúrgica (Surgical Safety Checklist, SSC) reduce la mortalidad y mejora el trabajo en equipo, así como el cumplimiento de las prácticas de seguridad perioperatorias. Los resultados de un trabajo piloto original se publicaron hace 10 años. El objetivo de este estudio fue determinar la prevalencia actual y los predictores de uso de la SSC a nivel mundial. MÉTODOS: Se analizaron los datos agrupados de los estudios GlobalSurg y Surgical Outcomes para describir la utilización de la SSC entre 2014-2016. La principal variable de exposición fue el índice de desarrollo humano (Human Development Index, HDI) del país informante y la principal variable de resultado, la tasa de utilización de la SCC. Para determinar las diferencias en la utilización de la SSC por paciente, centro y características nacionales se utilizó una ecuación de estimación generalizada con conglomerados por centros. RESULTADOS: Se incluyeron 85.957 pacientes de 1.464 centros en 94 países. La tasa media de utilización de la SSC fue del 75,4% de las operaciones. Al compararlos con países de HDI muy alto, la utilización de la SCC fue menor en los países con HDI bajo (razón de oportunidades, odds ratio, OR 0,08, i.c. del 95% 0,05-0,12). En países con HDI bajo, la SSC se utilizó menos en operaciones urgentes en comparación con operaciones electivas (OR 0,68, i.c. del 95% 0,53- 0,86) a diferencia de los países con HDI elevado, en los que se utilizó por igual en ambas situaciones (OR 0,96, i.c. del 95% 0,87-1,06). La utilización de la SSC fue menor en operaciones de obstetricia y ginecología que en cirugía abdominal (OR 0,91, i.c. del 95% 0,85 a 0,98) y en aquellos países en los que el idioma habitual u oficial era diferente a los idiomas oficiales de la OMS (OR 0,30, i.c. del 95% 0,23 a 0,39). CONCLUSIÓN: A nivel mundial, el uso de SSC en general es alto, pero existe una variabilidad significativa. Se deben desarrollar estrategias de implementación y difusión para resolver esta variabilidad.

Investigation of high-frequency hearing loss and outer hair cell function of the cochlea in patients with psoriasis: a case-control study.

The inner ear can be the target of autoimmune attacks, and sensorineural hearing loss can occur as a complication in various non-organ-specific autoimmune diseases. The aim of this study was to compare cochlear functions and hearing evaluation in patients with psoriasis and controls. In total, 29 patients with psoriasis and 30 healthy controls (HCs) were included in the study. Pure-tone audiometry at 250, 500, 1000, 2000, 4000, 8000, 10 000, 12 000, 14 000 and 16 000 Hz was performed for patients as HCs, as were immittance measures including tympanometry, acoustic reflex and otoacoustic emission testing. There were statistically significant (P < 0.05) differences between patients and HCs for pure-tone thresholds at high frequencies, and for distortion product otoacoustic emission (DPOAE) responses and signal : noise ratio at all frequencies. In our study, based on DPOAE and audiological findings, there was damage to the outer hair cells of the cochlea, resulting in high-frequency hearing loss in patients with psoriasis.

Role of non-coding RNAs in head and neck squamous cell carcinoma: A narrative review.

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide with high recurrence, metastasis, and poor treatment outcome. Recent studies have reported that non-coding RNA (ncRNA) might play critical role in regulating different types of cancer. MicroRNAs (miRs) are short ncRNAs (20-25 nucleotides) responsible for post-transcriptional regulation of gene expression and may have a role in oncogenesis by acting as oncomiRs or tumor suppressor miRs. Long non-coding RNAs (lncRNAs) are heterogenous group of ncRNAs more than 200 nucleotides long, can act in cis and/or in trans, and have been also implicated in carcinogenesis. These molecules have been suggested to be promising candidates as diagnostic and prognostic biomarkers and for development of novel therapeutic approaches. In this review, we have summarized recent findings on role of these ncRNAs in HPV-negative (HPV-ve) and HPV-positive (HPV+ve) HNSCC. The available literature supports differential expression of both microRNAs and long non-coding RNAs, which include oncogenic ncRNAs (miR-21, miR-31, miR-155, miR-211, HOTAIR, and MALAT1) and tumor suppressor ncRNAs (let7d, miR-17, miR-375, miR-139, and MEG3) in HPV+ve HNSCC tumors as compared to HPV-ve tumors and they have distinct role in the pathophysiology of these two types of HNSCCs.

