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International audience; Purpose: To assess the variability of renal artery (RA) anatomy and presence of RA-pathology in patients with mild-to-moderate hypertension enrolled in the RADIANCE-HTN SOLO trial.Background: RADIANCE-HTN SOLO was a multicenter, international, blinded, randomized, sham-controlled trial evaluating ultrasound-based endovascular renal denervation (RDN) in patients with mild-to-moderate hypertension while off antihypertensive medications.Methods: Eligible subjects had pre-randomization renal CT- or MR- angiography (CTA, MRA) to confirm anatomic suitability and to define RA ablation sites. All images were sent for independent review for evaluation of RA anatomy and other vascular pathology.Results: A total of 324 patients underwent RA imaging (282 CTA and 42 MRA). Of those, 178 had simple anatomy with a single left and single right RA with mean diameters of 5.4 ± 0.9 and 5.1 ± 0.8 mm and mean lengths of 40.0 ± 12.9 and 52.0 ± 13.1 mm, respectively. Twenty-seven patients (8.3%) had unilateral or bilateral dual RAs with mean diameters of 4.0 ± 0.9 mm on the left and 3.9 ± 0.9 mm on the right. Forty percent (129/324) of patients had at least 1 accessory RA, with mean accessory diameters of 2.4 ± 0.8 mm on the left and 2.3 ± 0.8 mm on the right. Twenty-eight patients (8.6%) had at least 1 short (

Respiratory distress is one of the leading causes of neonatal morbidity and mortality. Factors such as gestational age at birth, pulmonary maturity, and congenital factors are peculiar to this demographic. Clinical evaluation accompanied by chest radiography is the standard protocol for evaluating the underlying causative factors. Knowledge of the radiographic appearances of various pathologies and associations with certain congenital factors is quintessential for radiologists and primary neonatal care providers to steer the management in the right direction.

Blindness is a major public health problem in most developing countries. Corneal ulcer (Keratitis) is a major cause of blindness throughout the world. About 10% cases of blindness are due to corneal ulcer. “Corneal ulcer means loss of corneal substances as a result of infection and formation of raw, excavated area.” Bacterial keratitis is an acute or chronic, transient or recurrent infection of the cornea with varying predilection for anatomical and topographical parts of the cornea like marginal or central. This study demonstrates the Novel pathogenic bacteria Exiguobacterium aurantiacum with bad pigment production, which are causing corneal ulcer and determine the best possible empirical therapy and specific therapy. Particular attention should be given to this condition as it can progress very rapidly with complete corneal destruction can be occur within 24–48 hours. Keywords: Corneal Ulcer, Exiguobacterium aurantiacum, Molecular characterization, Antibiotic treatment, Pigment.

Since January 2020, there has been a worldwide pandemic of COVID-19, caused by a novel coronavirus–severe acute respiratory syndrome coronavirus 2. The United States has been particularly affected, with the largest number of confirmed cases in a single country in the world. Healthcare systems for adults as well as children have dealt with challenges. This article will reflect on the experiences of selected children’s hospitals in Seattle, New York City, and New Orleans, three of the “hotspots” in the US and share common aspects and lessons learned from these experiences. This article discusses testing and cohorting of patients, personal protective equipment utilization, limiting workplace exposure, and information sharing.

Patients in the intensive care units suffer from a myriad of cardiopulmonary processes for which portable chest radiography is the most utilized imaging modality. A pragmatic approach toward evaluating the nearly similar radiographic findings seen in most of the pathologies with comparative review and strong clinical acumen can help the radiologists and clinicians achieve a rapid and precise diagnosis.

