Diffuse large B-cell lymphoma as an extra-hepatic manifestation of hepatitis C and co-infection of helicobacter pylori: A case report.

Along with infecting hepatocytes, the Hepatitis C virus (HCV) is also a lymphotropic virus. Chronic HCV infection can mutate the Bcl2, a proto-oncogene that inhibits apoptosis. This causes continuous stimulation of B lymphocytes, which results in clonal growth of these immunoglobulin-producing cells. In Western countries, there is a well-documented link between HCV and lymphoproliferative illness. HCV and Non-Hodgkin lymphoma (NHL) have been found to be significantly correlated in Europe, Japan, and the southern United States. There, however, has been no association found in central and northern Europe, the northwestern United States, and some Asian countries. A literature deficit exists in South Asia about the incidence of HCV infection in lymphoma patients. Here, the first documented instance of Diffuse Large B-cell NHL (germinal center type) is reported in a 35-year-old patient. The patient presented to the outpatient department at Ruth KM Pfau, Civil Hospital Karachi, in July of 2022, with the chief complaints of altered bowel habits due to involvement of the anorectal junction and concomitant infection by Helicobacter pylori with a prior history of HCV infection.

Comparison of efficacy of daily and alternate day maintenance treatment of GERD with Vonoprazan 10-mg using Gastroesophageal Reflux Disease Symptom Assessment Scale.

Objectives: To compare efficacy of 10-mg of vonoprazan daily & on alternate days by Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS). Method: This prospective interventional cohort was done at Department of Medicine/Gastroenterology Dow Medical College, Karachi, Pakistan during the period August 2022 & January 2023. Potential participants fulfilling inclusion and exclusion criteria were asked to fill out GSAS questionnaires after their written consent. Patients were allocated in to two groups using random tables. Group-A was given Tab Vonoprazan 10-mg daily for two weeks. Group-B was given Tab Vonoprazan 10-mg on alternate day. GSAS was scored by totaling scores across symptoms and then they are divided by the total number of non-missing symptom scores. Both groups were assessed week-0 & week-2. Results: Only 90 proformas that were completely filled were included, Group-A had 30 males and 15 females while Group-B had 29 males and 16 females. No significant difference in score was found in GSAS score at week-0 except that in item 'gurgling' while at week two there was no significant difference between any of the items. Total GSAS score were significantly lower at Week-2 than at week-0 (p = <.001). Conclusions: Vonoprazan of 10-mg on alternate day is equally effective as 10-mg daily in maintenance of GERD patients at two weeks.

Validation and exploratory factor analysis of Urdu Version of Chronic Liver Disease Questionnaire.

Objective: To present and validate psychometric properties of Urdu version CLDQ, yet another objective was to do exploratory factorial analysis (EFA) of CLDQ Urdu version. Methods: This Cross-sectional Analytical Study was conducted at Dr. Ruth K.M. Pfau Civil Hospital Karachi during the period Nov. 15, 2021 to Jan. 30, 2022. CLDQ Urdu questionnaire was self-administered by the patients. The questionnaire consisted of 29 items and responses were recorded on 7-point Likert type scale. Reliability testing was done by Cronbach's α, test value of >0.7 is taken as reliable. Exploratory factor analysis (EFA) was conducted with principal component analysis with varimax rotation. Adequacies for conduction of EFA depended on Kaiser-Meyer-Olkin (KMO) value of ≥0.5 and Bartlett's Test of Sphericity (BTS) of ≤0.05. Mean CLDQ Urdu scores were also compared with Child Class using ANOVA and post-hoc analysis was done. Results: A total of 320 patients were selected after informed consent. All conditions for adequate EFA were met (Cronbach's α =.949; KMO = .846; BTS ≤.001). Mean CLDQ Urdu score was 156.74 in male and 133.27 in female (p<.001). Child Class-A had best quality of life with score of 186.63 ±6.91 and Child Class-C had the worst with scores of 109.78 ±21.33. EFA resulted in reduction of domains to 4 (Muscular Symptoms, Emotional Symptoms, Abdominal Symptoms & Somnolence) & reduced the number of items from 29 to 11. Conclusion: Urdu CLDQ version is validated in our settings. EFA resulted in reductions in number of domains and items. CLDQ Urdu showed that quality of life decreases significantly with Child Class.

