Barriers to Pediatric Pain Management in Children Undergoing Surgery: A Survey of Health Care Providers

The appropriate pain management in neonates and children is lacking. Factors that prevent the execution of proper pain relief vary from center to center. We studied the factors responsible for it in a surgical unit. We conducted a survey at a tertiary-level institute among the resident doctors and nursing staff by means of an informal questionnaire analyzing their basic knowledge. The questions pertained mainly to pain assessment, analgesic usage, role of opioids, and formal training, and the responses so obtained were analyzed under these four headings. Seventy-three percent (22/30) of the residents and 74% (26/35) of the nursing staff knew about pain assessment scoring system in pediatric patients. However, assessment of pain in emergency cases was always done by only 6.6% of the residents. Effect of analgesia on severity of pain was never recorded by 33% (10/30) of the residents. Eighty-six percent (26/30) of the residents and 91% (32/35) of the nursing staff had adequate knowledge about analgesic dosage and interval for routine use. Ten of the 30 (33%) residents believed that analgesic administration in an acute abdomen, before definitive diagnosis, will always mask the symptoms. During a minor procedure, 56% (17/30) of the residents always used analgesia. Only 3.3% (1/30) of residents and 2.8% (1/35) of the nursing staff had received a structured training for pain management. Although, 93% (28/30) of the residents claimed to know about the safety of use of opioids, only 46% (14/30) used them routinely as analgesics. Pain management in surgical neonates and children is often ignored. Lack of formal training, inadequate knowledge, and standard protocols are the barriers in our setup, which may in turn be due to overwhelming attention given to the surgical condition.     

Tolerance of house fly, Musca domestica L. (Diptera: Muscidae) to dichlorvos (76% EC) an insecticide used for fly control in the tsunami-hit coastal villages of southern India

The Directorate of Public Health (DPH), Tamil Nadu, in southern India employed spraying of dichlorvos (76% EC) for quick elimination of fly concentrations in the tsunami-hit coastal villages at the concentration of 304g (a.i.)/10,000m(2). However, nuisance of house flies remained high particularly in temporary shelters and centralized relief kitchens. Susceptibility of house fly, Musca domestica to dichlorvos was determined in the laboratory to provide information for an effective management of this pest. Various concentrations of dichlorvos (76% EC) viz., 0.1, 0.2, 0.4, 0.6 and 0.8microg (a.i.) per fly, were tested using topical application against F(1) progenies of house flies collected 12 months after insecticide applications from different habitats in the tsunami-hit coastal villages. Fly mortality was recorded at 24h post treatment. Parallel controls were maintained for comparison. Mortality of the house flies varied between 17.5% and 100% and increased with an increase in dosage of the insecticide. Mortality was >80% at 0.6 and 0.8microg (a.i.) per fly. The LD(50) of dichlorvos tested against flies collected from different villages varied from 0.218microg (a.i.) to 0.235microg (a.i.) per fly and the LD(90) varied from 0.574microg (a.i.) to 0.639microg (a.i.) per fly. House flies collected from a rural village, Thirukanur that had never been exposed for insecticide treatment in the past one decade, when tested, the mortality varied between 92.5% and 100% and increased with concentration of dichlorvos. Mortality was >90% from 0.2microg (a.i.) per fly and the LD(50) was 0.0399microg (a.i.)/fly, while the LD(90) was 0.1604microg (a.i.)/fly. The LD(90) values of the flies collected from the tsunami-hit villages were 3.5-3.9 times higher than that of the flies collected from Thirukanur. Fly abundance remained high in tsunami-hit villages with no marked reduction, suggesting that the flies had developed tolerance to dichlorvos. It is suggested that for an effective management of these resistant populations changing insecticides, application of unrelated insecticide, together with an appropriate environmental sanitation measure is necessary to keep the population under check.     

Congenital giant diverticulum of the left ventricle in an adult

Congenital diverticulum of the left ventricle is a rare anomaly. Echocardiography, cardiac catheterization, and magnetic resonance imaging of the heart diagnosed a giant left ventricular diverticulum in a 20-year-old male with a history of dyspnea and palpitations. He underwent successful surgical correction of the left ventricular diverticulum.     