Detection of active human papilloma virus-16 in head and neck cancers of Asian North Indian patients.

BACKGROUND: Head and neck cancers (HNC) are one of the most common cancers in India. Human papillomavirus (HPV) has been identified as an emerging risk factor for HNC. METHODS: The present study was carried out to determine the active form of HPV-16 using a combination of PCR, viral load determination, HPV-16 E7 mRNA expression, p16, p53, and pRB immuno-histochemistry (IHC). RESULTS: A total of 226 HNC patients were enrolled in the present study. Sixty-seven (29.7%) of HNC cases were found to be HPV DNA positive. Thirty-two (14%) cases were HPV-16 DNA positive and 20 (9%) cases expressed HPV-16 E7 mRNA. HPV-16 mRNA/p16 positive cases had significantly increased viral load and integrated HPV-16 DNA. In summary, of total HNC patients, 6% cases were positive for both HPV-16 DNA and p16, and 5% were positive for both E7 mRNA and p16 IHC. We observed similar HPV-16 DNA/E7mRNA prevalence in oropharynx and oral cavity sites, however, oropharynx SCC had significantly higher viral load. CONCLUSION: Our results show low prevalence of active HPV-16 in North Indian HNC patients. HPV-16 E7 mRNA expression correlated with p16 nuclear positivity and increased viral load. Therefore, E7 mRNA expression may be used as a good surrogate indicator for active form of HPV-16 infection.

Predominance of PR3 specific immune response and skewed TH17 vs. T-regulatory milieu in active granulomatosis with polyangiitis.

OBJECTIVE: We compared levels of Th1/Th2/Th17 cytokines and T-regulatory cells in active and remitting granulomatosis with polyangiitis (GPA). METHODOLOGY: Twenty-one cases of GPA in active state as well as in remitting state and 20 healthy controls (HC) were enrolled in the study. Cytokines were detected in culture supernatants of PBMCs after stimulation with proteinase-3 (PR3) and phytohemagglutinin antigen (PHA). Serum IL-17 cytokine was studied by ELISA. T-regulatory cells (Tregs) were analyzed by flow cytometry. Gene expression of FOXP3 and ROR-γt was compared by Real Time PCR. RESULTS: We observed significantly increased level of IL-17 in serum as well in culture supernatants of PBMCs after PR3 stimulation along with ROR-γt gene expression in active disease state of GPA as compared to HC. Importantly, remitting state showed low levels of serum IL-17 with decreased ROR-γt gene expression and increased FOXP3 expression. Using PR3 as an immunostimulant, we could demonstrate the generation of IL-17 and TNF-α secreting effector memory cells during remission. Reduced FOXP3 expression with reduced IL-10 levels in active disease indicated the reduced function of Tregs in active disease. CONCLUSION: We observed Th17 dominant environment in peripheral blood of patients in active state of disease, with "hyporesponsiveness", in, in vitro stimulated PBMC-in their ability to secrete TNF-α and IL-6. Treg numbers were unaltered but function was compromised. Targeting PR3 specific effector memory cells, to prevent relapse, and instituting anti IL-17 therapy, or modulating Tregs could be newer forms of therapy for this serious autoimmune disease.

Role of autophagy in head and neck cancer and therapeutic resistance.

Head and neck squamous cell carcinomas (HNSCC) are one of the most common cancers worldwide, accounting for almost 50% of all malignancies in developing nations. Autophagy is a catabolic process involving turnover of long-lived proteins and organelles and is an important mechanism for cell survival under stress conditions. Autophagy has been shown to play a pivotal role in etio-pathogenesis of several cancers. Autophagy and apoptosis may be triggered by common upstream signals, and sometimes this results in combined autophagy and apoptosis, or defective apoptosis rendering immortalized epithelial cells highly tumorigenic. Autophagy has been found to buffer metabolic stress and may help in cell survival; however, inhibiting autophagy under conditions of nutrient limitation can restore cell death to apoptosis-refractory tumors. Therefore, autophagy acts as a double-edged sword in cancer therapeutics. Role of autophagy in pathophysiology and as a potential cancer therapeutics is a subject of intensive research. This review will focus on the role of autophagy and how it contributes to the pathogenesis and overcoming therapeutic resistance in HNSCC.

