Epidural steroid injections (ESI) have been used to treat radicular pain. However, no prospective research has been undertaken to determine the benefits associated with combining different epidural steroid injection techniques. Objective: This study was conducted to assess the efficacy of combining transforaminal epidural steroid injection (TFESI) with caudal epidural steroid injection (CESI) versus TFESI with interlaminar epidural steroid injection (ILESI) on patient pain, anxiety, and disability status in individuals suffering from radicular pain. Methods: A cross-sectional study was conducted in the National Hospital & Medical Centre Lahore from September 2022 to September 2023. Eighty patients with low backache and radicular pain who met the inclusion criteria were enrolled. The patients were randomly divided into Group A (TFESI + CESI, n=40) and Group B (TFESI + ILESI, n=40). Baseline demographic data were collected, and pain, anxiety, and disability were assessed using the Numerical Rating Scale (NRS), Hamilton Anxiety Scale, and Oswestry Low Back Disability Index, respectively. These parameters were measured at baseline, 2 weeks, 4 weeks, and 12 weeks post-intervention. Data were analysed using SPSS software, with comparisons made using the independent t-test and chi-square test, and a p-value of <0.05 considered statistically significant. Results: The mean age of the patients in Group A was 59.4 ± 10.2 years, while in Group B, it was 57.6 ± 11.1 years. Most patients were females, accounting for 58 (72.5%) of the study population. There was a significant decrease in the mean NRS score at 2, 4, and 12 weeks compared to the baseline value in Group B (p=0.01). Similarly, the mean Hamilton Anxiety Score and Oswestry Disability Score were significantly reduced after the intervention in Group B (p=0.04, p=0.01, respectively). Comparable findings were observed in Group A, with significant decreases in the mean NRS score at 2, 4, and 12 weeks (p=0.02) and substantial reductions in the Hamilton Anxiety Score and Oswestry Disability Score (p=0.001, p=0.03, respectively). Conclusion: This study found that combining CESI and TFESI with catheter offered a slightly more effective pain reduction than TFESI and ILESI after 12 weeks. The clinical effects of combining CESI with TFESI were similar to those of combining TFESI with ILESI in treating radicular pain. Both methods significantly reduced pain scores and improved anxiety and disability status in both groups.

Soft tissue rheumatism, known as myofascial pain syndrome (MPS), is typified by taut bands, transferred pain that is distinct, sensory alterations that occur, and a local twitch response. It is also connected with trigger points in one or more muscles. The purpose of the research is to evaluate the effects of injections of Ropivacaine alone vs. Ropivacaine with methylprednisolone in decreasing pain in people in our community who have myofascial pain caused by trigger points. The design of this study was a randomized controlled trial. This study was carried out from July 2022 to August 2023. The research comprised 50 individuals (27 females and 23 males) diagnosed with MPS who came to our clinic. Using online randomization software, the patients were randomly divided into two groups. Group B got a mixture of 0.25% Ropivacaine & 10mg methylprednisolone in 3ml normal saline at each trigger point, whereas Group A received 3ml of 0.25% Ropivacaine. Dry needling of trigger sites was done in both groups. Patients were assessed at two, four, and eight weeks of intervention. The patients' pre-treatment assessment measures showed no statistically significant differences. After 4 and 8 weeks of assessment, Group B NRS pain and BDI scores showed statistically significant improvements compared to pre-treatment results (p<0.05). NRS and BDI scores were reduced in group A compared to their pretreatment values, but that was not clinically significant. Results of our study showed that there was a statistically significant difference between both groups in terms of pain, stress, and anxiety after the intervention. Ropivacaine with methylprednisolone gave better results than Ropivacaine alone in reducing pain and anxiety among the study population.