BACKGROUND AND OBJECTIVES The Accreditation Council for Graduate Medical Education requires that residents demonstrate increasing autonomy during their training. Although residents report a better educational environment with hospitalists present during family-centered rounds (FCRs), there is a concern that attending presence may reduce resident autonomy. We aim to determine the effect of FCRs without an attending during rounds on senior residents’ sense of autonomy. METHODS We conducted a multicenter, retrospective, preintervention-postintervention study at 5 children’s hospitals to evaluate the effect of rounding without an attending on senior residents’ self-efficacy, using a questionnaire developed by using Bandura’s principles of self-efficacy and Accreditation Council for Graduate Medical Education milestones. Questions addressed skills of diagnosis and/or management, communication, teaching, and team management. We compared preintervention and postintervention results using paired t tests and Wilcoxon rank tests. One-way analysis of variance tests were used to compare means among >2 groups. RESULTS 116 (82% response rate) of 142 eligible senior residents completed the questionnaire, which yielded a high reliability (α = 0.80) with a 1-factor score. The average composite score of self-efficacy significantly improved after intervention compared with the preintervention score (66.71 ± 6.95 vs 60.91 ± 6.82; P < .001). Additional analyses revealed meaningful improvement of each individual item postintervention. The highest gain was reported in directing bedside teaching (71.8% vs 42.5%; P < .001) and answering learner questions on rounds (70.7% vs 47.0%; P < .001). CONCLUSIONS Conducting FCRs without an attending increases resident reported self-efficacy regarding core elements of patient care and team leadership. In future studies, researchers should examine the impact of rounding without the attending on other stakeholders, such as students, interns, patients and/or families.

BackgroundIn 2014, data from a comprehensive multiplatform analysis of 496 adult papillary thyroid cancer samples reported by The Cancer Genome Atlas project suggested that reclassification of thyroid cancer into molecular subtypes, RAS-like and BRAF-like, better reflects clinical behavior than sole reliance on pathological classification. The aim of this study was to categorize the common oncogenic variants in pediatric differentiated thyroid cancer and investigate if mutation subtype classification correlated with the risk of metastasis and response to initial therapy in pediatric DTC.MethodsSomatic cancer gene panel analysis was completed on DTC from 131 pediatric patients. DTC were categorized into RAS-mutant (H-K-NRAS), BRAF-mutant (BRAF p.V600E) and RET/NTRK fusion (RET, NTRK1 and NTRK3 fusions) to determine differences between subtype classification in regard to pathological data (AJCC TNM) as well as response to therapy 1-year after initial treatment had been completed.ResultsMutation-based subtype categories were significant in most variables, including age at diagnosis, metastatic behavior, and the likelihood of remission at 1-year. Patients with RET/NTRK fusions were significantly more likely to have advanced lymph node and distant metastasis and less likely to achieve remission at one year than patients within RAS- or BRAF-mut subgroups.ConclusionsOur data supports that genetic subtyping of pediatric DTC more accurately reflects clinical behavior than sole reliance on pathological classification with patients with RET/NTRK fusions having worse outcomes than those with BRAF-mutant disease. Future trials should consider inclusion of molecular subtype into risk stratification.

ObjectivesCOVIDTrach is a UK multicentre prospective cohort study project that aims to evaluate the outcomes of tracheostomy in patients with COVID-19 receiving mechanical ventilation and record the incidence of SARS-CoV-2 infection among healthcare workers involved in the procedure.DesignData on patient demographic, clinical history and outcomes were entered prospectively and updated over time via an online database (REDCap). Clinical variables were compared with outcomes, with logistic regression used to develop a model for mortality. Participants recorded whether any operators tested positive for SARS-CoV-2 within 2 weeks of the procedure.SettingUK National Health Service departments involved in treating patients with COVID-19 receiving mechanical ventilation.ParticipantsThe cohort comprised 1605 tracheostomy cases from 126 UK hospitals collected between 6 April and 26 August 2020.Main outcome measuresMortality following tracheostomy, successful wean from mechanical ventilation and length of time from tracheostomy to wean, discharge from hospital, complications from tracheostomy, reported SARS-CoV-2 infection among operators.ResultsThe median time from intubation to tracheostomy was 15 days (IQR 11, 21). 285 (18%) patients died following the procedure. 1229 (93%) of the survivors had been successfully weaned from mechanical ventilation at censoring and 1049 (81%) had been discharged from hospital. Age, inspired oxygen concentration, positive end-expiratory pressure setting, fever, number of days of ventilation before tracheostomy, C reactive protein and the use of anticoagulation and inotropic support independently predicted mortality. Six reports were received of operators testing positive for SARS-CoV-2 within 2 weeks of the procedure.ConclusionsTracheostomy appears to be safe in mechanically ventilated patients with COVID-19 and to operators performing the procedure and we identified clinical parameters that are predictive of mortality.Trial registration numberThe study is registered with ClinicalTrials.Gov (NCT04572438).

