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Airway compression due to distal aortic arch and descending aortic aneurysm repair has been documented. This case of tracheal and left main stem bronchus compression due to aortic aneurysm occurred in a 42-year-old man. The airway compression poses a challenge for the anesthesiologist in airway management during aortic aneurysm repair surgery. The fiber-optic bronchoscope is very helpful in decision-making both preoperatively and postoperatively in such cases. We report a case of airway compression in a 42-year-old patient who underwent elective distal aortic arch and descending aortic aneurysm repair.

A growing literature on collective action focuses on exploring the conditions that might help or hinder groups to work collectively. In this paper, we focus on community-based forest management in the inner Terai region of Nepal and explore the role of community and user attributes such as group size, social heterogeneities, forest user' perception on forests, and affiliation to the user group, in the collective action of managing community forests. Household surveys were carried out with 180 households across twelve community forest users' groups. We first measured ethnic diversity, income inequality, landholding inequality, and user perception towards the use and management of community forests to understand their effect on the participation of forest users in the management of community forests. Our results show that among the studied variables, group size (number of forest users affiliated to the community forests) and perception of the management of their community forests are strong predictors of forest user participation in community forest management. Income inequality and ethnic diversity were found to have no significant association. Land inequality, however, was found to decrease participation in the management and use of community forests. These community and user attributes play a crucial role in the success of collective action and may vary from community to community. Hence they need to be duly considered by the practitioners prior to any community-based project interventions for stimulating successful collective action.Forests 2018, 9, 136 2 of 20 management (CFM) is considered as one of the successful models of community-based forest governance [4]; the success of which depends on many factors, such as socio-economic heterogeneity, institutional setting, leadership, property rights regimes, degree of decentralization, community characteristics, technology, and market influence etc. [5,6]. The premise of the CFM asserts that communities or groups of forest users collectively engage in the management of the forest. Hence, the involvement and participation of the forest users has been deemed integral for the functioning of CFM as collective action in forest management [7][8][9][10].Over the years, many case studies have emerged in the literature, suggesting that some communities are more successful than others in achieving success in collective action [11][12][13][14][15][16]. This has sparked a notable debate among scholars on the diverse conditions and factors that may facilitate and/or hinder the collective action [17]. While there is consensus on the fact that a certain set of variables such as physical and socio-economic environment, local governance structures, social capital, community's willingness to participate, tenure rights etc. influence the likelihood of collective action [18], there is no consensus about the particular effect that these variables have. The communities managing the forests worldwide may differ in their capacity, interests, and perceptions regarding community forestry [...

Background: This prospective randomized double-blind study was designed to compare the analgesic efficacy and safety of intrathecal midazolam versus fentanyl as an adjunct to bupivacaine for endoscopic urology surgery. Methods: Sixty adult ASA grade I-II patients undergoing transurethral resection of prostate or bladder tumor under spinal anesthesia were randomly allocated into three groups. Group B (control group) received 2 ml 0.5% hyperbaric bupivacaine while group BM received midazolam 2 mg and group BF received fentanyl 25 μg along with 2 ml of 0.5% bupivacaine in subarachnoid block. Postoperative analgesia was provided with intravenous diclofenac. The onset and duration of sensory and motor blockade, postoperative pain and the time to 1st rescue analgesia was noted. Patients were observed for hypotension, bradycardia, sedation, respiratory depression, pruritus, and postoperative nausea-vomiting. Results:The onset times and the duration of motor blockade were comparable among groups while the time to sensory block regression was longer in group BM and group BF as compared to group B (p < 0.001).The duration of postoperative analgesia was significantly prolonged in group BM and group BF as compared with group B (p < 0.001) while there was no difference between group BM and BF. The incidence of pruritus and vomiting was more in group BF. Conclusions: Addition of midazolam to intrathecal bupivacaine provides prolonged postoperative analgesia similar to intrathecal fentanyl and appears safe in patients undergoing endoscopic urology surgery.