Allaying Pediatric Preoperative Anxiety, Where are we Now? - A Nationwide Survey.

Background: Preoperative anxiety (PA) in children is a common phenomenon associated with various negative patient outcomes. Allaying PA is accepted as a standard of care, but its use is not universal and often overlooked. This survey is designed to evaluate the nationwide current practice patterns and attitudes of anesthesiologists toward the practice of allaying PA in children. Materials and Methods: A questionnaire of 25 questions, including information on methods of relieving PA in children, reasons for noncompliance, and associated complications, was framed. It was circulated among members of the Indian Society of Anaesthesiologists through an online survey of Google Forms and manually. Results: Four hundred and fifty anesthesiologists were surveyed. Responses were predominantly from anesthesiologists practicing in medical colleges across the country. Although 97% of the surveyed respondents practiced anxiety-relieving strategies, only 37% used it consistently. Seventy-three percent of anesthesiologists practiced both pharmacological and nonpharmacological techniques. The most common reason for avoiding premedication was an anticipated difficult airway (88%). Inadequate sedation was a commonly reported problem. Ninety-five percent of participants felt that PA-relieving strategies should be integral to pediatric anesthesia practice. The most common reason for not following these practices was an inadequate hospital infrastructure (67%). Ninety-seven percent of the participants believed that more awareness is required on this crucial perioperative issue. Conclusion: Only 37% of the surveyed anesthesiologists consistently used some form of PA-relieving strategy and the practice varied widely. Further improvement and team approach involving anesthesiologists, surgeons, and nurses is required to ensure the quality of pediatric PA-relieving services and establish it as a standard of care.

Current practice of Rapid Sequence Induction (RSI) in pediatric anesthesia: A survey from India.

Background and Aims: Rapid Sequence Induction (RSI) is an established technique to secure the airway in patients who are at risk of aspiration. The practice of RSI in the pediatric population is highly variable due to numerous patient factors. We conducted a survey to find the prevalent practices and adherence of anesthesiologists to the practice of RSI in different pediatric age groups and whether it differs with the experience of the anesthesiologist or the age of the child. Material and Methods: The survey was conducted among residents and consultants attending the pediatric national anesthesia conference. The questionnaire consisted of 17 questions on anesthesiologist's experience, adherence, conduct of pediatric RSI, and the reason for nonadherence. Results: The response rate was 75% (192/256). Anesthetists having less than 10 years of experience adhered to RSI more often as compared to respondents with more experience. Succinylcholine was the most commonly used muscle relaxant for induction, with use increasing in higher age groups. The application of cricoid pressure increased with increasing age groups. Anesthetists with >10 years of experience used cricoid pressure more often in age groups of <1 year (P < 0.05). In a scenario of intestinal obstruction, adherence to RSI was low in pediatrics as compared to adults, with 82% of respondents agreeing to this. Conclusion: This survey on the practice of RSI in the pediatric population demonstrates wide variation in the practice among individuals and the reasons for nonadherence as compared to adults. It highlights the need felt by almost all the participants for more research and protocol in the practice of pediatric RSI.

Comparative evaluation of landmark technique and ultrasound-guided caudal epidural injection in pediatric population: A systematic review and meta-analysis.