Introduction Covid-19 caused many service changes, yet Trauma surgery continued throughout. We compare mortality rates from In-Patient (IP) and Day Case (DC) trauma patients and compare the mortality rates of patients who tested positive or negative for Covid-19. Method We reviewed all trauma admissions that underwent surgical intervention in both our IP and DC services during 31 days from March 23rd 2020. We recorded their sex, age, operation, Covid-19 symptoms, Covid-19 test results and mortality. The findings were compared between the groups. Results In total 127 patients underwent surgery (66 IP; 61 DC). There were 6 deaths (9.1%) within the IP group and 0 deaths in the DC group (p = 0.006). In the IP group 8 patients (12.1%) tested positive for Covid-19 of which 4 died (50%) compared to the remaining 58 patients (87.9%) of which 2 (3.4%) died (p Conclusion Covid-19 positive patients requiring in-patient admission for trauma surgery have a significantly higher mortality rate than both in-patient admissions that were Covid-19 negative or asymptomatic and patients that were treated with Day Case Trauma surgery.

Introduction ACL reconstruction surgery commonly utilises a hamstring tendon graft. Grafts are normally covered with a wet swab prior to implantation. The aim of this study was to determine the variance in graft diameter when comparing the traditional wet swab to a dry swab. Method Flexor tendons from a selection of fresh pig trotters were isolated and prepared with a standard ACL graft preparation technique. Half of the grafts were covered with a wet swab; the other half were covered with a dry swab. Graft diameters were measured at 10-minute intervals. After 30 minutes the grafts were submerged in Hartmann’s solution to simulate the post-operative haemarthrosis, diameters were checked again after 1 hour in the solution. Results Use of a dry swab resulted in a 0.5mm greater reduction in diameter than the wet swab group. The dry swab group also showed an increase in diameter by 0.5mm when soaked in Hartmann’s solution, this was not seen in the wet swab group. Conclusions Using a dry swab produces a smaller graft diameter, this would allow smaller bone tunnels, retaining bone stock. The subsequent rebound in diameter when in solution may increase the press fit mechanism and facilitate improved integration into the bone tunnel.

Introduction Covid-19 caused many service changes including limitations on operations due to potential increased mortality risk to patients. We report our findings from Trauma & Orthopaedic (T&O) surgical mortality through this period and the effectiveness of using a scoring system (The Manchester Equation) to predict likelihood of mortality. Method We reviewed all T&O admissions that underwent surgical intervention during the height of the pandemic. We recorded numerous factors for each patient including mortality and Covid status. From this we created a scoring system which is the product of Covid status, Anaesthetic type, Medical co-morbidities and other medical factors and ASA Score. We then analysed the findings to determine whether the score could be predictive of mortality rate. Results Of 123 patients undergoing surgery 6 deaths were observed (mean score of 51.3) compared to 117 patients surviving (mean score 31.9), p = 0.001. A score of less than 32 carried a 0% chance of death whereas a score of 32 or more resulted in a 14.6% mortality rate (p = 0.01). Conclusion The Manchester Equation can be used to help predict the mortality rate of T&O surgery in the presence of Covid-19 and may be useful for clinical decision making and consent purposes.

