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BackgroundHypoxia in patients with COVID-19 is one of the strongest predictors of mortality. Silent hypoxia is characterized by the presence of hypoxia without dyspnea.. Silent hypoxia has been shown to affect the outcomes in previous studies.Research QuestionAre the outcomes in patients presenting with silent hypoxia different from those presenting with dyspneic hypoxia?Study design and MethodsThis was a retrospective study of a cohort of patients with SARS-CoV-2 infection who were hypoxic at presentation. Clinical, laboratory, and treatment parameters in patients with silent hypoxia and dyspneic hypoxia were compared. Multivariate logistic regression models were fitted to identify the factors predicting mortality.ResultsAmong 2080 patients with COVID-19 admitted to our hospital, 811 patients were hypoxic with SpO2P=0.202). The odds ratio of death was 1.1 (95% CI 0.41-2.97) in the patients with silent hypoxia after adjusting for baseline characteristics, laboratory parameters, treatment, and in-hospital complications, which did not reach statistical significance (P=0.851).InterpretationSilent hypoxia may be the only presenting feature of COVID-19. Since the case fatality rate is comparable between silent and dyspneic hypoxia, it should be recognized early and treated as aggressively. Since home isolation is recommended in patients with COVID-19, it is essential to use pulse oximetry at the home setting to identify these patients.

PurposeAlthough unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse.MethodsIn this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and mortality records.ResultsForty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27–74) days. The median (range) time to hospital discharge was 53.5 (10–85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03).ConclusionIn patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.

BackgroundDue to the unprecedented speed of SARS-CoV-2 vaccine development, their efficacy trials and issuance of emergency use approvals and marketing authorizations, additional scientific questions remain that need to be answered regarding vaccine effectiveness, vaccination regimens and the need for booster doses. While long-term studies on the correlates of protection, vaccine effectiveness, and enhanced surveillance are awaited, studies on breakthrough infections help us understand the nature and course of this illness among vaccinated individuals and guide in public health preparedness.MethodsThis observational cohort study aimed at comparing the differences in clinical, biochemical parameters and the hospitalization outcomes of 53 fully vaccinated individuals with those of unvaccinated (1,464) and partially vaccinated (231) individuals, among a cohort of 2,080 individuals hospitalized with SARS-CoV-2 infection.ResultsCompleting the course of vaccination protected individuals from developing severe COVID-19 as evidence by lower proportions of those with hypoxia, abnormal levels of inflammatory markers, requiring ventilatory support and death compared to unvaccinated and partially vaccinated individuals. There were no differences in these outcomes among patients who received either vaccine type approved in India.ConclusionWith a current rate of only 9.5% of the Indian population being fully vaccinated, efforts should be made to improve the vaccination rates as a timely measure to prepare for the upcoming waves of this highly transmissible pandemic. Vaccination rates of the communities may also guide in the planning of the health needs and appropriate use of medical resources.Research in contextEvidence before this studyThe Government of India started vaccinating its citizens from the 16thof January 2021, after emergency use authorization had been received for the use of two vaccines, BBV152, a COVID-19 vaccine based on the whole-virion SARS-CoV-2 vaccine strain NIV-2020-770, (Covaxin) and the recombinant replication-deficient chimpanzee adenovirus vector encoding the spike protein ChAdOx1 nCoV-19 Corona Virus Vaccine (Covishield). These have been approved by the Indian regulatory authority based on randomized controlled studies. In these studies, was found that the vaccines led to more than 90% reduction in symptomatic COVID-19 disease. However, there is scarce evidence of the efficacy of these vaccines in real-world scenarios. A few studies have looked at vaccinated cohorts such as health care workers in whom the vaccines had an efficacy similar to the RCTs. In a study of patients with SARS-CoV-2 infection admitted to a tertiary care hospital in New Delhi, it was found that mortality in fully vaccinated patients was 12.5% as compared to 31.5% in the unvaccinated cohort.Added-value of this studyThis cohort of hospitalized patients with SARS-CoV-2 infection was studied during the peak of the second wave of COVID-19 in India during which the delta variant of concern was the predominant infecting strain and had 26% patients who were partially vaccinated and 71.4% who were unvaccinated. Only 3% of the patients were fully vaccinated and developed a breakthrough infection. At the time of presentation, 13% of the individuals with breakthrough infection and 48·5% in the non-vaccinated group were hypoxic. Inflammatory markers were significantly lower in the completely vaccinated patients with breakthrough infection. The need for use of steroids and anti-viral agents such as remdesivir was also significantly low in the breakthrough infection group. A significantly less proportion of the individuals with breakthrough infection required oxygen supplementation or ventilatory support. Very few deteriorated or progressed to critical illness during their hospital stay. Only 3 individuals (5.7%) out of the 53 who developed breakthrough infection succumbed to illness while case fatality rates were significantly higher in the unvaccinated (22.8%) and partially vaccinated (19.5%) groups. Propensity score weighted multivariate logistic regression analysis revealed lower odds of developing hypoxia, critical illness or death in those who were completely vaccinated.Implications of all the available evidenceThe real-world effectiveness of the vaccines against SARS-CoV-2 seems to be similar to the randomized controlled trials. The vaccines are very effective in reducing the incidence of severe COVID-19, hypoxia, critical illness and death. The reduced need for oxygen supplementation, mechanical ventilation and the requirement of corticosteroids or other expensive medications such as anti-viral drugs could go a long way in redistributing scarce health care resources. All nations must move forward and vaccinate the citizens, as the current evidence suggests that ‘prevention is better than cure’.