BACKGROUND: Caudal block is a common regional anesthesia technique in pediatrics with landmark method predominantly being practiced. Ultrasound-guided technique provides real-time visualization of the structures and injection while performing caudal block. We performed this meta-analysis to determine the utility of ultrasound in caudal blocks in children over the landmark-based technique. METHODS: Randomized controlled trials comparing ultrasound-guided caudal blocks and landmark technique in pediatrics were searched from databases-PubMed, Embase, Scopus, and CENTRAL from inception until August 2020. The primary objective was success rate between the two techniques and secondary objectives included time to perform the block, first puncture success, and complications. RESULTS: Five trials with 904 participants were included for this meta-analysis. There was no difference in success rate between the two techniques (Risk ratio-1.07; 95% CI [0.97, 1.18]; p = .15). Time to perform the block was similar (Mean difference-8.88 s; 95% CI [-21.64, 39.40; p = .57) while first puncture success was higher with ultrasound-guided technique (Risk ratio-1.31; 95% CI [1.15, 1.49]; p = .0001). Complications like vascular puncture and needle misplacement were lower in the ultrasound group, and no serious complications were seen in any patient. Needle visualization and sacral canal distension were seen in 82% and 97.5% of the cases, respectively, in ultrasound group. CONCLUSION: Ultrasound-guided caudal injection does not improve the success rate or time to perform the block but results in higher first puncture success and lower incidence of complications compared to landmark technique.

Comparison of Vonoprazan and Amoxicillin Dual Therapy with Standard Triple Therapy with Proton Pump Inhibitor for Helicobacter Pylori eradication: A Randomized Control Trial.

Objectives: To compare the efficacy of Vonoprazan based dual treatment versus PPI based treatment for the eradication of Helicobacter pylori infection. Methods: A randomized controlled trial was conducted in Department of Medicine/Gastroenterology Ruth KM Pfau Civil Hospital, DMC during the period of 22 June to 21 September 2021. Sample size was calculated as 96 in each Group. All patients of age 18-75 years with Helicobacter Pylori Infection were inducted and randomly allocated to two groups. Group-A: were given Capsule Amoxicillin 1 gm; Tablet Clarithromycin 500 mg; Capsule Omeprazole 20 mg all medications were given twice daily for two weeks. Group-B were given Capsule Amoxicillin 1 gm; Tablet Vonoprazan 20 mg (Vonozon©, m/s Getz Pharma, Pakistan) twice daily for two weeks. Confirmation of Hp eradication was done by stool Hp antigen test four weeks after completion of treatment. Nine and four patients were lost to follow-up in Group-A & B respectively. Analysis was conducted on 87 patients in Group-A and 92 patients in Group-B. Results: Out of eighty-seven patients in Group-A and ninety-two patients in Group-B, 73 (83.9%) patients in Group-A and 86 (93.5%) patients in Group-B had negative H pylori result respectively after treatment (p = .042). Significantly higher frequencies of adverse events were observed in Group-A as compared to Group-B in nausea/vomiting (p = .035) and bloating (p = .045). Conclusion: VA-dual provides an acceptable eradication rate with fewer adverse events.

Validation of a Bench-Top Training Model for Retrograde Intrarenal Surgery.

OBJECTIVE: To validate the in-house built Styrofoam box bench-top training model for retrograde intrarenal surgery (RIRS). MATERIALS AND METHODS: This study was performed in the setting of a half-day RIRS course. During the course, participants performed RIRS on a locally built bench-top model. We recruited 26 participants, comprising 20 trainees and 6 experts. Trainees and experts were asked to fill a self-administered questionnaire assessing various components of RIRS to assess the face and content validity. For construct validity, experts using Objective Structured Assessment of Technical Skills (OSATS) rated trainees and the mean OSATS score of junior versus senior residents was compared. RESULTS: As per trainees, the model was 86% (4.3/5) realistic, which was backed by experts who found this model to be 87.6% (4.38/5) realistic. The overall face validity of the model was 86.4% (4.32/5). The overall content validity of this model was 83.4% (4.17/5). Majority of the participants thought that this tool is useful for learning technique (4.38 ± 0.49) and safe-conduct (4.31 ± 0.73) of the procedure. The trainees concurred that the skills acquired are transferable to the operating room (4.23 ± 0.76). However, the construct validity by comparing mean OSATS score of junior versus senior residents was 19.5 ± 3.5 and 23 ± 4.5. A p value of 0.11 could not be established. CONCLUSION: This study has demonstrated the face, content, and construct validity of the bench-top training model for RIRS. Further evaluation is necessary to compare its effectiveness against other available models to demonstrate concurrent validity.

