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Background: The transversus abdominis plane block (TAP block) in the petit triangle is being used since 2001 for analgesia by blocking the T6 to T12 nerves, which is devoid of the sympathetic blockade and has opioid-sparing effect during and after abdominal operations. The appropriateness and efficacy of using double pop blind transversus abdominis plane block were studied in abdominal surgeries using bupivacaine with butorphanol as additive. Subjects and Methods: A total of 78 adult patients of ASA I and II were included, who were to undergo laparoscopic cholecystectomy under general anesthesia. The control group patients received tramadol, diclofenac, and paracetamol in the perioperative period. The study group patients received TAP block by double pop blind technique after induction of anesthesia but before surgical incision as preemptive analgesia. The p-value, the mean and the confidence interval were calculated by using Student t-test with the use of online software by graphpad.com. Results: Each of the two groups had 39 patients, and none met the exclusion criteria. Patients of the study (TAP) group remained pain-free for a longer time by 439 (416 – 463) minutes more than the control (IV, Intravenous) group. Rescue analgesia in the study group was required 640 minutes after the end of the surgery, but in the control group, rescue analgesia was required earlier at 200 minutes only after the surgery. Conclusion: Double pop blind technique for TAP block is appropriate and without complications if done with carefulness as to avoid penetration of the blunted green needle beyond the fascia between the internal oblique and the transversus abdominis muscle.

Machine learning is used increasingly in clinical care to improve diagnosis, treatment selection, and health system efficiency. Because machine-learning models learn from historically collected data, populations that have experienced human and structural biases in the past—called protected groups—are vulnerable to harm by incorrect predictions or withholding of resources. This article describes how model design, biases in data, and the interactions of model predictions with clinicians and patients may exacerbate health care disparities. Rather than simply guarding against these harms passively, machine-learning systems should be used proactively to advance health equity. For that goal to be achieved, principles of distributive justice must be incorporated into model design, deployment, and evaluation. The article describes several technical implementations of distributive justice—specifically those that ensure equality in patient outcomes, performance, and resource allocation—and guides clinicians as to when they should prioritize each principle. Machine learning is providing increasingly sophisticated decision support and population-level monitoring, and it should encode principles of justice to ensure that models benefit all patients.

Summary Steroids and calcineurin inhibitors (CNI) have been mainstays of immunosuppression but both have numerous side effects that are associated with substantial morbidity and mortality. This study was carried out to determine if steroids can be eliminated with early discontinuation of cyclosporine A (CsA) and later discontinuation of mycophenolate mofetil (MMF). Ninety-six patients with kidney transplants were entered into four subgroups of two pilot studies. All patients received Thymoglobulin® induction, rapamycin (RAPA), and the immunonutrients arginine and an oil containing ω-3 fatty acids. Mycophenolate mofetil was started in standard doses and discontinued by 2 years. CsA was given in reduced doses for either 4, 6, or 12 months. Follow-up was 12–36 months. Thirteen first rejection episodes occurred during the first year (14%). Combining all patients, 86% were rejection-free at 1 year, 80% at 2 years and 79% at 3 years. No kidney has been lost to acute rejection. Ninety percent of the 84 patients at risk at the end of the study were steroid-free and 87% were off CNI. Fifty-seven percent of 54 patients with a functioning kidney at 3 years were receiving monotherapy with RAPA. We conclude that this therapeutic strategy is worthy of a prospective multi-center clinical trial.

Background. Morbid obesity occurs frequently in patients with renal failure and is associated with an increased mortality, particularly from cardiovascular disease, as well as a marked increase in comorbid conditions affecting quality of life. Morbid obesity is also associated with an increased risk of complications and death in transplant patients and is often a cause for denial for access to transplantation. Methods. Thirty morbidly obese patients with chronic renal failure or transplantation underwent gastric bypass (GBP). Nineteen patients had chronic renal failure at the time of GBP, eight had transplantation followed by GBP, and three had GBP and then transplantation. Results. The reduction in excess body mass index (above 25) after GBP at 1, 2, and 3 years was similar to patients without transplantation or chronic renal failure, approximately 70% at 1 year. Comorbid conditions were diminished in each subset of patients, decreasing their risk for potential cardiovascular complications. One patient died 7.9 years after a GBP and 6.1 years after transplantation from cardiovascular disease related to longstanding diabetes that was present before her renal failure. Conclusions. GBP is a safe and effective means for achieving significant long-term weight loss and relief of comorbid conditions in patients with renal failure on dialysis, in preparation for transplantation, or after transplantation.