BackgroundThe second wave of the COVID-19 pandemic hit India from early April 2021 to June 2021 and more than 400,000 cases per day were reported in the country. We describe the clinical features, demography, treatment trends, baseline laboratory parameters of a cohort of patients admitted at the All India Institute of Medical Sciences, New Delhi with SARS-CoV-2 infection and their association with the outcome.MethodsThis was a retrospective cohort study describing the clinical, laboratory and treatment patterns of consecutive patients admitted with SARS-CoV-2 infection. Multivariate logistic regression models were fitted to identify the clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay and death.FindingsA total of 2080 patients were included in the study. The case fatality rate was 19.5%. Amongst the survivors, the median duration of hospital stay was 8 (5-11) days. Out of 853 (42.3%%) of patients who had COVID-19 Acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged 45-60 years [OR (95% CI): 1.8 (1.2-2.6)p =0.003] and those aged >60 years [OR (95%CI): 3.4 (2.3-5.2), p500 mg/dL [OR (95% CI): 3.2 (2.2-4.6), p 0.5 mg/L [OR (95% CI): 3.8 (1.1-13), p=0.037] had higher odds of death. Patients who were admitted in the second week had lower odds of death and those admitted in the third week had higher odds of death.InterpretationThis is the largest cohort of patients admitted with COVID-19 from India reported to date and has shown that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Strategies should be made to improve vaccination rates and early admission of patients with moderate and severe COVID-19 to improve outcomes.Research in contextEvidence before this studyThe COVID-19 pandemic has been ravaging the world since December 2019 and the cases in various regions are being reported in waves. We found that the case fatality rates ranging from 1.4% to 28.3% have been reported in the first wave in India. Older age and the presence of comorbidities are known predictors of mortality. There are no reports regarding the effectiveness of vaccination, correlation of mortality with the timing of admission to the health care facility and inflammatory markers in the ‘second wave’ of the COVID-19 pandemic in India.Added-value of this studyThis study reports the real-world situation where patients get admitted at varying time points of their illness due to the mismatch between the availability of hospital beds and the rising number of COVID-19 patients during the pandemic. It reports the odds of developing severe hypoxia necessitating oxygen therapy and death thus helping identify priority groups for admission.Implications of all the available evidenceThis study found increased odds of requiring oxygen support or death in patients older than 45 years of age, with comorbidities, and those who had hyper-inflammation with raised C-reactive peptide, d-dimer or leukocytosis. Patients who were admitted in the second week of illness had lower odds of death as compared to those admitted in the third week implying that treatment with corticosteroids in the second week of the illness during the ‘inflammatory phase’ could lead to reduced mortality. These findings would help triage patients and provide guidance for developing admission policy during times where hospital beds are scarce. Vaccination was found to reduce the odds of deterioration or death and should be fast-tracked to prevent further ‘waves’ of the pandemic.