Pharmacological treatment of depression in people with a primary brain tumour.

BACKGROUND: This is the second updated version of the Cochrane Review published in Issue 3, 2010 and first updated in Issue 5, 2013. People with a primary brain tumour often experience depression, for which drug treatment may be prescribed. However, they are also at high risk of epileptic seizures, cognitive impairment, and fatigue, all of which are potential adverse side effects of antidepressants. The benefit, or harm, of pharmacological treatment of depression in people with a primary brain tumour is unclear. OBJECTIVES: To assess the benefits and harms of pharmacological treatment of depression in people with a primary brain tumour. SEARCH METHODS: We updated the search to include CENTRAL, MEDLINE, Embase, and PsycINFO to September 2019. As in the original review, we also handsearched Neuro-Oncology, Journal of Neuro-Oncology, Journal of Neurology, Neurosurgery and Psychiatry, and Journal of Clinical Oncology: for the current update we handsearched the latest three years of articles from these journals (up to November 2019). SELECTION CRITERIA: We searched for all randomised controlled trials (RCTs), controlled clinical trials, cohort studies, and case-control studies of any pharmacological treatment of depression in people with a histologically diagnosed primary brain tumour. DATA COLLECTION AND ANALYSIS: No studies met the inclusion criteria. MAIN RESULTS: We found no eligible studies evaluating the benefits of any pharmacological treatment of depression in people with a primary brain tumour. AUTHORS' CONCLUSIONS: We identified no high-quality studies that investigated the value of pharmacological treatment of depression in people with a primary brain tumour. RCTs and detailed prospective studies are required to inform the effective pharmacological treatment of this common and important complication of brain tumours. Since the last version of this review none of the related new literature has provided additional information to change these conclusions.

Role of Coccidioides Antigen Testing in the Cerebrospinal Fluid for the Diagnosis of Coccidioidal Meningitis.

BACKGROUND: Coccidioidal meningitis (CM), a common cause of chronic meningitis in endemic area, is usually diagnosed by detection of anti-Coccidioides antibodies in cerebrospinal fluid (CSF), and findings may be negative in up to one-third of cases. CSF cultures and cytology are infrequently positive. Antigen detection has been used for the diagnosis of other forms of coccidioidomycosis and meningitis caused by other mycoses. The purpose of this study was to assess the diagnostic utility of CSF Coccidioides antigen (CAg) detection for the diagnosis of CM. METHODS: The medical records of patients with clinically suspected meningitis, in whom CSF was tested for Coccidioides antibodies and CAg, were retrospectively reviewed, and CSF CAg testing was prospectively conducted in patients with CM. All specimens were submitted for CAg testing. RESULTS: Thirty-six patients with 42 episode of CM were studied. The sensitivity and specificity of CAg were 93% and 100%, respectively. Cultures of CSF were positive in 7%, antibodies were demonstrated by immunodiffusion in 67% and complement fixation in 70%, and immunoglobulin M and G antibodies were demonstrated by enzyme immunoassay in 8% and 85%, respectively. CONCLUSIONS: Testing CSF for CAg is a useful addition to diagnostic methods in suspected CM and complements testing with CSF antibodies and culture.

A predictor-informed multi-subject bayesian approach for dynamic functional connectivity.