Respondent Driven Sampling (RDS) is a novel variant of link tracing sampling that has primarily been used to estimate the characteristics of hard-to-reach groups, such as the HIV prevalence of drug users.1 ‘Seeds’ are selected by convenience from a population of interest (target population) and given coupons. Seeds then use these coupons to recruit other people, who themselves become recruiters. Recruits are given compensation, usually money, for taking part in the survey and also an incentive for recruiting others. This process continues in recruitment ‘waves’ until the survey is stopped. Estimation methods are then applied to account for the biased recruitment, for example, the presumed over-recruitment of people with more acquaintances, in an attempt to generate estimates for the underlying population. RDS has quickly become popular and relied on by major public health organisations, including the US Centers for Disease Control and Prevention and Family Health International, chiefly because it is often found to be an efficient method of recruitment in hard-to-reach groups, but also because of the availability of custom written software incorporating inference methods that are designed to generate estimates that are representative of the wider population of interest, despite the biased sampling. As demonstrated by RDS's popularity,1 there was a clear need for new methods of data collection on hard-to-reach groups. However, RDS has not been without its critics. Its reliance on the target population for recruitment introduced ethicalw1 and sampling concerns.w2 If RDS estimates are overly biased or the variance is unacceptably high, then RDS will be little more than another method of convenience sampling. If these errors can be minimised however, then RDS has the potential to become a very useful survey methodology. In this editorial we highlight that ‘RDS’ includes both data collection and statistical inference methods, discuss the limitations …

Objective To evaluate the influence of intraperitoneal (IP) antibiotic (AB) prophylaxis on the quality of healing and infection rates of exit sites in peritoneal dialysis catheters. Study Design Twenty-one Sprague-Dawley rats were dialyzed 3 times per day for 6 weeks. Dianeal solution containing AB was used for all the rats during the first 5 days. The animals were randomized on the sixth day into three groups: group A (AB-free after randomization), group B (AB for 3 weeks), and group C (AB during 6 weeks). Scores were given to each exit site according to the observation. Mean scores from each group were compared in an attempt to find significant differences between the groups. Dialysate and exit-site drainage samples were taken weekly for microbiology. Results Eight episodes of peritonitis were diagnosed, six in group A and two in group B. The most common bacteria causing peritonitis were gram-negative rods. The mean scores were not significantly different between groups C and B throughout the study, even after the discontinuation of the prophylaxis. Group A, when compared to the other two groups, had significantly higher scores after the second week and throughout the rest of the study. Conclusion Intraperitoneal antibiotic prophylaxis for 3 weeks after catheter implantation is an effective way to prevent early colonization of exit sites, providing a better healing quality and lower incidence of catheter-related infection. Although the extension of the prophylaxis for 6 weeks seems to be beneficial, it was not statistically proven in this study.

ObjectiveTo determine if peritoneal dialysis modality has an impact on protein losses in dialysate.DesignRetrospective, cross-sectional study.Patients190 patients who had selected peritoneal dialysis were classified into one of four transport categories (high, high-average, low-average, or low) based on standard peritoneal equilibration test results. Patients were then assigned to continuous ambulatory peritoneal dialysis (CAPD) or nightly intermittent peritoneal dialysis (NIPD) based on membrane transport characteristics and individual preferences.ResultsPatients with similar membrane transport characteristics had essentially no differences in dialysate protein and albumin losses whether treated with CAPD or NIPD.ConclusionsAlthough high transporters may be better managed with short -dwell therapies such as nocturnal intermittent peritoneal dialysis or daily ambulatory peritoneal dialysis, consistent marked decreases in protein losses cannot be cited as a benefit of NIPD over CAPD.

Carbamylated hemoglobin: A potential marker for the adequacy of hemodialysis therapy in end-stage renal failure. Urea can dissociate in vivo to form isocyanic acid which can react with hemoglobin to form carbamylated hemoglobin. Previous work has shown that formation of carbamylated hemoglobin depends upon both the severity and the duration of renal failure. To determine whether carbamylated hemoglobin can be used as an assessment of the adequacy of hemodialysis treatment, we prospectively studied 55 stable patients who regularly attended our hospital dialysis program. Carbamylated hemoglobin was greater in those patients with a Kt/V of ≤ 1.1 compared to those with a Kt/V of > 1.1 (120 ± 8 µgVH/gHb versus 99 ± 7, P < 0.01), and there was a negative correlation with Kt/V (r = -0.37, P = 0.007). There were positive correlations between carbamylated hemoglobin and the time-averaged urea concentration (r = 0.4, P = 0.004), and a negative correlation with the urea reduction ratio (r = -0.37, P = 0.01). Carbamylated hemoglobin may therefore be a useful marker of the degree of uremia, just as glycosylated hemoglobin is used in the assessment of patients with diabetes mellitus.