Background: In invasive breast cancer patients being treated with neoadjuvant chemotherapy (NACT), achieving pathological complete response (pCR) is a useful goal of treatment. Monitoring response to NACT and predicting pCR is helpful in planning further therapy and providing robust prognostic information. Digital mammography (DM) and additional digital breast tomosynthesis (DBT) features are important tell-tales of tumor characteristics and behaviour. Following NACT, the mammographic features- both DM and DBT- of responding tumors can vary considerably. In this prospective study, we correlated the DM and DBT features of pre-NACT and post-NACT mammograms to investigate if these can reliably predict pCR to NACT. Methods: Following approval by institutional ethics committee, starting January 2016, 200 consecutive invasive breast carcinoma patients (mean age 51.2 years, all palpable breast masses) undergoing diagnostic breast imaging had their DM and DBT reviewed by two radiologists independently, who were blinded of the cyto/histology and the original DM and DBT reporting. Of these, 47 patients who were treated with NACT and had pre- and post-NACT DM and DBT were recruited. After a core-biopsy, radio-opaque marker(s) were placed in tumor core/margin. The pre- and post-NACT DM and DBT findings were compared and correlated with the extent of response of the primary breast tumor to NACT. DM and DBT characteristics predictive of (in-breast) pCR of index breast lesion were identified. Results: Of the 47 patients who underwent NACT, 44 received both anthracycline and taxane, and 3 received only an anthracycline based combination chemotherapy. Twelve patients underwent breast conservative surgery and the remaining underwent mastectomy. pCR was seen in 17 (36.2%) patients based on the surgical specimen histology. On clinical examination, 19 (40.4%) patients had clinical complete response (cCR) of the breast tumor, 11 (64.7%) of whom had pCR as well. Five patients had radiological complete response (rCR, no breast lesion visualised on post-NACT imaging)- 2 patients on DM alone, 2 patients on DBT alone, and one patient on both DM and DBT. Radio-opaque clips had some obscuring effects in 3 of these 5 patients, especially on DBT, in form of reduced visibility of breast lesion on DBT, c.w. corresponding DM images. All 5 patients with rCR had pCR (sensitivity=29.4%, specificity=100%), in contrast to only 11 (57.9%) patients with cCR having pCR. Patients with pCR had benign appearing (forced Bi-RADS 2 and 3) lesions on mammography more commonly on DM (p Conclusions: Post-NACT DM and DBT features can predict pCR with high specificity but with low sensitivity. Pre-NACT DM and DBT features did not reliably predict response to NACT, and pCR in this study. DM may be better than DBT for assessing response to NACT in the presence of radio-opaque markers/clips. Citation Format: Agarwal G, Sonthineni C, Mohindra N, Jain N, Neyaz Z, Agrawal V, Krishnani N, Maylivahnan S, Mishra A, Lal P. Predicting pathological complete response (pCR) to neoadjuvant chemotherapy (NACT) based on pre- and post-NACT digital mammography and digital breast tomosynthesis findings [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-11.

Coronary luminal dimensions change during the cardiac cycle. However, contemporary volumetric intravascular ultrasound (IVUS) analysis is performed in non-gated images as existing methods to acquire gated or to retrospectively gate IVUS images have failed to dominate in research. We developed a novel deep learning (DL)-methodology for end-diastolic frame detection in IVUS and compared its efficacy against expert analysts and a previously established methodology using electrocardiographic (ECG)-estimations as reference standard. Near-infrared spectroscopy-IVUS (NIRS-IVUS) data were prospectively acquired from 20 coronary arteries and co-registered with the concurrent ECG-signal to identify end-diastolic frames. A DL-methodology which takes advantage of changes in intensity of corresponding pixels in consecutive NIRS-IVUS frames and consists of a network model designed in a bidirectional gated-recurrent-unit (Bi-GRU) structure was trained to detect end-diastolic frames. The efficacy of the DL-methodology in identifying end-diastolic frames was compared with two expert analysts and a conventional image-based (CIB)-methodology that relies on detecting vessel movement to estimate phases of the cardiac cycle. A window of ± 100 ms from the ECG estimations was used to define accurate end-diastolic frames detection. The ECG-signal identified 3,167 end-diastolic frames. The mean difference between DL and ECG estimations was 3 ± 112 ms while the mean differences between the 1st-analyst and ECG, 2nd-analyst and ECG and CIB-methodology and ECG were 86 ± 192 ms, 78 ± 183 ms and 59 ± 207 ms, respectively. The DL-methodology was able to accurately detect 80.4%, while the two analysts and the CIB-methodology detected 39.0%, 43.4% and 42.8% of end-diastolic frames, respectively (P