Early evaluation of voice quality in glottic cancer (T1, T2) following curative radiotherapy.

BACKGROUND: This is prospective study analyzing the subjective and objective quality of voice and voice related quality of life in patients of early glottic cancer (T1, T2 disease) before and after receiving curative radiotherapy. METHODS: Fifteen patients of early glottic carcinoma (T1, T2) underwent voice assessment using multidimensional voice protocol based on recommendation by European Laryngological Society which included Perceptual analysis of voice by speech therapist and otolaryngologist, acoustic analysis; aerodynamic efficiency analysis-Maximum phonation time; patient's self perception of voice analysis--Voice handicap index; and videolaryngostroboscopy. Assessment was done prior to commencement of radiation therapy and at 1 month and 3 months following radio- therapy. RESULTS: There was significant improvement in majority of the voice parameters post radiotherapy. Perceptual analysis showed significant improvement in GRBAS score following radiotherapy. Perturbation measures (jitter, shimmer, SNR, HNR) showed improvement post radiotherapy though remained inferior compared to controls. Mean fundamental frequency (Mean F0) and habitual frequency (habitual F0) decreased post radiotherapy. Intensity of voice increased following radiotherapy which was statistically significant (p < 0.05). There was significant improvement in the patient's perception of their quality of voice and voice related quality of life post radiotherapy. Maximum phonation time showed statistically significant improvement post-radiotherapy. Perceptual analysis of voice by professional observer correlated well with patients self perception of his own voice. CONCLUSION: Voice quality improves following radiotherapy but not all the patients regain normal voice. Improvement in voice quality improves quality of life of patients shown by improved voice handicap index.

Pyriform sinus injury in thyroidectomy: the unknown complicating the known.

Thyroidectomy is a common procedural skill in the armamentarium of an otolaryngologist but has its own set of complications. The more common complications are hypocalcaemia, recurrent laryngeal nerve palsy, injury to the external branch of the superior laryngeal nerve, postoperative bleeding, wound infection and, rarely, thyroid storm. High pyriform sinus injury during hemithyroidectomy is extremely rare, with this report being only the second reported case in the literature. A 61-year-old man presented with complaints of right-sided neck swelling. The patient had a 10cm × 8cm sized swelling in the anterior neck on examination. A contrast-enhanced computed tomography scan revealed a heterogeneously enhancing mass lesion involving the right lobe of the thyroid and isthmus with multiple nodules. The patient underwent right hemithyroidectomy with no intraoperative complications. The histopathology report describes a papillary thyroid carcinoma (cT3 N0 M0) with the presence of angioinvasion. On the fifth postoperative day, the patient complained of neck pain, suture site swelling and a change of voice. A volume of 50ml of whitish purulent fluid was evacuated. A laryngeal exam revealed restriction in mobility of the right vocal cord. The oesophagogram revealed the iatrogenic injury to the hypopharynx. The oesophageal leak gradually resolved after 6 weeks, as evidenced by multiple contrast oesophagogram, without any need for surgical intervention. We theorise that, while operating on long-standing monster thyroids, extra care should be given while dissecting in the tracheoesophageal groove as the stretched mucosa, an extracapsular extension of disease and lymphovascular invasion can all jeopardise the underlying structures.

Hypermethylation of carcinogen metabolism genes, CYP1A1, CYP2A13 and GSTM1 genes in head and neck cancer.