Summary Our aim was to prospectively determine the predictive capabilities of SEPSIS ‐1 and SEPSIS ‐3 definitions in the emergency departments and general wards. Patients with National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled over a 24‐h period in 13 Welsh hospitals. The primary outcome measure was mortality within 30 days. Out of the 5422 patients screened, 431 fulfilled inclusion criteria and 380 (88%) were recruited. Using the SEPSIS ‐1 definition, 212 patients had sepsis. When using the SEPSIS ‐3 definitions with Sequential Organ Failure Assessment (SOFA) score ≥ 2, there were 272 septic patients, whereas with quick SOFA score ≥ 2, 50 patients were identified. For the prediction of primary outcome, SEPSIS ‐1 criteria had a sensitivity (95%CI) of 65% (54–75%) and specificity of 47% (41–53%); SEPSIS ‐3 criteria had a sensitivity of 86% (76–92%) and specificity of 32% (27–38%). SEPSIS ‐3 and SEPSIS ‐1 definitions were associated with a hazard ratio (95%CI) 2.7 (1.5–5.6) and 1.6 (1.3–2.5), respectively. Scoring system discrimination evaluated by receiver operating characteristic curves was highest for Sequential Organ Failure Assessment score (0.69 (95%CI 0.63–0.76)), followed by NEWS (0.58 (0.51–0.66)) (p < 0.001). Systemic inflammatory response syndrome criteria (0.55 (0.49–0.61)) and quick SOFA score (0.56 (0.49–0.64)) could not predict outcome. The SEPSIS ‐3 definition identified patients with the highest risk. Sequential Organ Failure Assessment score and NEWS were better predictors of poor outcome. The Sequential Organ Failure Assessment score appeared to be the best tool for identifying patients with high risk of death and sepsis‐induced organ dysfunction.

AIM:To evaluate whether thyroid surgery be decided based on ultrasonographic criteria of the nodule(s), irrespective of cytopathological findings. MATERIALS AND METHODS:The histopathological findings of resected thyroid lobes were retrospectively reviewed and the findings were compared with the preoperative ultrasonographic and cytopathological findings. RESULTS:The results suggest that the decision to operate on thyroid lesions based on suspicious sonographic findings was correct in a significant number of patients irrespective of the preoperative cytopathological findings. CONCLUSION:Sonographic features suspicious for malignancy should be taken seriously even if the cytopathological results are inconclusive or are suggestive of benignity.

Background & Objectives: Trend of cesarean deliveries is on the rise in obstetric patients1,4. Most of cesarean deliveries are performed under regional anesthesia due to risk of disastrous outcomes of general anesthesia(GA) especially failed intubation2. Expected incidence of failed tracheal intubation has been reported as 1 in 224 3. It has also been observed that where GA for Cesarean is administered more frequently, the incidence of failed intubation is less, probably due to more experience5. The purpose of this study was to determine frequency of failed and difficult intubations in our set up where majority of patients request for GA and all intubations are done by consultants. Materials & Methods: This is a retrospective observational analysis. We reviewed the data of all patients who underwent cesarean sections under GA from 1st Jan, 2014 to 24th Feb, 2016 in a tertiary care obstetric facility. Both emergency and elective cases were included. We determined the number of difficult and failed intubations in these patients. Results: Total 3057 cesarean section were done under GA during this period. 97.2% of total intubations were uneventful. 79 intubations (2.6%) required assistance while repeated attempts were done in 6 patients (0.2%). There was only 1 failed intubation in which airway was rescued with LMA without any significant aspiration, hypoxia or fetal morbidity. The data was also analyzed for association of laryngoscopy grade with obesity (p value 0.001), Hypertension (p value 0.006), Mandibular protrusion (p value <0.001) and malampatti (p value <0.001). Our final results may contain more retrospective data. Conclusion: We found failed intubation incidence 1:3057 (0.03%) and difficult intubation incidence 1:509 (0.19%). We related this very low incidence of failed intubation to round the clock consultants’ presence and better opportunities for training in obstetric airway handling. References: 1. A. Palanisamy, et al. IJOA (2011); 20, 10–16 2. Pamela Flood, Mark D. Rollins. Anesthesia for Obstetrics. Miller RD, Eriksson LI, Fleisher LA, Weiner-Kronish JP, Young WL, editors. Miller’s Anesthesia. 8th Ed. USA: Churchill Livingston-Elsevier; 2015. 3. Quinn AC, et al.BJA(2013);110(1) 74-80 4. Health and social care information centre: HES Online: NHS maternity statistics 2011-2012 5. Djabatey EA,Barclay PM. difficult and failed intubation in 3430 obstetric general anaesthetics Anaesthesia (2009);64:1168-71 Disclosure of Interest: None declared