Dynamic functional connectivity investigates how the interactions among brain regions vary over the course of an fMRI experiment. Such transitions between different individual connectivity states can be modulated by changes in underlying physiological mechanisms that drive functional network dynamics, e.g., changes in attention or cognitive effort. In this paper, we develop a multi-subject Bayesian framework where the estimation of dynamic functional networks is informed by time-varying exogenous physiological covariates that are simultaneously recorded in each subject during the fMRI experiment. More specifically, we consider a dynamic Gaussian graphical model approach where a non-homogeneous hidden Markov model is employed to classify the fMRI time series into latent neurological states. We assume the state-transition probabilities to vary over time and across subjects as a function of the underlying covariates, allowing for the estimation of recurrent connectivity patterns and the sharing of networks among the subjects. We further assume sparsity in the network structures via shrinkage priors, and achieve edge selection in the estimated graph structures by introducing a multi-comparison procedure for shrinkage-based inferences with Bayesian false discovery rate control. We evaluate the performances of our method vs alternative approaches on synthetic data. We apply our modeling framework on a resting-state experiment where fMRI data have been collected concurrently with pupillometry measurements, as a proxy of cognitive processing, and assess the heterogeneity of the effects of changes in pupil dilation on the subjects' propensity to change connectivity states. The heterogeneity of state occupancy across subjects provides an understanding of the relationship between increased pupil dilation and transitions toward different cognitive states.

The Safety of Cold Versus Hot Snare Polypectomy in Polyps 10-20 mm: A Systematic Review and Meta-Analysis.

Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I2 of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I2 of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.

Effect of N95 Filtering Facepiece Respirator on Venous Blood Carbon Dioxide Levels and Hemodynamic Changes in Health Care Workers.

Background: N95 filtering facepiece respirators (FFR) are used by health care workers for prevention of airborne infection, and its use has increased manifolds during COVID-19 pandemic. Prolonged use may result in carbon dioxide (CO2) accumulation, affect hemodynamics, and blood gas values. Although arterial blood gas values accurately measure the blood CO2 levels, venous blood gas values also show acceptable correlation. Aim: To evaluate the physiological impact of N95 FFRs on health care workers, including hemodynamic changes and venous blood levels of CO2 during a period of 6 h. Settings and Design: Prospective observational study in a tertiary care hospital. Methods: The study was conducted on 30 health care workers who performed routine duties while wearing N95 FFR. Venous blood gas values (CO2, pH, and bicarbonate) and vitals (respiratory rate, heart rate, blood pressure, and saturation) were noted at baseline, 2 (T2), and 6 h (T6) after wearing the mask. Discomfort level was also measured on a Visual Analogue Scale (VAS) of 1-10. Statistical Analysis: Repeated measures analysis was done using repeated measures ANOVA or Friedman's test. Group comparisons for continuously distributed data were made using independent sample "t" test or Wilcoxon test. Results and Conclusion: Hemodynamic and blood gas values did not change over time. The VAS for discomfort because of respirator use was 1.33 (1.42) at T2 and 2.77 (1.91) at T6. This was a significant increase in discomfort over time (P = 0.001). About 80% of participants experienced discomfort during this period. N95 FFR did not lead to significant alteration in hemodynamics or change in blood gas values after 6 h of continuous usage. However, discomfort significantly increased over time.

A Novel Hidden Markov Approach to Studying Dynamic Functional Connectivity States in Human Neuroimaging.

Introduction: Hidden Markov models (HMMs) are a popular choice to extract and examine recurring patterns of activity or functional connectivity in neuroimaging data, both in terms of spatial patterns and their temporal progression. Although many diverse HMMs have been applied to neuroimaging data, most have defined states based on activity levels (intensity-based [IB] states) rather than patterns of functional connectivity between brain areas (connectivity-based states), which is problematic if we want to understand connectivity dynamics: IB states are unlikely to provide comprehensive information about dynamic connectivity patterns. Methods: We addressed this problem by introducing a new HMM that defines states based on full functional connectivity (FFC) profiles among brain regions. We empirically explored the behavior of this new model in comparison to existing approaches based on IB or summed functional connectivity states using the Human Connectome Project unrelated 100 functional magnetic resonance imaging "resting-state" dataset. Results: Our FFC model discovered connectivity states with more distinguishable (i.e., unique and separable from each other) patterns than previous approaches, and recovered simulated connectivity-based states more faithfully than the other models tested. Discussion: Thus, if our goal is to extract and interpret connectivity states in neuroimaging data, our new model outperforms previous methods, which miss crucial information about the evolution of functional connectivity in the brain. Impact statement Hidden Markov models (HMMs) can be used to investigate brain states noninvasively. Previous models "recover" connectivity from intensity-based hidden states, or from connectivity "summed" across nodes. In this study, we introduce a novel connectivity-based HMM and show how it can reveal true connectivity hidden states under minimal assumptions.