A 26-year-old postpartum COVID-positive mother admitted in COVID isolation facility at a tertiary care center in India. Her primary physical concern was suture site pain and concerns related to expressed breast milk discarding. Her psychological concerns include distrust on COVID report, belief of unjust isolation, lack of family support, loneliness, feeling of not breast feeding her baby, fear, anxiety, anger, stress, and depression. She was concerned about the stigma anticipated for herself and her baby. Spiritually, she was concerned as she was not able to make harmony between herself and environment.

Objective: To understand the trend of prevalence of symptoms of coronavirus disease 2019 (COVID-19) pandemic, some studies have been conducted outside India, but for Indian patients, there is no such study available. Therefore, this study was designed to analyze the trends of symptoms in Indian patients during COVID-19 pandemic. Methods: A retrospective study was conducted on 100 patients (73 males, 24 females, and 3 transgenders) admitted under institutional isolation at a tertiary care center in India using a self-designed survey-based questionnaire. A descriptive analysis of results done based on age and sex. Results: COVID incidence recorded is high in male (73%) as compared to female (24%), yet female patients have a higher prevalence of symptoms as compared to male patients. Conclusion: Male patients are more as far as COVID incidence is concerned, while female patients show high prevalence of symptoms as compared to male patients. Patients presenting with COVID-positive report suffer a significant burden of symptoms, and timely recognition of symptoms and their management can significantly reduce morbidity and mortality due to COVID-19.

Introduction There is a lack of large multicentric studies in children with COVID-19 from developing countries. We aimed to describe the clinical profile and risk factors for severe disease in children hospitalized with COVID-19 from India. Methods In this multicentric retrospective study, we retrieved data related to demographic details, clinical features, including the severity of disease, laboratory investigations and outcome. Results We included 402 children with a median (IQR) age of 7 (2–11) years. Fever was the most common symptom, present in 38.2% of children. About 44% had underlying comorbidity. The majority were asymptomatic (144, 35.8%) or mildly symptomatic (219, 54.5%). There were 39 (9.7%) moderate-severe cases and 13 (3.2%) deaths. The laboratory abnormalities included lymphopenia 25.4%, thrombocytopenia 22.1%, transaminitis 26.4%, low total serum protein 34.7%, low serum albumin 37.9% and low alkaline phosphatase 40%. Out of those who were tested, raised inflammatory markers were ferritin 58.9% (56/95), c-reactive protein 33.3% (41/123), procalcitonin 53.5% (46/86) and interleukin-6 (IL-6) 76%. The presence of fever, rash, vomiting, underlying comorbidity, increased total leucocyte count, thrombocytopenia, high urea, low total serum protein and raised c-reactive protein was factors associated with moderate to severe disease. Conclusion Fever was the commonest symptom. We identified additional laboratory abnormalities, namely lymphopenia, low total serum protein and albumin and low alkaline phosphatase. The majority of the children were asymptomatic or mildly symptomatic. We found high urea and low total serum protein as risk factors for moderate to severe disease for the first time.