Background: Myocardial protection in Tetralogy of Fallot patients undergoing intracardiac repair is suboptimal due to hypertrophied right ventricle. Hypertrophied myocardium is more susceptible to poor myocardial preservation because of inadequate capillary density as compared to the myocytes. There is a capillary to myocyte ratio mismatch. But del Nido Cardioplegia owing to its less viscosity is able to get more evenly distributed under hypothermic cardiopulmonary bypass as opposed to blood Cardioplegia. We hypothesized that the del Nido Cardioplegia technique, would be beneficial in myocardial protection because of its composition and method of delivery, leading into better early and late clinical outcomes in patients undergoing Tetralogy of Fallot repair as compared to blood cardioplegia reconstituted using St Thomas Cardioplegia solution. The objective of the study was to identify a better technique of myocardial preservation in Tetralogy of Fallot patient. Methods: In total, 56 Tetralogy of Fallot patients undergoing intracardiac repair under mild hypothermic cardiopulmonary bypass were randomly allocated to receive antegrade Cardioplegia with either standard blood Cardioplegia (Group I) or del Nido Cardioplegia (Group II). Preoperative as well as postoperative data including echocardiographic parameters for right ventricle functions, creatine kinase MB level, inotropic requirement, mechanical ventilation duration, intensive care unit stay and hospital mortality were evaluated. Results: Inotropic score in the first 24 hours postoperatively was significantly lower in Group II compared to Group I (13.4 ± 7.2 vs. 21.2 ± 9.6, p = 0.003). Creatine kinase MB level (ng/mL) was comparable between the groups. Echocardiographic parameters for right ventricle functions were also comparable between the groups during early as well as after 3 to 6 months postoperatively. Conclusion: Del Nido Cardioplegia is equally efficacious in providing myocardial protection during intracardiac repair under mild hypothermic cardiopulmonary bypass in Tetralogy of Fallot patients as compared to blood Cardioplegia solution with the added benefit of reducing inotropic requirement in first 24 hours postoperative period.

Dry forests today are managed following the standards of scientific forestry imported in the tropics in the XIX th century by the colonial empires. The model proved efficient to control deforestation and regulate production but its evolution even after decolonization increased the segmentation between forests and agriculture and the lack of consideration for local knowledge by the forest administration. The process of decentralization of forest management that disseminated in the 1990s aimed at bringing back local communities within the formal management of forests. However the results of this process, often restricted to a simple transfer of tools and techniques, have fallen below expectations. If discourses shifted towards a better recognition of local needs, knowledge and constraints, the day-to-day implementation of participatory forest management in the dry lands remains fraught with administrative inefficiencies and a mistrust of local communities. Sustainable management of dry forests is yet to be invented.

Introduction Congenital heart diseases (CHD) present with wide spectrum of lesions leading to diagnostic dilemmas and it is quite possible to miss correct diagnosis during preoperative transthoracic echocardiography (TTE) in an inadequately sedated child, especially in a busy outpatient setting. It is a routine practice in our center to do baseline TTE after induction of anesthesia followed by pre and postcardiopulmonary bypass (CPB) transesophageal echocardiography (TEE) in all CHD patients thus helping us review our surgical plan. Materials and methods All pediatric patients <18 years undergoing cardiac surgery from January 2013 to December 2013 at our tertiary care center in whom perioperative echocardiograhy was done were included. Appropriate sized TTE and TEE probes were used with the Philips iE33 echocardiography platform (Philips, Andover, MA). Results Out of total 352 pediatric cardiac surgical patients, perioperative echocardiography was done in 347(98.5%) patients. Baseline TTE showed new findings leading to change in surgical plan in 11 (3.1%) patients while additional new findings in baseline TEE were seen in 9 (2.6%). Post bypass TEE showed residual lesions requiring a CPB rerun in 19 (5.5%) patients. Intraoperative echocardiography was found to be cost effective with an estimated savings per patient of ₹ 3950 to 5373($61 - 83). Conclusion Intraoperative echocardiography is an important tool in armamentarium of perioperative physician which can be used to review diagnosis and help to formulate an informed surgical plan. Post-bypass transesophageal echocardiography is also useful as it identifies the residual lesions and establishes anatomical correction, which ultimately translates to lesser redo surgeries and a better postoperative outcome. How to cite this article Mishra A, Madhavan JS, Ghuman BPS, Raj R, Kumar A, Dutta V, Negi S, Tandon Y, Kumar A, Arya VK, Kumar B, Jayant A, Puri GD. Impact and Cost Effectiveness of Routine Intraoperative Transthoracic and Transesophageal Echocardiography on Surgical Decision Making in Pediatric Cardiac Surgery. J Perioper Echocardiogr 2014;2(1):3-9.