The nasal route of administration is gaining a lot of interest these days in order to achieve the efficient brain targeting. The superior therapeutic outcomes of nasal delivery are due to surpassing the demerits of the conventional drug delivery viz. first-pass metabolism, enzymatic degradation in gastric environment, poor absorption rate, and reduced bioavailability. This route suffers several drawbacks viz. mucociliary clearance, reduced residence time, and poor permeability through nasal mucosa, which made it difficult task for the formulators to fabricate the efficient nasal delivery system. The intranasal delivery extends various merits over systemic drug delivery because it directly allows the entry of drug in the brain via olfactory route and trigeminal nerve pathways. In addition, the amount of drug in the olfactory bulb enhances the drug bioavailability and cuts down the drug degradation and loss through systemic clearance. Currently, many vesicular carriers (liposomes, niosomes, ethosomes, transferosomes, virosomes, and novasomes) have shown promising outcomes to encounter the drawbacks of nasal route of drug administration. This chapter includes brief discussion on the above-mentioned vesicular carriers along with their difference in structure, composition, physicochemical properties, penetrability, and drug entrapment efficiency. The efforts taken by the researchers to develop vesicular carriers with an aim to obtain nose-to-brain delivery need a lot more thrust. This chapter also includes the clinical translational updates of various formulations and challenges encountered.

BACKGROUND: One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit. METHODS: An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions. RESULTS: A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation. CONCLUSIONS: Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited–English-proficiency families.

Introduction Intraperitoneal (IP) Chemotherapy and HIPEC have come to be accepted as standard options in advanced EOC, but are associated with morbidities and treatment delay. This study was done to evaluate the feasibility of administering single dose intraoperative normothermic IP carboplatin in advanced EOC after optimal primary or interval debulking surgery. Methods In a Phase II non randomized prospective study from January 2015 to December 2019, patients of optimally cytoreduced advanced high grade serous ovarian cancer, were administered single dose intraoperative IP carboplatin at room temperature. The immediate ( Results Of 356 patients who underwent surgery for advanced EOC, 86 patients met the inclusion and exclusion criteria. 12 (14%) patients underwent PDS and 74 (86%) IDS. 13 (15.1%) patients underwent laparoscopic/robotic IDS. All patients tolerated IP carboplatin well with no or minimal adverse events. Three cases (3.5%) needed re-suturing for burst abdomen, three cases (3.5%) had paralytic ileus, one case underwent re-exploration for hemorrhage, and one patient died due to due late sepsis. 84 (97.7%) patients received adjuvant IV chemotherapy on time. Conclusion Single dose normothermic intraoperative IP carboplatin is a feasible procedure with no or minimal manageable morbidity. The procedure is user friendly combining the prognostic benefits of IP chemotherapy with assurance of early timely administration of chemotherapy in advanced EOC. Our study is hypothesis generating for future clinical trials comparing single dose NIPEC versus HIPEC in advanced EOC.

AIM: The study aimed to investigate the penetration depth of calcium hydroxide-based root canal sealer into buccolingual and mesiodistal aspects of roots with and without the butterfly effect at coronal and middle root sections. METHODS AND MATERIALS: Twenty single-rooted maxillary premolars were decoronated at the cementoenamel junction and viewed under a light microscope and grouped as Group 1 – butterfly (B) and Group 2 – non-butterfly according to the presence or absence of the effect. Canals were prepared till working length followed with copious irrigation. Canals were finally rinsed with 5 ml of 17% ethylenediaminetetraacetic acid solution and activated using EndoActivator followed by obturation using gutta-percha (warm vertical compaction technique) with Sealapex sealer. To provide fluorescence for confocal laser scanning microscopy (CLSM), the Sealapex was mixed with rhodamine B dye. Root sectioning yielded coronal and middle sections. CLSM was used to assess the penetration of the sealer. STATISTICAL ANALYSIS: Shapiro–Wilk test, unpaired “t-test.” RESULTS: Teeth with the butterfly effect had greater mean penetration buccolingually (905.2 μm) than mesiodistally (182.1 μm; p < 0.001). Coronal sections had greater penetration (517.4 μm) compared with the middle (354.6 μm). CONCLUSION: Sealapex sealer exhibited maximum tubular penetration in teeth with butterfly effect in buccolingual direction at the coronal third level.