In nine patients on continuous ambulatory peritoneal dialysis (CAPD) who were in stable condition, the authors measured the effects of an extra daily exchange on small solute removals and clearances and the measured/predicted creatinine production (M/P). The goal was to evaluate the sensitivity of M/P to single exchange noncompliance. Daily collections of urine and dialysate were performed on the usual prescribed program and on the next day with an extra exchange of usual exchange volume. The average increase in drain volume of 26% was associated with an average increase in M/P of 6%. The maximum M/P increase was 15%; the percentage increase in M/P correlated inversely with renal creatinine clearance. Daily total urea clearance normalized to total body water by dialysis and renal function increased 12%. Extrapolating these findings suggests that an average patient with a baseline M/P near 1.0 and renal creatinine clearance of 5 ml/min would require more than 50% drain volume noncompliance to yield a M/P of 1.24 on the complaint day. A 50% noncompliance may not yield a M/P greater than 1.0 on the first compliant day if baseline M/P is less than 0.94. The authors suggest monitoring daily urine and dialysis creatinine output because M/P creatinine is relatively insensitive to noncompliance (particularly in patients with residual renal function) and because there are questions about the accuracy of predictions in patients with renal failure using formulae established in different populations. The authors recommend simply monitoring total daily creatinine output and establishing patients as their own controls. The authors provide a table for the interpretation of changes in creatinine output in conjunction with changes in other routinely monitored parameters.

Many factors can affect interpretation of glycohemoglobin (GHB/HbA1c) measurements in patients with chronic renal failure (CRF). Several reports have suggested that erythrocyte survival is substantially lowered in most patients with CRF; this would be expected to lower GHB results (1)(2)(3)(4)(5)(6). Several reports have also suggested that GHB methods, especially those based on charge separation (e.g., ion-exchange HPLC), may have interference by carbamylated hemoglobin that would be expected to falsely increase GHB results (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Many of these reports evaluated older assay methods; newer ion-exchange methods may show improved separation of the HbA1c fraction from other hemoglobin adducts (15)(17). Because renal failure is common in patients with diabetes and GHB is widely used as an index of mean blood glucose in these patients, we examined GHB results in patients with CRF by several different GHB assay methods. We also investigated the impact of shortened erythrocyte lifespan by comparing the GHB results obtained for nondiabetic patients with and without CRF. Fifty-five patients with CRF (blood urea nitrogen >400 mg/L) were recruited for this study. Twenty-nine were not receiving dialysis and …

Respondent-driven sampling (RDS) is a network-based technique for estimating traits in hard-to-reach populations, for example, the prevalence of HIV among drug injectors. In recent years RDS has been used in more than 120 studies in more than 20 countries and by leading public health organizations, including the Centers for Disease Control and Prevention in the United States. Despite the widespread use and growing popularity of RDS, there has been little empirical validation of the methodology. Here we investigate the performance of RDS by simulating sampling from 85 known, network populations. Across a variety of traits we find that RDS is substantially less accurate than generally acknowledged and that reported RDS confidence intervals are misleadingly narrow. Moreover, because we model a best-case scenario in which the theoretical RDS sampling assumptions hold exactly, it is unlikely that RDS performs any better in practice than in our simulations. Notably, the poor performance of RDS is driven not by the bias but by the high variance of estimates, a possibility that had been largely overlooked in the RDS literature. Given the consistency of our results across networks and our generous sampling conditions, we conclude that RDS as currently practiced may not be suitable for key aspects of public health surveillance where it is now extensively applied.

Decision makers can benefit from the subjective judgment of experts. For example, estimates of disease prevalence are quite valuable, yet can be difficult to measure objectively. Useful features of mechanisms for aggregating expert opinions include the ability to: (1) incentivize participants to be truthful; (2) adjust for the fact that some experts are better informed than others; and (3) circumvent the need for objective, "ground truth" observations. Subsets of these properties are attainable by previous elicitation methods, including proper scoring rules, prediction markets, and the Bayesian truth serum. Our mechanism of collective revelation, however, is the first to simultaneously achieve all three. Furthermore, we introduce a general technique for constructing budget-balanced mechanisms-where no net payments are made to participants--that applies both to collective revelation and to past peer-prediction methods.