BackgroundAccording to IDF Diabetes Atlas 2019, globally, 463 million people live with Diabetes mellitus. Out of that, 88 million people are in South East Asia. By 2045, it is expected to increase by 51% globally and 74% in South East Asia. Global variation in susceptibility to diabetes, insulin sensitivity, and regimen intensity due to race and ethnic differences pose a challenge regarding the optimal choice of second-line therapy for clinicians. Asian populations are at higher risk of developing diabetes mellitus than the European population. The current study was carried out to see the relative efficacy of currently available long-acting insulins in reducing blood sugar, HbA1c and the occurrence of hypoglycemia as a complication associated with them.MethodsA systematic literature search was done using various search engines (PubMed, Cochrane, Google Scholar, Scopus, and Embase) and included published RCTs in English before December 2019. Further, a manual search was performed by screening the reference list of the identified articles.ResultsWe included four RCTs with 534 participants (349 in the insulin degludec group and 185 in the insulin glargine group) with T2DM. Results show that both insulin glargine and degludec are equally efficacious in reducing fasting blood glucose and HbA1c. However, insulin glargine was associated with lower risks of hypoglycemia.ConclusionsInsulin glargine and degludec are comparable in achieving glycemic control with fewer hypoglycemic episodes in insulin glargine treated group.

Background & objectives: In December 2019, a novel coronavirus (SARS-CoV-2) emerged in China and rapidly spread globally including India. The characteristic clinical observations and outcomes of this disease (COVID-19) have been reported from different countries. The present study was aimed to describe the clinico-demographic characteristics and in-hospital outcomes of a group of COVID-19 patients in north India. Methods: This was a prospective, single-centre collection of data regarding epidemiological, demographic, clinical and laboratory parameters, management and outcome of COVID-19 patients admitted in a tertiary care facility in north India. Patient outcomes were recorded as death, discharge and still admitted. Results: Data of 144 patients with COVID-19 were recorded and analyzed. The mean age of the patients was 40.1±13.1 yr, with 93.1 per cent males, and included 10 (6.9%) foreign nationals. Domestic travel to or from affected States (77.1%) and close contact with COVID-19 patients in congregations (82.6%) constituted the most commonly documented exposure. Nine (6.3%) patients were smokers, with a median smoking index of 200. Comorbidities were present in 23 (15.9%) patients, of which diabetes mellitus (n=16; 11.1%) was the most common. A significant proportion of patients had no symptoms (n=64; 44.4%); among the symptomatic, cough (34.7%) was the most common symptom followed by fever (17.4%) and nasal symptoms (2.15%). Majority of the patients were managed with supportive treatment with hydroxychloroquine and azithromycin given on a case-to-case basis. Only five (3.5%) patients required oxygen supplementation, four (2.8%) patients had severe disease requiring intensive care, one required mechanical ventilation and mortality occurred in two (1.4%) patients. The time to reverse transcription-polymerase chain reaction (RT-PCR) negativity was 16-18 days. Interpretation & conclusions: In this single-centre study of 144 hospitalized patients with confirmed COVID-19 in north India, the characteristic findings included younger age, high proportion of asymptomatic patients, long time to PCR negativity and low need for intensive care unit care.

COVID-19 emerged as a unique type of health-care crisis. With no established protocols, it became a difficult task to manage this pandemic. Not only individual patients were the point of concern but also multiple clusters were getting reported. Management of these clusters has its own challenges varying from administrative and infrastructural to psychosocial- and stigma-related issues. A well-sought administrative will power along with a dedicated team of health care professionals handled the situation in their best capacity leaving an imprint of peace and harmony.

Background: Epidural steroids injections (ESI) are frequently used to treat lumbar radicular pain. Although different volume have been used for interlaminar ESI in adults, there is no controlled trial comparing the effect of different volumes on pain relief for the same dose of steroid . Objective: To compare the effect of increase in volume of epidural drug on pain relief in lumbar ESI . Study design: Randomized double blind trial Settings: Pain OR of a tertiary care centre Methods: Sixty patients were randomly allocated to 1 of 3 groups: Group A (4 mL), Group B (6 mL), and Group C (8 mL). Pain was evaluated using visual analog scale (VAS) and improvement in disability using modified Oswestry Disability Questionnaire scores (MODQS) at 2, 4, 8, 12, and 24 weeks. Patients having less than 50% pain relief from baseline received an additional epidural injection of the same volume with a maximum of 3 injections at least 15 days apart. The primary objective of the study was incidence of patients attaining more than 50% pain relief at 6 months. Secondary outcome included MODQS and pattern of spread of iodinated contrast on fluoroscopy. Results: At the end of 6 months, there was no significant difference in the effective pain relief between the 3 groups (Group A-16/22 (72.7%), Group B-15/20 (75%), Group C-13/18 (72.2%); P = 0.98, chi- square test). All groups demonstrated a significant reduction in mean VAS scores. There was no significant intergroup difference in VAS sores and MODQS at all the time intervals. The pattern of contrast spread did not differ between the 3 groups. Limitation: Not a placebo controlled trial Conclusions: An increase in volume of the injectate from 4 mL to 8 mL did not increase the efficacy of interlaminar ESI. Key words: Epidural steroid, volume, low back pain, interlaminar