Background:The COVID-19 pandemic has resulted in uncertainty and negative psychological outcomes for patients with autoimmune rheumatic diseases for several reasons.1The anxiety is due to “underlying conditions” that are expected to increase the risk of infection and / or severe complications. Patients with rheumatological disorders fall into this group as they are believed to be immunosuppressed due to disease or the treatment. It is essential to understand the level of anxiety among the rheumatic disease patients at the current situation of COVID-19.Objectives:To study difference in Anxiety score (Mean/Avg Score) among following groups-underlying rheumatic disease, age, gender, marital status, educational status, employment status, medications, those who were on steroids/not, those who are Biologicals / Not.Methods:A web-based cross-sectional multi-centre survey was done across 5 rheumatology centres in India. The study duration was between 9th May and 16th May 2020.The questionnaire included consent, demographic details, medication history, opinion about tele rheumatology services and anxiety score measured by Beck Anxiety Inventory (BAI)2.Results:The survey was sent to 2987 patients, there were 933 responses and 581 were complete (Male =175). Complete responses were considered for data analysis. Most respondents were less than 50 years of age (70.6%). Rheumatoid arthritis (RA) was the most frequent (50.6%) diagnosis followed by other conditions. Most of the patients (43%) were on combination DMARD therapy, 12.7% of patients were on biological drugs and 23.9% of patients were on glucocorticoids. Statistically significant higher anxiety scores were observed in females, patients suffering from fibromyalgia, patients on glucocorticoids and biological agents. There was no difference in the anxiety scores with regard to age, educational status, and employment status.Difficulty in meeting rheumatologists and getting medications was expressed by 327 (56.2%) and 73 (29.7%) respondents respectively. Majority of respondents (86.6 %) agreed/strongly agreed regarding use of telemedicine to access health care during the crisis.Conclusion:The findings of the study revealed that anxiety is a major concern in patients with autoimmune rheumatic diseases. Fibromyalgia patients and those who were on glucocorticoids and biological drugs were found to have more anxiety levels compared to other groups of patients. In such periods of public health crises, telemedicine is a great tool for patients to access healthcare without fear of going to hospital. There is a need to intensify the awareness and address the mental health issues of rheumatology patients during this COVID-19 pandemic.References:[1]Pope, J.E. What Does the COVID-19 Pandemic Mean for Rheumatology Patients?. Curr Treat Options in Rheum (2020).https://doi.org/10.1007/s40674-020-00145-y.[2]Oh H, Park K, Yoon S, Kim Y, Lee SH, Choi YY, et al. Clinical utility of beck anxiety inventory in clinical and nonclinical Korean samples. Front Psychiatry.2018;9:666.https://doi.org/10.3389/fpsyt.2018.00666Disclosure of Interests:None declared

Chronic pain is one of the most common reasons adults seek medical care. According to the 2016 National Health Interview Survey (NHIS) data, an estimated 20.4% (50.0 million) of US adults had chronic pain, with higher prevalence of chronic pain reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents. Providing adequate pain control in patients with addictive disorders presents unique challenges. The medicinal value of opium has been acknowledged for centuries. Even though possessing a widespread side-effect profile, morphine, isolated from opium more than 200 years ago, remains the gold standard for treating pain. While relapse in a recovering individual may occur despite appropriate pain management, inadequate pain relief is also a risk factor for relapse. Some of the challenges that physicians face include distinguishing between seeking pain relief and seeking drugs for euphoric effects and identifying predictable neuroadaptations such as tolerance and physiological dependence that can be misinterpreted as drug-seeking behavior. In addition, comorbid psychiatric and medical illnesses may complicate effective pain management. This chapter addresses the following areas related to successful pain management in patients with an addictive disorder: (1) substance-abuse terminology, (2) active addiction versus recovery, and (3) management strategy for acute, chronic, and end-of-life pain.