Background Animal studies have shown that dietary supplementation with arginine and lipids containing the omega-3 and omega-9 fatty acids prolong allograft survival in animals receiving a short course of low-dose cyclosporine. They also reduce cardiovascular complications and infections in humans. Methods Adult renal transplant patients receiving standard immunosuppression were stratified according to gender, diabetic state, donor source (LD or CD), and first versus repeat transplant, and randomized to receive or not receive supplemental arginine and canola oil (containing both omega-3 and omega-9 fatty acids) twice daily. Patients were followed for a minimum of 3 years. Results Seventy-six patients were randomized to the supplement group (S) and 71 patients to the control group (C). Intent-to-treat analysis revealed that S patients had fewer post-30 day first rejection episodes (5.4%) when compared with the C group (23.7%) (P=0.01) and fewer post-30 day episodes of calcineurin inhibitor (CNI) drug toxicity (9.2% vs. 35.3%, P=0.003). S patients developed new onset diabetes mellitus (NODM) less frequently by 3 years (2.3% vs. 14.5%, P=0.04), had fewer cardiac events (5.0% vs. 17.1%, P=0.05), and fewer episodes of sepsis (6.5% vs. 18.7%, P=0.05). Conclusions Dietary supplementation with L-arginine and canola oil is a safe, inexpensive, and unique treatment, which is associated with decreased rejection rates and CNI toxicity after the first month in renal transplant patients. Due to reductions in NODM and cardiac events, long-term benefits for patient survival may be particularly important.

The procedure of laryngoscopy and endotracheal intubation frequently induces a cardiovascular stress response characterized by hypertension, tachycardia, arrhythmias and increased serum concentration of catecholamines. Our study was undertaken to evaluate and compare the influence of lignocaine and diltiazem on the cardiovascular responses to laryngoscopy and intubation. A total of sixty patients of ASA grade I or II patients, between 18 -60 years of age, of either sex, scheduled for non-cardiac surgery, were selected for the study. Baseline parameters i.e. heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure were recorded and same parameters were recorded at one minute interval till the completion of study period. The percentage change (increase or decrease) was calculated and was analyzed statistically. There was minimal change in heart rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure after intubation in patients who were given diltiazem as compared to lignocaine and was more stable drug. We concluded that Diltiazem 0.3 mg/kg is able to attenuate the haemodynamic response better as compared to lignocaine.

A Prospective double blind randomized study was conducted on 60 adults patients undergoing laproscpic surgery. Patients of group ? received butorphanol (25μg/kg) and patients of group II received tramadol (2mg/kg) just before induction of anaesthesia. Haemodynamic parameters including heart rate, systolic and diastolic blood pressure were recorded throughout the surgery. On statistical analysis of data, there was statistically significant increase in heart rate, systolic and diastolic blood pressure in tramadol group as compared to butorphanol group just after intubation, which got settled after 10 minutes of intubation. So, we concluded that Butorphanol (25μg/kg) is a good alternative to tramadol (2mg/Kg) as a balanced anaesthetic technique for laproscopic cholecystectomy.

Peritoneal dialysis (PD) is a safe, effective, low-cost intracorporeal renal replacement modality with some inherent advantages. The peritoneal membrane is a biocompatible, internally located dialyzer which limits ingress of bacteria and their products, removes uremic toxins, allows continuous, gentle 24-hour dialysis and ultrafiltration, while avoiding the use of anticoagulants [l, 2].

Respondent-driven sampling is a network-based technique for estimating traits in hard-to-reach populations, for example, the prevalence of HIV among drug injectors. In recent years RDS has been used in more than 120 studies in more than 20 countries, and by leading public health organisations, including the Centers for Disease Control and Prevention in the USA. Despite the widespread use and growing popularity of RDS, there has been little empirical validation of the methodology. In this talk, I investigate the performance of RDS by simulating sampling from 85 known, network populations. Across a variety of traits we find that RDS is substantially less accurate than generally acknowledged, and that reported RDS CI are misleadingly narrow. Moreover, it is unlikely RDS performs any better in practice than in our simulations as we model a best-case scenario in which the theoretical RDS sampling assumptions hold exactly. Notably, the poor performance of RDS is driven not by the bias, but by the high variance of estimates, a possibility that had been largely overlooked in the RDS literature. Given the consistency of our results across networks and our generous sampling conditions, we conclude that RDS as currently practiced may not be suitable for key aspects of public health surveillance where it is now extensively applied. This work is joint with Matthew Salganik.