Background & Objectives: Trend of cesarean deliveries is increasing in obstetric patients 1,2. Major Obstetric hemorrhage (MOH) remains one of the leading causes of maternal mortality & morbidity worldwide3. MOH is defined as blood loss > 1.5L. According to WHO, United Nations (UN) and The World Bank (2010) estimates, Maternal mortality rate (MMR) in developed regions is 16 deaths/100, 000 live births, whereas in developing countries, this ratio is estimated at 240 deaths/ 100, 000 live births. Pakistan ranks third highest in the entire world in account for the increased maternal mortalities. 220deaths/100,000 live births4. The purpose of this study was to determine the incidence and to elucidate risk factors contributing to the major obstetric hemorrhage in our population. Materials & Methods: This is a retrospective observational study. We reviewed the data of all patients who underwent cesareans from 1st Jan’ 2015 to 31st Dec, 2015 in a tertiary care obstetric facility.Both emergency and elective cases were included. We determined total number of normal deliveries, Cesarean sections, incidence of major obstetric hemorrhage and the factors leading to MOH. Results: In 2015 total number of Normal deliveries were 795. Total cesareans were 1898. Major obstetric hemorrhage was noted in 83 patients out of 1898 cesarean deliveries. Descriptive statistics of these patients showed age (range 20-43yrs; mean 30.96±4.94), weight (55-126kg; mean 79.84±12.81), preoperative hemoglobin (6.5-14.2g/dl; mean 11.25±1.47), estimated blood loss (1500-9000 ml; mean 2512.05±1581.17). Among these MOH patients, 32 had placenta previa {Type 1(n= 2), Type 2(n= 4), Type 3(n= 7) and Type 4(n= 19) p-value<0.001}. The observed distribution regarding Placental invasion was Accreta 9 patients, Increta 2 and percreta 5; placental placement Anterior 45, posterior 20, fundal 3, lateral 3 and twin anterior posterior in 3 patients. Previous history of myomectomy was seen in 7 patients. After categorizing MOH patients in 5 subgroups, we found strong association between MOH and parity (p= 0.03), previous cesareans (p< 0.001) and placental invasion (p<0.001). Conclusion: In 1 year data we found MOH in 4.37% of cesarean deliveries. None of the mortality, morbidity was reported in these patients. We determine that besides placenta previa, parity, previous cesareans, previous uterine surgeries, placental location & invasion are also important risk factors. References: 1. A. Palanisamy, et al. IJOA (2011); 20, 10–16 2. Health and social care information centre: HES Online: NHS maternity statistics 2011-2012 3. World Health Organization. The World Health report 2005: make every mother and child count. Geneva, Switzerland: WHO Press, 2005; 62. 4. Determinants of Maternal Mortality: A Thorn Remains in Our Side Submitted by JPMS Blogs Admin on July 8, 2013. Disclosure of Interest: None declared

This paper presents the comparative performance analysis of two energy detection algorithms, single and double threshold energy detection, in the Cooperative-Cognitive Networks. Path loss effect has been considered in order to measure the efficiency of the system in terms of detection accuracy interference with Primary User (PU). The two algorithms are analysed using single and multiple relays at different positions from PU. The path loss exponent is considered as 3 in order to get degenerative environment. We have used Monte Carlo Simulation for our proposed double threshold technique by considering AWGN channel and Maximal Ratio Combining (MRC) at the receiver. The simulation results are presented for the Probability of Detection (Pd), Collision probability (Pc) and unavailable probability (Pna) by considering both the algorithms.

Objective To evaluate whether Constraint-Induced Movement therapy (CI therapy) may benefit chronic upper extremity hemiparesis in progressive multiple sclerosis (MS).Methods Five patients with progressive MS, who had chronic upper extremity hemiparesis and evidence for learned non-use of the paretic limb in the life situation, underwent 30 hours of repetitive task training and shaping for the paretic limb over 2-10 consecutive weeks, along with physical restraint of the less-affected arm and a "transfer package" of behavioral techniques to reinforce treatment adherence.Results The patients showed significantly improved spontaneous, real-world limb use at post-treatment and 4 weeks post-treatment, along with improved fatigue ratings and maximal movement ability displayed in a laboratory motor test.Conclusions The findings suggest for the first time that slowly progressive MS may benefit from CI therapy. Further studies are needed to determine the retention of treatment responses.

A box shape prototype structure of honeycomb sandwich panels of aluminum 5052 facings was fabricated with one-shot fabrication technique which is an effective tool for cost reduction, reduced number of parts for assembly and constellation type space programs where mass production is required. Mathematical model was generated from Lagrange's method and influence coefficient method. Eigen values were calculated for 3-dof system for validation of mathematical model generated for prototype structure. Sine sweep testing was performed on prototype structure to investigate the survivability of applied fabrication techniques and validation of mathematical model. Modal analysis, normalization of modes and orthonormalization of Eigen vectors were performed to calculate the mode shapes, modal matrix and uncoupled equations of motion in principal coordinate system.