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Naegleria fowleri amebae are thermophilic, free-living, and found in soil and fresh water, such as lakes, rivers, ponds, and untreated swimming pools. The ameba enters the brain through the nose [...]

Objective: To evaluate the association of increased uric acid in pregnancy-induced hypertension with adverse perinatal outcomes. Study Design: Comparative cross-sectional study. Place and Duration of Study: Departments of Anesthesia, Gynecology & Obstetrics, Combined Military Hospital, Okara Pakistan, from Mar to Sep 2018. Methodology: After approval of the Hospital Ethical Committee, 106 patients with pregnancy-induced hypertension were included in our study (n=53 in each group). Group-A had patient with raised uric acid, whereas Group-B had normal uric acid. Perinatal outcomes were monitored prospectively. Results: There was no difference in demographic profile of the two study groups. Raised uric acid was shown to be associated with a higher cesarean mode of delivery (p=0.014); preterm delivery (0.001); intrauterine growth retardation (0.038); and low APGAR at 5mintues (0.008). Raised uric had a sensitivity greater than 65% and specificity greater than 50% for perinatal outcomes. Conclusion: Raised uric acid is associated with adverse perinatal outcomes in neonates. [ABSTRACT FROM AUTHOR]

Objective: To assess the frequency of preoperative leukocytosis and its association with wound infection. Study Design: Prospective-cross sectional, analytical study. Place and Duration of Study: Department of Gynecology and Obstetrics, Combined Military Hospital, Thall, from Jan to Dec 2017. Methodology: After the approval of hospital ethics committee, 340 pregnant ladies undergoing both elective and emergency cesarean section were included in our study. The outcome of our study was the frequency of preoperative leukocytosis and its association with postoperative wound infection. SPSS version 20 was used to analyze data. The qualitative data was presented as frequency and percentage. Chi-square was used to analyze significance. A p-value ≤0.05 was taken as significant. Results: Frequency of preoperative leukocytosis was 121 (36.6%). A total of 111 (64.1%) pregnant ladies had pre-operative leukocytosis without post-operative wound infection versus 10 (66.6%) in patients with wound infection, p≤0.05, odd ratio 3.77. The sensitivity of pre-op total leukocyte count (TLC) for prediction of post-op wound infection was 66.6% (95% CI 38.3 to 88.8%) and specificity of 65.1% (59.5% to 70.34%). Most patients, 13 (86.6%), with wound infection required only debridement and intravenous antibiotics: IV linezolid and metronidazole; rest 2(13.4%) required secondary suturing for patient recovery. Conclusion: Preoperative leukocytosis was common in parturient undergoing cesarean section incidence of wound infection was low in this study. The post-operative wound infection risk is shown to correlate with the preoperative leukocytosis. [ABSTRACT FROM AUTHOR]