ObjectivesOngoing pandemic due to COVID-19 has spread across countries, surprisingly with variable clinical characteristics and outcomes. This study was aimed at describing clinical characteristics and outcomes of admitted patients with mild COVID-19 illness in the initial phase of pandemic in India.DesignRetrospective (observational) study.SettingCOVID facilities under AIIMS, New Delhi, where, isolation facilities were designed to manage patients with mild illness and dedicated COVID ICUs was created to cater patients with moderate to severe illness.ParticipantsPatients aged 18 years or more, with confirmed illness were eligible for enrolment. Patients who were either asymptomatic or mildly ill at presentation were included. Patients with moderate to severe illness at admission, or incomplete clinical symptomatology records were excluded.MethodsData regarding demographic profile, comorbidities, clinical features, hospital course, treatment, details of results of RT-PCR for SARS-CoV-2 done at baseline and at day 14, chest radiographs (wherever available) as well as laboratory parameters was obtained retrospectively from the hospital records.Main outcome measuresFinal outcome was noted in terms of course of the disease, patients discharged, still admitted (at time of conclusion of study) or death.ResultsOut of 231 cases included, majority were males(78·3%) with a mean age of 39·8 years. Comorbidities were present in 21·2% of patients, diabetes mellitus and hypertension being most common. The most common symptoms were dry cough(81, 35%), fever(64, 27·7%), sore throat(36, 15·6%), and dyspnoea(24, 10·4%); asymptomatic infection was noted in 108(46.8%) patients. Presence of comorbidities was an independent predictor of symptomatic disease (OR- 2·66; 95% CI 1·08 to 6·53, p= 0·03). None of the patients progressed to moderate to severe COVID-19. There were no deaths in this cohort.ConclusionsPatients with mild disease at presentation had a stable disease course and therefore such cases can be managed outside hospital setting. A large proportion of patients remained asymptomatic throughout the course of infection and those with comorbidities are more likely to be symptomatic.Trial registrationNot applicable

Background: Vitamin D is an important vitamin required to maintain normal skeletal as well as nonskeletal functions. The daily supplementation of vitamin D not only have poor adherence to the regimen but also of doubtful efficacy in deficient patients. Objectives: The aim of this study was to compare the effect of oral high-dose vitamin D regimens (60,000 IU weekly) and daily low-dose vitamin D regimen of 1000 IU in mitigating symptoms and increase in serum levels of vitamin D in patients with hypovitaminosis D. Materials and Methods: A total of 90 patients aged 18–60 years with vitamin D deficiency (serum levels < 30 ng/mL) were enrolled. A total of 38 subjects received 60,000 IU of vitamin D weekly with 500 mg/day calcium and 40 subjects received a dose of 1000 IU of vitamin D daily with 500 mg/day calcium for 10 weeks. Baseline and follow-up total serum vitamin D levels and improvement in symptoms were measured within and between groups. Results: For high-dose vitamin D (60,000 IU weekly), the increase in mean serum vitamin D levels from baseline was 28.33 ng/mL over 10 weeks' treatment period; whereas for the low-dose group (1000 IU daily) the mean increment in serum vitamin D was 6.79 ng/mL for the same period. The mean difference in increase in serum vitamin D between two groups was highly significant (P < 0.001). In both the groups, decrease in myalgia as evaluated on visual analog scale was observed after 10 weeks. Conclusions: High-dose vitamin D (60,000 IU weekly) regimen rapidly normalized 25(OH) D levels and ensure symptomatic relief earlier than daily dosing of 1000 IU vitamin D for same duration.