OBJECTIVES: To investigate the role of aberrant hypermethylation of carcinogen metabolism pathway genes, CYP1A1, CYP2A13 and GSTM1 in head and neck cancer independently as well as its relation to tobacco and alcohol consumption and CYP1A1 and CYP2A13 polymorphisms in Indian population. METHODS: Seventy-three histologically confirmed head and neck cancer patients undergoing treatment in Postgraduate Institute of Medical Education and Research, Chandigarh, India were recruited. Non-cancerous tissues were obtained from 19 trauma subjects undergoing maxillofacial surgery. Methylation-specific PCR was performed to determine the methylation status of selected genes. RESULTS: The aberrant hypermethylation of CYP1A1, CYP2A13 and GSTM1 genes was found in cancer tissues with frequency of about 39.7%, 27.4%, and 58.1%, respectively, and in normal healthy tissues with a frequency of about 10.5%, 15.8%, and 20.0%, respectively. Hypermethylation of CYP1A1 (P 0.027) and GSTM1 (P 0.010) showed significant association with head and neck cancer. We also observed significant interaction between smoking and methylation status of CYP1A1 (P 0.029) and CYP2A13 (P -0.034) in head and neck cancer. No association was observed between methylation status and alcohol consumption, clinical features and genetic polymorphisms of CYP1A1 and CYP2A13. CONCLUSIONS: Hypermethylation of carcinogen metabolism pathway genes independently and in interaction with smoking is associated with increased risk of head and neck cancer.

Effect of pneumoperitoneum on intracranial pressure during supratentorial craniotomy: a case report.

Laparoscopic surgery has become the method of choice for many procedures previously performed by open techniques. However, its use in patients with a potentially decreased intracranial compliance warrants caution. We report a case of combined glioma excision and laparoscopic cholecystectomy procedures with evaluation of the effects of pneumoperitoneum on ICP and operative field. The clinical implications, safety and recommendations of conducting laparoscopic surgeries in neurosurgical patients are discussed. Performing pneumoperitoneum in patients with marginal intracranial compliance needs interdisciplinary discussions and ICP monitoring is mandatory.

Intrathecal neostigmine with bupivacaine for infants undergoing lower abdominal and urogenital procedures: dose response.

BACKGROUND: Intrathecal (IT) neostigmine produces dose-dependent analgesia in adults. However, the dose of spinal neostigmine has not been investigated in infants. The purpose of this study was to assess spinal anesthesia (SA) duration provided by four doses of spinal neostigmine added to bupivacaine for lower abdominal and urogenital procedures in infants. METHODS: Seventy-five infants were randomized into five groups. The control group B received IT plain 0.5% hyperbaric bupivacaine. Groups BN.25, BN.50, BN.75, and BN1.0 received bupivacaine with 0.25, 0.5, 0.75, and 1 microg/kg of neostigmine, respectively. The primary variable was the duration of anesthesia assessed by recovery of hip flexion. Postoperative pain with facial expression, leg activity, arm activity, crying and consolability scale score, and rescue analgesic requirements were the secondary variables measured, and the side effects were noted. RESULTS: Seventy-three infants completed the study. There was a significant linear increase in SA duration with IT neostigmine to 65.2 (4.3) min with 0.5 microg/kg (P<0.01), 88.2 (5.1) with 0.75 microg/kg (P<0.001) and 92 (4.3) with 1 microg/kg (P<0.001) from 52.4 (4.3) min with bupivacaine alone. SA duration showed no significant difference between plain bupivacaine and BN.25 (P=0.100) or between groups BN.75 and BN1.0 (P=0.451). Groups BN.75 and BN1.0 had significantly reduced pain scores, and the median duration before the first dose rescue analgesic was requested prolonged significantly (P<0.001) compared with the other three groups. CONCLUSIONS: IT neostigmine at a dose of 0.75 microg/kg added to bupivacaine significantly prolonged SA duration with reduced postoperative pain scores and rescue analgesic requirements in infants undergoing lower abdominal and urogenital procedures. No additional benefits were provided on increasing it to 1 microg/kg.

Invasive zygomycosis in India: experience in a tertiary care hospital.