Objective: To compare the midline and paramedian approaches of spinal anesthesia in terms of incidence of Post Dural Puncture Headache among patients undergoing surgery. Study Design: Comparative prospective study. Place and Duration of Study: Department of Anesthesiology, Pakistan Naval Ship (PNS) Shifa Karachi, from Jan to June 2018. Methodology: After the approval of the hospital ethics committee, 214 (n=107 in each group) patients undergoing elective infra-umbilical surgery were included in our study. Group A were administered spinal anesthesia in sitting position via midline approach; whereas, paramedian approach was used in group B. Results: A total of 214 participants were studied. The two groups did not vary in demographic profile (p=0.017). The frequency of post-dural puncture headache was 2 (1.8%) in group B versus 10 (9.3%) in group A. There was no effect of American Society of Anesthesiologist physical status, gender, type of surgery, and age on the frequency of post dural puncture headache. Conclusion: There was a significantly lower frequency of post dural puncture headache in the paramedian approach for spinal anesthesia. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the recovery of bowel function by chewing gum in comparison with standard care. Study Design: Randomized control trial (RCT). Place and Duration of Study: Department of Gynecology and Obstetrics, Combined Military Hospital, Okara Cantt for the duration of 6 months from Apr to Sep 2018. Methodology: After the approval of hospital ethics committee, 100 patients undergoing elective cesarean section were divided into two groups (n=50 in each group). Group A were told to chew gum for 1 hour, four hours postoperatively in addition to standard care. Group B were the control group, with no addition of chew gum. The data were analyzed by SPSS version 20. Qualitative data presented as frequency and percentage; chi-square used to calculate significance. Descriptive data were presented as mean ± SD; T-test used to calculate significance. A p-value less than 0.05 was taken as significant. Results: The two groups did not vary in their demographic profile. The mean time for auscultation of bowel sound was 6.5 hours ± 1.03 in group A versus 9.3 hours ± 1.56 in group B; p-value <0.05. The mean time to passage of flatus was 14.28 hours ± 3.05 in group A versus 18.3 hours ± 3.42 in group B; p-value <0.05. Conclusion: Chewing gum postoperatively results in early return of bowel function, as evidenced by earlier return of bowel sounds and passage of flatus. It can be an inexpensive and convenient method for improved patient comfort and outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine the magnitude of various types of maternal emergencies and neonatal outcomes in order to ascertain the impact of maternal presentation on perinatal mortality in a peripheral hospital in Khyber Pakhtun Khwa Province. Study Design: Retrospective cross-sectional study. Place and Duration of Study: This study was carried out in the Department of Anesthesiology and Gynecology & Obstetric Department, Combined Military Hospital Thal, from Oct 2016 to Mar 2017. Methodology: Total 181 obstetric patients were included in the study. The patients’ documents were evaluated retrospectively for adverse maternal and neonatal outcomes, the incidence of various obstetrical emergencies, average time before proceeding with the emergency surgery and average duration of stay in our hospital. Results: The mean age of our study group was 27.1 ± 5.7 years. The mean time to operative delivery 57.0 ± 49.1 minutes. The mean length of hospital stay was 2.0 ± 0.50 days. Most of the patients presented at night (51.2%), without any antenatal visits (67.4%) with obstructed labour (24.8%). There were 30 (16.6%) perinatal deaths. Perinatal was correlated to obstructed labour, maternal hemorrhagic disorder, fetal distress and hypertensive disorder and presentation at night; p<0.05. However, it was not correlated to antenatal visit; mode of referral or transport. Conclusion: Obstructed labour, fetal distress and maternal hemorrhagic were the most common of obstetric emergencies at our peripheral hospital; with a direct, significant correlation with the perinatal mortality. [ABSTRACT FROM AUTHOR]

Objective: To assess the incidence and risk factor for scar dehiscence in parturient with previous LSCS. Study Design: Prospective, observational study. Place and Duration of Study: Department of Gynecology and Obstetrics; department of Anesthesiology, Combined Military Hospital, Okara, from Jul to Dec 2018. Methodology: After the approval of hospital ethical committee, 300 parturient undergoing cesarean section were included in our study. The outcomes were incidence and risk factors for scar dehiscence. SPSS version 20 was used to analyze data. Descriptive data was presented as frequency and percentage. Chi square was used to calculate significance and p-value less than 0.05 taken as significant. Results: A total of 300 patients with previous cesarean delivery were included in our study. Our study has shown that no use of antepartum nutritional supplement (30.3% vs 66.7%), early term pregnancy, emergency LSCS (40.9% vs 8.1%), laboring patient (30.3% vs 4.7%) with duration of labor more than 24 hours (3% vs 0.9%) and inter-delivery gap (2.01years ± 1.05 vs 2.3 years ± 0.96) are independent risk factors for scar dehiscence in patient with history of previous cesarean sections, p-value <0.05. However parturient age, anemia, presence of comorbidity, previous gravidity or parity, previous number of LSCS did not show significant difference between patient with or without scar dehiscence. Conclusion: Scar dehiscence in setting of previous cesarean section fairly common in our population and high index of suspicion is required for timely diagnosis and management to improve maternal outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency of malposition of left sided double lumen endotracheal tube with fiberoptic bronchoscope after its correct positioning by auscultation. Study Design: Prospective observational study. Place and Duration of Study: Main operation theater, Combined Military Hospital, Rawalpindi, from Jul 2015 to Dec 2016. Methodology: After approval from ethical review committee and consent, 90 patients with American Standards Association (ASA) II and III status were included in study by consecutive sampling. Proper monitoring attached and patients were premedicated. After induction of general anesthesia left sided double lumen tube was inserted by direct laryngoscopy. After inflation of cuffs, auscultation was done to determine correct position of tube. Then position of tube was confirmed by fiber optic bronchoscope. Results: The mean age was 38.13 ± 15.43 years and 66 (73.3%) males. In all the patients, auscultation showed that the left sided double lumentube were in the correct position with adequate ventilation of left upper and lower lobes. However, flexible bronchoscopy showed that double lumentubes had been placed correctly in only 54 (60%) cases, while 36 (40%) cases had partially misplaced double lumentubes. Out of these 36 cases, 26 (72.2%) had distally malpositioned double lumentube and 10 (27.8%) patients had proximally displaced double lumentube. Conclusion: Auscultation was found an unreliable method for confirmation of correct position of double lumentube and fibreoptic bronchoscope should be used for the confirmation of correct position of double lumentube for better anesthetic management in one lung ventilation. [ABSTRACT FROM AUTHOR]