Biosorbent synthesized from dead leaves of Prunus Dulcis with chemical activation during the synthesis was applied for the removal of Acid Green 25 dye from wastewater. The obtained biosorbent was characterized using Brunauer-Emmett-Teller analysis, Fourier transform-infrared spectroscopy and scanning electron microscopy measurements. It was demonstrated that alkali treatment during the synthesis significantly increased surface area of biosorbent from 67.205 to 426.346 m2/g. The effect of various operating parameters on dye removal was investigated in batch operation and optimum values of parameters were established as pH of 2, 14 g/L as the dose of natural biosorbent and 6 g/L as the dose of alkali treated biosorbent. Relative error values were determined to check fitting of obtained data to the different kinetic and isotherm models. It was established that pseudo-second order kinetic model and Langmuir isotherm fitted suitably to the obtained batch experimental data. Maximum biosorption capacity values were estimated as 22.68 and 50.79 mg/g for natural biosorbent and for alkali activated Prunus Dulcis, respectively. Adsorption was observed as endothermic and activation energy of 6.22 kJ/mol confirmed physical type of adsorption. Column experiments were also conducted to probe the effectiveness of biosorbent for practical applications in continuous operation. Breakthrough parameters were established by studying the effect of biosorbent height, flow rate of dye solution and initial dye concentration on the extent of dye removal. The maximum biosorption capacity under optimized conditions in the column operation was estimated as 28.57 mg/g. Thomas and Yoon-Nelson models were found to be suitably fitted to obtained column data. Reusability study carried out in batch and continuous column operations confirmed that synthesized biosorbent can be used repeatedly for dye removal from wastewater.

Bilateral hyperplasia of the coronoid process of the mandible is an unusual entity which often presents with limited mouth opening. Thorough clinical and radiographic examination can help in the diagnosis and the treatment planning of this condition. This article consists of a case report of two patients. The patient in each case, presented with a reduced mouth opening, and when subjected to further investigations, was diagnosed with bilateral coronoid hyperplasia.

In recent years, there has been a growing fascination towards the development of new antimicrobial agents from various sources to combat microbial resistance. Klebsiella pneumonia and E. coli are the main urinary tract infection (UTI) causing agents. Herein, we report the synthesis and characterization of a novel carbonyl complex of Ru(II) that has been found a good antimicrobial agent against the selected microbes. Hence, may be suggested as potent agent against UTI. The compound on characterization was found octahedral in structure on the basis of comparative DFT-experimental characterization. Molecular specification under B3LYP functional, LANL2DZ basis set for Ru atom and 6-31 g(d,p) for all other atoms were employed. Electron density plots and geometrical optimization were the main theoretical aspects that were invoked. Elemental analysis, mass spectrometry, NMR, FT-IR, UV–Vis and cyclic voltammetry were the physio-chemical techniques at both the experimental and theoretical fronts that helped to establish the proposed structure. From the overall study, it may be remarked that both observed and computed outcomes have been found in good agreement with each other.

Photodynamic therapy (PDT) is a treatment that uses photosensitizing agents to kill cancer cells. Scientific community has been eager for decades to design an efficient PDT drug. Under such purview, the current report deals with the computational photodynamic behavior of ruthenium(II) nitrosyl complex containing N, N'-salicyldehyde-ethylenediimine (SalenH2), the synthesis and X-ray crystallography of which is already known [38] , [39] . Gaussian 09W software package was employed to carry out the density functional (DFT) studies. DFT calculations with Becke-3–Lee–Yang–Parr (B3LYP)/Los Alamos National Laboratory 2 Double Z (LanL2DZ) specified for Ru atom and B3LYP/6-31G(d,p) combination for all other atoms were used using effective core potential method. Both, the ground and excited states of the complex were evolved. Some known photosensitizers were compared with the target complex. Pthalocyanine and porphyrin derivatives were the compounds selected for the respective comparative study. It is suggested that effective photoactivity was found due to the presence of ruthenium core in the model complex. In addition to the evaluation of theoretical aspects in vitro anticancer aspects against COLO-205 human cancer cells have also been carried out with regard to the complex. More emphasis was laid to extrapolate DFT to depict the chemical power of the target compound to release nitric oxide. A promising visible light triggered nitric oxide releasing power of the compound has been inferred. In vitro antiproliferative studies of [RuCl3(PPh3)3] and [Ru(NO)(Salen)(Cl)] have revealed the model complex as an excellent anticancer agent. From IC50 values of 40.031 mg/mL in former and of 9.74 mg/mL in latter, it is established that latter bears more anticancer potentiality. From overall study the DFT based structural elucidation and the efficiency of NO, Ru and Salen co-ligands has shown promising drug delivery property and a good candidacy for both chemotherapy as well as light therapy.