Aim We aimed to identify the impact through the use of standard and novel echocardiographic parameters, i.e., speckle tracking echocardiography (STE) to evaluate the right and left ventricular (LV) myocardial function in patients who underwent lung resections. Materials and methods We identified patients that underwent lobectomy or pneumonectomy at our institution in 2016 to 2017. We performed preoperative transthoracic echocardiography (TTE) in each patient and on postoperative days (PODs) 2, 7, and 30 when available. Results Of a total of 26 patients included in the study, 5 underwent pneumonectomy, while the rest underwent lobectomy. Left and right pneumonectomy was performed in 38 and 62% of the patients respectively. None of the patients had right ventricular (RV) dilation or dysfunction on preoperative echocardiograms. Postoperatively, mean LV ejection fraction (LVEF) was 52 (±7.5) %. Mean RV strain in immediate postoperative period (day 2) was –15.1% (reduction of more than 20%). None of the patients progressed to RV failure or had mortality. Estimated RV systolic pressure was 41 (±20) mm Hg. The differences in RV echocardiographic parameters were significantly different pre- and postsurgery. The RV function decreased significantly on POD 2, which improved slightly thereafter. Extent of resection and side of resection did not make a difference in the RV functions. Conclusion After lung resection, patients developed deterioration in RV function that may be reflected by any of the echocardiographic parameters used to assess RV function. Deterioration in RV function is maximum in the immediate postoperative period (day 2), which improves to preoperative level by 4 weeks. How to cite this article Bhat IH, Kumar A, Kumar B, Ganesan R, Mandal B, Dutta V. Echocardiographic Evaluation of Right Ventricular Function in the Immediate Postoperative Period after Major Pulmonary Resections: A Prospective Observational Study. J Perioper Echocardiogr 2017;5(2):42-48.

Atrial septal defect (ASD) is common congenital heart disease in adults. Most of the cases are detected in childhood, whereas few cases reach adulthood undiagnosed. It is the most common congenital heart lesion in child bearing age group girls. ASD leads to various complications depending upon size, position of ASD and shunt flow direction and hemodynamic change. Pulmonary artery hypertension is one such complication which occurs due to large blood flow across pulmonary artery due to left to right shunting. Pulmonary hypertension is defined as a mean pulmonary arterial pressure greater than 25 mm Hg at rest or greater than 30 mmHg during exercise. We reported a case of double ASD of size 10 mm and 5 mm with moderate pulmonary artery hypertension which underwent emergency caesarean section for meconium stained liquor. Under all aseptic precaution epidural catheter was placed at L3-4 level in sitting position by loss of resistance technique and then spinal anesthesia was given at the same level with 26G needle. Total drug given in spinal was 2.5 ml which includes 2 ml of bupivacaine (heavy) and 0.5 ml fentanyl. The patient was managed successfully under regional (epidural with low dose spinal) anesthesia without facing any complication. During anesthesia our main aim was to prevent complications, like hypotension, hypoxia, hypercarbia, reversal of shunt, fluid overload and maintain systemic pulmonary vascular resistance. As these complications adversely affect the outcome in heart disease patients.