Locus coeruleus integrity predicts ease of attaining and maintaining neural states of high attentiveness.

The locus coeruleus (LC), a small subcortical structure in the brainstem, is the brain's principal source of norepinephrine. It plays a primary role in regulating stress, the sleep-wake cycle, and attention, and its degradation is associated with aging and neurodegenerative diseases associated with cognitive deficits (e.g., Parkinson's, Alzheimer's). Yet precisely how norepinephrine drives brain networks to support healthy cognitive function remains poorly understood - partly because LC's small size makes it difficult to study noninvasively in humans. Here, we characterized LC's influence on brain dynamics using a hidden Markov model fitted to functional neuroimaging data from healthy young adults across four attention-related brain networks and LC. We modulated LC activity using a behavioral paradigm and measured individual differences in LC magnetization transfer contrast. The model revealed five hidden states, including a stable state dominated by salience-network activity that occurred when subjects actively engaged with the task. LC magnetization transfer contrast correlated with this state's stability across experimental manipulations and with subjects' propensity to enter into and remain in this state. These results provide new insight into LC's role in driving spatiotemporal neural patterns associated with attention, and demonstrate that variation in LC integrity can explain individual differences in these patterns even in healthy young adults.

Frequency of domestic violence in pregnancy and its adverse maternal outcomes among Pakistani women.

Objective: To determine the frequency of domestic violence in pregnancy and its adverse maternal outcomes among Pakistani women. Material and methods: This was a prospective descriptive longitudinal study conducted at the Department of Obstetrics & Gynecology of Jinnah Postgraduate Medical Center, Karachi from October 2021 to March 2022. The questionnaire was filled during an interview. First part included demographic profile, second part comprised of 5 items with 'yes' or 'no' options. Any positive answer meant woman was subjected to abuse. Adverse maternal outcome was also assessed. Results: Out of a total of 105 pregnant women, 43(41%) women suffered domestic violence. Verbal or emotional violence (39%) was the most common type of violence. In our study, anemia (71.4%) was the most common complication. Preterm labor (63.8%) was the second on the list. was significantly associated with domestic violence (P-value<0.05). Educational status, employment status, substance abuse, and household monthly income of spouse had a significant association (P-value<0.05) with domestic violence. Conclusion: Our study shows that high frequency of violence at the time of pregnancy is related to negative maternal outcomes. Women should be screened for violence and support services for such women should be provided in the country.

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.

Impact of Locus Coeruleus and Its Projections on Memory and Aging.

Introduction: Locus coeruleus (LC) is the primary source of norepinephrine to the brain and its efferent projections innervate many brain regions, including the thalamus. The LC degrades with normal aging, but not much is known regarding whether its structural connectivity evolves with age or predicts aspects of cognition. Methods: Here, we use high-resolution diffusion tensor imaging-based tractography to examine structural connectivity between LC and the thalamus in younger and older adults. Results: We found LC projections to be bundled in a fiber tract anatomically consistent with the central tegmental tract (CTT) and branched from this tract into the thalamus. The older cohort exhibited a significant reduction in mean and radial diffusivity within CTT, as compared with the young cohort. We also observed a significant correlation between CTT mean, axial, and radial diffusivities and memory performance (delayed recall) in the older adult cohort. Discussion: These observations suggest that although LC projections degrade with age, the degree of degradation is associated with cognitive abilities in older adults. Impact statement Locus coeruleus (LC) modulates several cognitive processes, including modulating arousal, attention modulation, and memory. Sustaining the integrity of LC neurons is hypothesized to play a key role in staving off age-related cognitive decline. However, less is known about how efferent projections of LC change with age or cognition. Here, we examine how age affects the microstructure of the central tegmental tract, a fiber tract in which LC efferent projections are bundled, and whether age-related changes in the microstructure of this tract are associated with cognitive decline.