India has a high prevalence of chronic disorders which may be associated with persistent pain. Despite the availability of multiple treatment options, chronic pain is largely untreated and contributes to disability and mortality. Medical consumption of opioids remains low due to various barriers that prevent access to opioids for patients and healthcare practitioners. Stringent regulatory provisions outlined in the Narcotic Drugs and Psychotropic Substances Act (1985) have been major deterrents to adequate opioid use. Although multiple amendments to the act have ensured ease of opioid access for medicinal purposes, concerns such as lack of awareness and prescribing practices and attitudes of physicians/patients still need to be addressed. This review aims to identify these barriers and suggest recommendations to overcome them.

Posterior shoulder instability is an entity of low prevalence. An atraumatic etiology makes its diagnosis more difficult owing to the absence of inciting factors. A specific clinical and diagnostic examination is required to make the correct diagnosis. Scapular dyskinesis offers insight into the pathogenesis and thus helps rationalizing conservative treatment as the first choice in most cases. The rehabilitation protocol should be analyzed and customized to correct the abnormal biomechanics of the shoulder, providing a strengthening program to avoid persistence of symptoms or recurrence. Failure of conservative treatment warrants surgical interventions such as arthroscopic stabilization, posterior bone block, or, rarely, shoulder arthrodesis.

A narrative is a brief summary of specific events experienced by patients, during the course of a clinical trial. Narrative writing involves multiple activities such as generation of patient profiles, review of data sources, and identification of events for which narratives are required. A sponsor outsources narrative writing activities to leverage the expertise of service providers which in turn requires effective management of resources, cost, time, quality, and overall project management. Narratives are included as an appendix to the clinical study report and are submitted to the regulatory authorities as a part of dossier. Narratives aid in the evaluation of the safety profile of the investigational drug under study. To deliver high-quality narratives within the specified timeframe to the sponsor can be achieved by standardizing processes, increasing efficiency, optimizing working capacity, implementing automation, and reducing cost. This paper focuses on effective ways to design narrative writing process and suggested best practices, which enable timely delivery of high-quality narratives to fulfill the regulatory requirement.

Introduction: To compare pain scores at rest and ambulation and to assess patient satisfaction between the different modalities of pain management at different time points after surgery. Settings and Design: The ASSIST (Patient Satisfaction Survey: Pain Management) was an investigator-initiated, prospective, multicenter survey conducted among 1046 postoperative patients from India. Material and Methods: Pain scores, patient's and caregiver's satisfaction toward postoperative pain treatment, and overall pain management at the hospital were captured at three different time points through a specially designed questionnaire. The survey assessed if the presence of acute pain services (APSs) leads to better pain scores and patient satisfaction scores. Statistical Analysis: One-way ANOVA was used to evaluate the statistical significance between different modalities of pain management, and paired t-test was used to compare pain and patient satisfaction scores between the APS and non-APS groups. Results: The results indicated that about 88.4% of patients reported postoperative pain during the first 24 h after surgery. The mean pain score at rest on a scale of 1–10 was 2.3 ± 1.8 during the first 24 h after surgery and 1.1 ± 1.5 at 72 h; the patient satisfaction was 7.9/10. Significant pain relief from all pain treatment was reported by patients in the non-APS group (81.6%) compared with those in the APS (77.8%) group (P < 0.0016). Conclusion: This investigator-initiated survey from the Indian subcontinent demonstrates that current standards of care in postoperative pain management remain suboptimal and that APS service, wherever it exists, is yet to reach its full potential.