Objective: To compare the current practices in obstetric anesthesia in different level of hospitals across Pakistan and their adherence to guidelines and standards. Study Design: Cross sectional analytical study. Place and Duration of Study: Department of Anesthesiology, Combined Military Hospital Okara for two months, from Dec 2018 to Feb 2019. Material and Methods: Five hundred questionnaire were sent to Department of Anesthesiology of 100 different hospitals. The proforma was a self-administered 22-questions that asked about the various aspects of the conduct of obstetric anesthesia. The data were analyzed using SPSS version 20. The qualitative variables were presented as frequency and percentage. Chi square used to calculate significance; p-value ≤0.05 taken as significant. Results: We received 311 questionnaires (62.2%) from various institutes. At the tertiary care hospital, most of respondents were aged less than 35 years and had an experience of 11-20 years as compared to 35-50 years in primary and secondary care hospitals; p<0.01. Although males (68.5%) make up a bulk of anesthetist, most of the females were working in tertiary care hospitals, p-value<0.01. Most of the obstetric anesthesia practices were comparable between the levels of hospitals. Anesthetist at tertiary care hospitals more commonly used colloid preload; a lesser volume for preload; routine left uterine tilt, prophylactic vasopressors and epidural analgesia for painless labor in obstetric anesthesia practices, p<0.05. Conclusion: Most the obstetric anesthesia practices were comparable between the three levels of hospital. These are in accordance with the latest guidelines by international societies. [ABSTRACT FROM AUTHOR]

Objective: To compare the effect of prophylactic phenylephrine infusion on the fluid management and physician intervention as compared with rescue boluses of phenylephrine alone. Study Design: Randomized controlled trial. Place and Duration of Study: Anesthesiology department, Combined Military Hospital, Rawalpindi; from Feb to Jul 2016. Material and Methods: A total of 70 patients were randomly divided into two groups, 35 in each. After a preload of 10ml/kg of ringer lactate; spinal anesthesia was given with 12 mg 0.75% hyperbaric bupivacaine. Group A given prophylactic phenylephrine infusion at the rate of 0.75ug/kg/minute for 5minutes after initiation of spinal anesthesia. Group B was given 50ug rescue bolus of phenylephrine when hypotension occurred. Results: The two groups did not differ in their demographic profile and mean fluid pre-load. The mean preload was 691.4ml (±110.1) in group A versus 721.4ml (±89.3) in group B, p-value 0.215. The total fluid administered in group A was lower than group B, 1634.2ml (±232.5) versus 1777.1 ml (±328.1); p-value 0.039. An average of 0.23 (±0.49) number of physician interventions were done in hypotensive patients in group A versus 1.26 (±1.29 in group B; p-value 0.06, which is statistically insignificant. The groupA received a much higher dose of phenylephrine, mean dose 287.2ug ± 48.8 versus 64.2ug ± 64.8; p value<0.001. The mean rescue phenylephrine bolus dose in group A was 15.7ug (±31.5) in group A versus 64.2 ± 64.8ug, p-value<0.001; which is statistically insignificant. Conclusion: Prophylactic phenylephrine infusion with crystalloid preload was found associated with reduced number of rescue boluses and rescue phenylephrine dose and lesser total intraoperative fluid administration, when compared to preload with rescue boluses. [ABSTRACT FROM AUTHOR]