Epidemiology of irritable bowel syndrome in hospitalized patients with inflammatory bowel disease: Nationwide Inpatient Sample analysis from 2007-2016.

Background: Despite effective treatments for inflammatory bowel disease (IBD), patients in remission may still suffer from gastrointestinal symptoms attributable to overlying irritable bowel syndrome (IBS). In this population-based cohort study, we investigated the epidemiology of IBS in hospitalized IBD patients and explored the differences between hospitalized IBD-IBS vs. IBD patients to distinguish this patient population. Methods: Using the Nationwide Inpatient Sample database from 2007-2016, we identified patients with a primary or secondary discharge diagnosis of IBD, with or without IBS, using ICD-9 and ICD-10 codes. We extracted information on demographics, psychological comorbidities, IBD complications, cost and duration of stay of each group, from either discharge records or diagnosis codes. These were analyzed using SAS version 4.0. Results: There was a rise in the prevalence of IBS among inpatients with ulcerative colitis (P=0.025) and Crohn's disease (P=0.0014) over the study period. This study revealed that IBD patients with IBS tend to be female, younger, are less likely to be morbidly obese and have higher rates of psychological disorders (P<0.001) compared to IBD patients with no IBS co-diagnosis. They also have fewer IBD-specific complications, such as strictures, obstruction, fistula and abdominal abscess (P<0.001). Shorter hospital stays (P<0.001) and lower hospital charges (P<0.001) were also noted in these patients. Conclusions: IBD patients with IBS are significantly different from other IBD patients, and are associated with less severe disease, a shorter hospital stay and lower hospital expenses. Early and accurate classification of this patient population may prevent unnecessary treatment and hospitalization in the future.

An Assessment of the Impact of Flow Disruptions on Mental Workload and Performance of Surgeons During Percutaneous Nephrolithotomy.

Objective The aim of this study was to assess the impact of intraoperative disruptions on surgeons' workload and performance during percutaneous nephrolithotomy (PCNL). Materials and methods A structured and standardized tool was used to identify disruptions and interferences that occurred during 33 PCNL procedures. The surgical steps during PCNL were divided into four phases: ureteric catheter placement (phase I), puncture and tract dilation (phase II), intra-calyceal navigation and stone fragmentation (phase III), and tube placement (phase IV). Surgeons' workload was evaluated using a validated tool: Surgery Task Load Index (SURG-TLX), and correlated with the mean observed intraoperative disruptions. All operating team members evaluated the teamwork immediately after the procedure. Statistical analysis was performed using SPSS Statistics version 22 (IBM, Armonk, NY). Results A total of 1,897 disturbances were observed, with an average of 57.48 ± 16.36 disruptions per case. The largest number of disruptions occurred during phase III of PCNL (32.06 ± 14.12). The most common cause of the disruption was people entering or exiting the operating room (OR) (29.1 ± 10.03/case), followed by the ringing of phones or pagers (6.42 ± 2.4). The mean observed intraoperative disruptions were significantly associated with the operating surgeon's mental workload, and it had a significant impact on all domains of surgeons' mental workload as measured by SURG-TLX. Compared to other team members, surgeons' assistants experienced an inferior sense of teamwork (r=-0.433; p=0.012). Conclusion Significant intraoperative disruptions were observed during PCNL. They were observed to directly correlate with the surgeon's workload and had a detrimental effect on teamwork. Improving OR dynamics by reducing unnecessary disruptions would help establish an efficient and smooth surgical work environment for safe surgical care.