AIM: To report the natural history and clinical course of zygomycosis from a single tertiary care centre in India where doctors maintain an institutional zygomycosis registry. METHODS: The clinical and laboratory data collected prospectively from patients with antemortem diagnosis for invasive zygomycosis, and retrospectively from autopsy diagnosed cases, over an 18 month period (July 2006-December 2007) were combined and analysed. RESULTS: During the period 75 cases (50 cases/year) of zygomycosis were reported. Antemortem diagnosis could be made in 81% of cases and 9% of patients had nosocomial zygomycosis. The spectrum of disease included rhino-orbito-cerebral (48%), pulmonary (17%), gastrointestinal (13%), cutaneous (11%), renal and disseminated zygomycosis (5% each). Uncontrolled type 2 diabetes (58%) and diabetic ketoacidosis (38%) in the rhino-orbito-cerebral type, renal failure (69%) in the pulmonary type, prematurity (70%) in the gastrointestinal type, and breach of skin (88%) in cutaneous zygomycosis, were the significant (p<0.05) underlying illnesses. Rhizopus oryzae (69%) was the most common isolate followed by Apophysomyces elegans (19%). Overall mortality was 45% in patients who could be treated. Outcome was significantly poor when surgical debridement could not be performed or the patients were treated only with amphotericin B deoxycholate. On multivariate analysis, patients with a Glasgow Coma Score (GCS) >or=9 had a better prognosis. CONCLUSIONS: Zygomycosis is a threat in uncontrolled diabetes. New risk factors such as renal failure and chronic liver disease require attention. A elegans is an emerging agent in India. The need for surgical debridement in addition to medical treatment is emphasised. GCS is an independent marker of prognosis in cases of invasive zygomycosis.

Normalisation of voice parameters in patients with unilateral vocal fold palsy: is it realistic?

BACKGROUND: Disorders of voice can limit an individual's participation and impair social interaction, thus affecting overall quality of life. Perceptual and objective evaluations can provide the clinician with detailed information regarding voice disorders. METHODS: This study comprised 40 subjects aged 34-46 years, 20 of whom (10 male, 10 female) had unilateral vocal fold palsy. Data were obtained for all participants from: the Voice Handicap Index, the grade, roughness, breathiness, asthenia and strain ('GRBAS') scale, acoustic voice analysis, electroglottography, and voice range profiles. RESULTS: The voice evaluations revealed statistically significant (p < 0.05) differences between the controls and study group, both in males and females, pre- and post-therapy. CONCLUSION: Despite the normalisation of vocal parameters, acoustic, perceptual and self-rated assessments revealed statistically significant differences after therapy. Hence, acoustic measures, namely electroglottographic perturbation, and voice frequency and intensity range, are recommended prior to termination of therapy.

Combination of low doses of intrathecal ketamine and midazolam with bupivacaine improves postoperative analgesia in orthopaedic surgery.

BACKGROUND: Intrathecal ketamine produces a short period of analgesia with stable haemodynamics. Midazolam with bupivacaine prolongs the duration of analgesia when administered intrathecally but does not prevent hypotension. The objective of this study was to assess the effect of a combination of intrathecal bupivacaine, ketamine and midazolam on the duration of analgesia and haemodynamic parameters. METHODS: A prospective, randomized, double-blind study was carried out in 60 ASA I and II patients undergoing lower limb surgery under spinal anaesthesia. Patients were divided into three groups of 20 each. Patients in all the three groups received 3 mL of hyperbaric bupivacaine (0.5%) intrathecally. In addition, patients in Groups II and III received intrathecal ketamine (0.1 mg kg-1) and the same dose of ketamine along with midazolam (0.02 mg kg-1), respectively. All patients were evaluated for block characteristics, duration of pain-free period, total rescue analgesic requirement in the 24-h postoperative period, total dose of mephenteramine to treat hypotension and any central or neurological complication. RESULTS: No patients in Group II required mephenteramine while 40% of patients in Group I and 10% in Group III required mephenteramine to maintain blood pressure after spinal anaesthesia. The mean +/- standard deviation duration of pain-free period was 331.5 +/- 89.9, 369.7 +/- 124.2 and 730.5 +/- 81.5 min in Group I, II and III, respectively. The pain-free interval was significantly greater in Group III compared to Groups I and II (P < 0.001). No patient had any complications. CONCLUSION: A low dose of midazolam and ketamine with bupivacaine intrathecally results in prolonged analgesia and less haemodynamic fluctuations. However, the safety of this combination needs to be proved before its use in clinical practice.

A deterministic evaluation of heat stress mitigation and feed cost under climate change within the smallholder dairy sector.