Objective: We compared right and left sided double lumen endobronchial tube (DLT) regarding their clinical efficacy and safety profile in when they are used in conjunction with flexible fiberoptic bronchoscope. Study Design: Quasi experimental study. Place and Duration of Study: Anesthesiology department, Combined Military Hospital Rawalpindi for 05 months, from Apr to Aug 2017. Material and Methods: After the approval of the hospital ethical committee, 90 patients were included in our study. Auscultation was used to check proper position. A flexible fiberoptic bronchoscope was used to confirm auscultation finding. The insertion time; incidence of tube malposition (supine and lateral); intra-operative hypoxia and hypercapnia were recorded. Results: A total of 90 patients underwent various thoracic surgery procedures with one lung ventilation. After the data collection, 13 patients were excluded from final analysis. Of the 77 cases, 55 patients (group L) had placement of left sided double lumen endobronchial tube; whereas 22 patients (group R) had right sided double lumen endobronchial tube. The two groups didn't vary in their demographic profile. The insertion time was significantly longer in right DLT insertion, 296.6 ± 49.8 second versus 239 ± 33.4 second (p-value<0.001). The frequency of tube malposition was higher in right DLT, 45.4% versus 16.6% in left, p-value 0.01. However, the incidence of hypoxia, hypercapnia and tube migration (all p-value>0.05) did not vary between the two groups. One patient in right DLT versus two patients in left group required return to two lung ventilation for treatment of hypoxia, p-value 0.64. Conclusion: Our study has shown that right sided double lumen endobronchial tubehad similar clinical efficacy as left double lumen endobronchial tube when they are used for fiberoptic bronchoscope. [ABSTRACT FROM AUTHOR]

Intraoperative cardiac arrest in usual position (prone or lateral) present a unique challenge to the anesthesiologist, where changing to supine position can result in undue delay in initiating CPR or it is not feasible due to skull being fixed and opened by the surgeon. A 25 kg girl, 6 years old, was undergoing posterior cranial fossa surgery for fourth ventricle tumor excision. She went into hemorrhagic hypovolemic cardiac arrest, despite fluid resuscitation. Immediately, CPR was started in prone position with one hand at the midthoracic spine between the scapulae. The patient had ROSC after 20 min of CPR. Our patient did not have a favorable outcome, but the resuscitation in the prone position generated sufficient cardiac output while the correction of hypovolemia and hemostasis could be achieved. We recommend that immediate initiation of CPR even in prone position is the best choice in intraoperative patients, where change in position would result in delay in chest compression or make the surgical access impossible. [ABSTRACT FROM AUTHOR]

We present a case of large multinodular goiter with retrosternal extension scheduled for thyroidectomy under general anesthesia (GA). We anticipated difficult airway due to tracheal compression as well as perioperative hemodynamic instability. She had had hyperthyroidism previously, which had been treated successfully. We planned and prepared to encounter airway problems in the light of Difficult Airway Society guidelines. After counselling and consent, her upper airways were sprayed with local anesthetic solution. Awake, flexible fiberoptic nasal intubation was performed and GA was induced. She had two episodes of bradycardia and hypotension peri-operatively, which were treated with inj atropine. Tracheostomy was performed in anticipation of tracheomalacia, which was de-cannulated on 3rd postoperative day. She was discharged on 4th post-operative day. [ABSTRACT FROM AUTHOR]