Comparison of sensory recovery at the subfascial and suprafascial donor sites of the free radial flap

The radial flap may be raised using a subfascial or suprafascial approach. The latter donor site is associated with fewer healing complications. We retrospectively evaluated the quality of sensory recovery within two comparable groups of 30 patients with subfascial and suprafascial donor sites. When considering the two groups, two-point discrimination was the modality most commonly reduced, with 97% of patients in both groups having reduced sensation in at least one anatomical zone. Sensation of sharp touch was most often lost; 90% in the subfascial and 83% in the suprafascial groups lost sensation in at least one anatomical zone. Roughly half the patients had reduced perception of light touch (43% and 50%), whilst perception of heat (27% and 17%) and cold (33% and 27%) were lost least often. At least one modality in at least one anatomical zone was lost or reduced in all patients, and roughly two-thirds (73% and 63%) had a reduction in 3 or more. The only significant difference between the donor and non-donor arms was reduced perception of sharp touch in the anterior forearm in both groups (p<0.001). Perception at the two sites (including the anatomical snuff box) was similar except for superior thenar palmar light touch (p=0.015) in the suprafascial group, which may indicate injury to the thenar cutaneous sensory branches during subfascial dissection.     

Solitary glomus tumor recurring as multiple glomus tumors

Most glomus tumors arise as a single nodule. However, up to 10?% of glomus tumors may be multiple. We report a case in which a single glomus tumor of the leg that evolved several years after surgery to multiple glomus tumors requiring additional resections.     

Genetic analysis of HA gene of pandemic H1N1 2009 influenza viruses circulating in India

The H1N1 2009 influenza pandemic took the health care workers by surprise in spite of warning about influenza pandemic. Influenza A virus has the ability to overcome immunity from previous infections through the acquisition of genetic changes by shift or drift. Thus, understanding the evolution of the viruses in human is important for the surveillance and the selection of vaccine strains. A total of 23 pandemic A/H1N1 2009 viral HA gene sequences were downloaded from NCBI submitted during March and May 2010 by NIV and were analysed. Along with that the vaccine strain A/California/07/2009 was also downloaded from NCBI. All the sequences were used to analyse the evolution of the haemagglutinin (HA) by phylogenetic analysis. The HA gene could be divided into four groups with shift from 1 to lV revealing that the HA genes of the influenza A viruses evolved in a sequential way, in comparison to vaccine strain A/California/07/2009. Amino acid sequence analysis of the HA genes of the A/H1N1 2009 isolates, revealed mutations at positions 100, 220 and additional mutations in different positions 114, 171, 179, 190, 208, 219, 222, 239, 240, 247, 251, 260 and 285 .The mutations identified showed the adaptation of the new virus to the host that could lead to genetic changes inherent to the virus resulting in a reassortant which could be catastrophic, hence continuous monitoring of strains is mandatory.     

Studies on the protective role of lycopene against polychlorinated biphenyls (Aroclor 1254)-induced changes in StAR protein and cytochrome P450 scc enzyme expression on Leydig cells of adult rats

Polychlorinated biphenyls (PCBs) are ubiquitous and persistent environmental contaminants that disturb normal endocrine functions, including gonadal functions in humans and mammals. PCBs (Aroclor 1254) - induced toxic manifestations are associated with the production of free radicals. Lycopene belongs to the group of natural carotenoids, which are found in many fruits, vegetables and other green plants. Lycopene, the most potent antioxidant protects against oxidative damage. The present study was conducted to elucidate the protective role of lycopene against Aroclor 1254-induced changes in Leydig cellular steroidogenic acute regulatory (StAR) protein, cytochrome P450 side chain cleavage (P450 scc) enzyme expression and 3β-hydroxy steroid dehydrogenase (3β-HSD) activity. The rats were divided into four groups. Each group consists of six animals. Group I rats were administered with corn oil intraperitoneally (i.p.) for 30 days. Group II rats were treated with Aroclor 1254 (i.p.) 2 mg kg^?1 body weight (bwt) day^?1 for 30 days. Group III rats were treated with Aroclor 1254 (i.p.) 2 mg kg^?1 bwt day^?1 along with simultaneous supplementation of lycopene 4 mg kg^?1 bwt day^?1 (gavage) for 30 days. Group IV rats administered with lycopene alone at the dose of 4 mg kg^?1 bwt day^?1 (gavage) for 30 days. After 24 h of the last treatment, animals were decapitated, blood was collected and serum testosterone level was estimated by radioimmunoassay (RIA). Testes were removed and Leydig cells were isolated in aseptic condition. StAR protein, cytochrome P450 scc enzyme expression were studied by Western blot analysis and 3β-HSD activity was estimated spectrophotometrically. Aroclor 1254 treatment significantly reduced the serum testosterone level. Simultaneous supplementation of lycopene maintained the serum testosterone to near normal. Aroclor 1254 exposure decreased Leydig cellular StAR protein, cytochrome P450 scc enzyme expression and activity of 3β-HSD. However, simultaneous supplementation of lycopene improved Leydig cellular StAR protein, cytochrome P450 scc expression and activity of 3β-HSD. These results suggested that lycopene have ameliorative role against Aroclor 1254 induced Leydig cell dysfunction.