In the global South, dairying is often promoted as a means of poverty alleviation. Yet, under conditions of climate warming, little is known regarding the ability of small-scale dairy producers to maintain production and/or the robustness of possible adaptation options in meeting the challenges presented, particularly heat stress. The authors created a simple, deterministic model to explore the influence of breed and heat stress relief options on smallholder dairy farmers in Odisha, India. Breeds included indigenous Indian (non-descript), low-grade Jersey crossbreed and high-grade Jersey crossbreed. Relief strategies included providing shade, fanning and bathing. The impact of predicted critical global climate parameters, a 2°C and 4°C temperature rise were explored. A feed price scenario was modelled to illustrate the importance of feed in impact estimation. Feed costs were increased by 10% to 30%. Across the simulations, high-grade Jersey crossbreeds maintained higher milk yields, despite being the most sensitive to the negative effects of temperature. Low-capital relief strategies were the most effective at reducing heat stress impacts on household income. However, as feed costs increased the lower-grade Jersey crossbreed became the most profitable breed. The high-grade Jersey crossbreed was only marginally (4.64%) more profitable than the indigenous breed. The results demonstrate the importance of understanding the factors and practical trade-offs that underpin adaptation. The model also highlights the need for hot-climate dairying projects and programmes to consider animal genetic resources alongside environmentally sustainable adaptation measures for greatest poverty impact.

A novel electrospinning approach to fabricate high strength aqueous silk fibroin nanofibers.

The present paper describes a rapid method of producing concentrated aqueous regenerated Bombyx mori silk fibroin (RSF) solution by applying mild shearing under forced dehumidified air and generation of electrospun SF nanofibers from concentrated solution with high mechanical strength using free liquid surface electrospinning machine. The shear induced concentrating mechanism favoured the electrospinning process by enhancing the viscosity (>2.43Pas as onset for electrospinning) and decreasing the surface tension of the solution (40.1-37.7mN/m). Shearing reduced the ß-turns and random coil molecular conformation and thereby, intensified the ß-sheet content from 16.9% to 34% which is the minimum content needed to commence RSF nanofibers formation. Subsequently, electrospun nanofibrous mats were produced from different batches of concentrated SF solutions (15-21wt%). Among the concentrated RSF, 17wt% RSF solution was the most favourable concentration producing electrospun nanofibrous mat having lowest average fiber diameters of 183±55nm and good tensile strength. The mechanical strength of the nanofibrous sheet was further improved by cross-linking with 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide hydrochloride and N-hydroxysuccinimide (EDC+NHS) which might be due to enhancement of ß-sheet content. These nanofibers exhibited 17.57±1.13MPa ultimate tensile strength, 12.48±1.46% tensile strain at break and 37.7% increase in root mean square surface roughness which is favourable feature for cell adhesion and neo-tissue formation.

Carboxymethyl cellulose enables silk fibroin nanofibrous scaffold with enhanced biomimetic potential for bone tissue engineering application.

Novel silk fibroin (SF) and carboxymethyl cellulose (CMC) composite nanofibrous scaffold (SFC) were developed to investigate their ability to nucleate bioactive nanosized calcium phosphate (Ca/P) by biomineralization for bone tissue engineering application. The composite nanofibrous scaffold was prepared by free liquid surface electrospinning method. The developed composite nanofibrous scaffold was observed to control the size of Ca/P particle (≤100nm) as well as uniform nucleation of Ca/P over the surface. The obtained nanofibrous scaffolds were fully characterized for their functional, structural and mechanical property. The XRD and EDX analysis depicted the development of apatite like crystals over SFC scaffolds of nanospherical in morphology and distributed uniformly throughout the surface of scaffold. Additionally, hydrophilicity as a measure of contact angle and water uptake capacity is higher than pure SF scaffold representing the superior cell supporting property of the SF/CMC scaffold. The effect of biomimetic Ca/P on osteogenic differentiation of umbilical cord blood derived human mesenchymal stem cells (hMSCs) studied in early and late stage of differentiation shows the improved osteoblastic differentiation capability as compared to pure silk fibroin. The obtained result confirms the positive correlation of alkaline phosphatase activity, alizarin staining and expression of runt-related transcription factor 2, osteocalcin and type1 collagen representing the biomimetic property of the scaffolds. Thus, the developed composite has been demonstrated to be a potential scaffold for bone tissue engineering application.