Wheat has been one of the first domesticated food crop and important food grain source for humans. Sixty wheat advanced lines/varieties received from different Research Institutes of the Punjab, Pakistan were screened for genetic potential against Bipolaris sorokiniana, a pathogen of wheat leaf blight in two consecutive years under inoculated conditions. Before sowing, the seeds were inoculated with the pathogen. Considering the lower percent of disease and higher vigour index, 12 wheat lines, namely 8C006, 8C007, 9C033; 9C035, 9C036, 7C002; 088186, 088195; 076395, 076309, V. 07142 and V.05068 were identified as tolerant against the pathogen. Among the four fungicides, Score 25% EC and Craze 80% WP were found the most effective as seed treatment to control the disease. [ABSTRACT FROM AUTHOR]

Objectives: Effective post-operative pain control is an essential component of care of surgical patients. Various analgesic regimens have been used to ensure adequate postoperative pin relief. We conducted this study to compare the efficacy of spinal anesthesia versus general anesthesia regarding post-operative pain following laparoscopic cholecystectomy. Methodology: After approval of the hospital ethical committee, 120 females were included in our randomized, control trial from 1 July 2015 to 31 Dec 2015. Patients were explained about the study and informed consent was signed by them or their guardians. Patients were randomly divided into two groups; in Group-A patients, spinal anesthesia was achieved with 3 ml 0.5% hyperbaric bupivacaine hydrochloride and 25 µg fentanyl. Group-B was given GA. All the patients were premedicated with IV metoclopramide 10 mg and dexamethasone 8 mg; preemptive analgesia with 0.1 mg/kg nalbuphine was done. Induction of GA was done with propofol 2 mg/kg, muscle relaxation was achieved with atracurium besylate 0.5 mg/kg. Endotracheal intubation with 6.5 or 7 mm cuffed tube was done, Visual analogue scale (VAS) was used to assess pain severity at immediate post-operative period (S-0) and at 6 hours (S-6). Data was analyzed using SPSS version 16.0. For quantitative variables like pain score and age, mean and standard deviation (SD) were calculated. For qualitative variables like severity of pain, frequency and percentages were calculated. Chi-square test was used to measure frequency of pain between two groups. P-value < 0.05 was taken as significant. Results: The two groups did not differ in demographic profiles. At S-0, the mean score in Group-A was 2.89 ± 2.49 (mode = 1, median 2) versus 3.83 ± 2.56 (mode = 3, median = 3), p value 0.0364. At zero hours (S-0); 6 (10%) patients in Group-A had no pain (VAS less than 2), 28(46.6%) patients had mild pain and 26 (43.3%) patients had severe pain. In Group-B 8(13.3%) had no pain, 20(33.3%) had mild pain and 32(55%) patients had severe pain. The p value was 0.947, which is statistically insignificant. At S-6, the mean VAS was 6.94 (median = 7, mode = 8) in Group-A versus 6.23 ± 2.11 (median = 6, mode = 5) in Group-B, p value 0.0277. At six hours (S-6), 31(51.6%) patients no mild pain in Group-A, 24(40%) had mild pain and 5(8.3%) had severe pain. Whereas 30 (50%) patients had no pain, 8 (13.3%) patients had mild pain and 22 (36.6%) patients had severe pain in Group-B. The p-value was 0.022, which is statistically significant. Conclusion: Our study has shown that single shot spinal anesthesia provides better postoperative analgesia in the postsurgical period. The addition of intrathecal fentanyl provides adequate analgesia, including relief from shoulder tip pain. So, spinal anesthesia can be safely used as sole anesthesia for laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Primary amebic meningoencephalitis caused by Naegleria fowleri is a rare but nearly always fatal parasitic infection of the brain. Globally, few survivors have been reported, and the disease has no specific treatment. We report a confirmed case in Pakistan in a 22-year-old man who survived after aggressive therapy.