Context: Neuraxial techniques have sedative properties secondary to decreased inputs from sensory and motor afferents. We hypothesized that caudal analgesia decreases the requirement of desflurane as measured by bispectral index (BIS). Aims: This study aims to determine the minimum alveolar concentration (MAC) of desflurane for maintaining BIS below 50 (MACBIS50) in children undergoing infraumbilical surgeries with laryngeal mask airway (LMA) and study the effect of caudal analgesia on the same. Settings and Design: This is prospective and observational study. Subjects and Methods: Thirty-nine American Society of Anesthesiologists physical status Classes I and II children in between 1 and 8 years of age undergoing elective infraumbilical surgery under general anesthesia were allocated randomly into two groups (Group C and Group D) after induction with sevoflurane and LMA insertion. In Group C, caudal block was performed with 0.75 mL/kg of 0.25% bupivacaine and BIS values were recorded after 10 min for 1 min at 10 s intervals. In Group D, BIS was recorded for desflurane for 1 min at 10 s intervals followed by a caudal block with the same dose. Statistical Analysis Used: Dixon up-down method with a step size of 0.5%, and probit analysis were used for analysis. Results: A total of 39 patients were enrolled. MAC of desflurane for maintaining MACBIS50 was 5.57 (95% confidence interval [CI] 5.22–5.95) in Group D and 4.31 (95% CI 3.12–5.08) in Group C. The use of caudal anesthesia lowered the MAC of desflurane for maintaining MACBIS50 in children by 22.36% (P < 0.001). Conclusions: The use of caudal analgesia significantly reduced MAC of desflurane for maintaining MACBIS50 in children undergoing infraumbilical surgeries using LMA.

Limb girdle muscle dystrophy (LGMD) is group of rare hereditary disorders primarily involving hip and shoulder muscles. Due to scarcity of literature, definite anesthetic management strategy is lacking. We, report the successful management of 28 yr parturient with LGMD for elective caesarian delivery under spinal anesthesia. The anesthetic management is discussed with brief review of literature. Keywords: Limb girdle muscle dystrophy, Caesarian delivery

Complex congenital heart diseases (CHD) often present as multiple cardiac lesions. The presence of one anomaly should stimulate the physician to perform a comprehensive assessment and look for other associated anomalies.1 Multimodal imaging may be necessary to diagnose such associated lesions as single imaging may occasionally miss them. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are complimentary to each other. Routine use of TEE during intraoperative period may help us to refine diagnosis, detect the missing components and guide effective surgical repair. We present one such case where diagnosis and management were optimized by multimodal imaging. How to cite this article Kumar B, Madhavan JS, Puri GD, Rana SS. Role of TEE in Improving Diagnostic Accuracy of Congenital Heart Disease. J Perioper Echocardiogr 2014;2(2):68-70.

In the title compound C27H22Cl2N4O2, the pyrazol-5-ol ring makes a dihedral angle of 34.80 (11)° with the phenyl ring to which it is bound, while the pyrazolone ring is inclined at 34.34 (12)° to its attached phenyl ring. In the crystal, N—H...O and C—H...Cl hydrogen bonds link the molecules into chains along [010]. Intermolecular π–π interactions are observed between the pyrazolone ring and the phenyl ring bound to the pyrazol-5-ol ring system [centroid–centroid separation = 3.916 (2) Å].

Anhydrous iron(III) chloride reacts with pure carboxylic acids RCOOH [where R = C2H5, n-C3H7, CH2Cl, CHCl2 and CCl3] at low temperature to yield Fe2Cl5 (OOCR)·nRCOOH [n = 3 when R = C2H5 and n-C3H7 and n = 2 when R = CH2Cl, CHCl2 and CCl3] and [Fe3O(OOCR)6(H2O)3][FeCl4] at about 70–80°C. These reactions reveal that no hydrogen chloride is evolved but an acyl chloride is formed. Pyridine combines with [Fe3O(OOCR)6(H2O)3][FeCl 4] (R = C2H5 and n-C3H7) to form [Fe3O(OOCR)6(C5H5N)3][FeCl4]. Piperidine, on the other hand, reacts with the elimination of piperidinium chloride to form [Fe3O(OOCR)6(H2O)3][Fe(NC5H10)4] compounds containing covalently bonded piperidide. Compounds containing polyatomic ligands such as NO3− and NCS− instead of the chloro group in [Fe3O(OOCR)6(H2O)3][FeCl4] (R = C2H5 and n-C3H7) have been prepared. All these compounds have been characterized on the basis of IR, UV-vis., molar conductance, molecular weight and room temperature magnetic susceptibility measurements.