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Diabetes affects most of the organs causing macrovascular and microvascular complications. Diabetic retinopathy (DR) results from the prolonged uncontrolled hyperglycemia which causes impairment of vision. Quality of life (QoL) of patients with DR is affected due to vision loss. National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) is the questionnaire used to study the effect of DR on QoL.To assess the QoL of the patients with DR.The study enrolled 149 (male-104 and female 45) patients with DR. The previous translated and validated version of NEI-VFQ-25 questionnaire was used in the study.Cronbach alpha for internal consistency was between 0.6 and 0.8. The male patient showed significantly higher (p0.05) QoL scores (60.73±1.63) as compared to the female patients (53.15±2.84). Hypertensive patients showed poor QoL as compared to non-hypertensive patients. The patients with a history of diabetes for 16-30 yrs. showed better QoL as compared to other patients.DR affects the QoL of life of patients. Routine assessment of QoL using NEI-VFQ-25 questionnaire would be useful for physicians and health care team. more...

Introduction Caregiver plays a vital role in taking good care of a cancer patient. But often, the caregiver’s quality of life (QOL) is overlooked. Objectives This study aimed to understand the Caregiver QOL Index—Cancer (CQOL-C) score of the primary caregivers and to find the significant predictors affecting CQOL-C. Materials and Methods A cross-sectional study was conducted among the caregivers attending a rural cancer center in western Maharashtra. The primary caregiver is an immediate relative who assists the patient in most routine activities and is not a professional caregiver. A pretested and predesigned questionnaire using the CQOL-C scale was used to interview the caregivers from December 2019 to June 2020. We analyzed the data using Statistical Package of Social Sciences (SPSS) software. Univariate analysis was done using Student’s t-test and a multivariate model was generated using linear regression analysis of the data. Results A total of 114 caregivers were interviewed. The mean total CQOL-C score was 44.15 ± 17.24 (confidence interval [CI]: 41–47.3). About 71% of the caregivers reported moderate-to-severe hampering of their QOL. The mean CQOL-C scores in caregivers of patients with and without recurrent cancer were 58.24 (CI: 51.66–64.81) and 40.58 (CI: 37.35–43.80), respectively (p < 0.001). The mean CQOL-C scores in caregivers of patients with and without metastatic cancer were 56.68 (CI: 51. 13–62.22) and 39.80 (CI: 36.45–43.14), respectively (p < 0.001). The mean CQOL-C score in caregivers of patients with hematological malignancies was 60.03 (CI: 58.88–61.17) which was significantly higher compared with other sites (p = 0.0257). Conclusion The majority of the caregivers in our study have moderate-to-severe detrimental QOL. Recurrence of cancer and metastatic cancer at presentation are the two significant factors affecting CQOL-C. There is an unmet need to cater to the primary caregiver’s concerns while we focus on treating cancer patients. more...

With the advent of the novel coronavirus (COVID-19) pandemic, health-care workers have been faced with an inordinately high level of trauma as frontline providers. The Medical College of Wisconsin (MCW) partnered with affiliate hospitals and community partners to mobilize a matrix of available support and interventions to deliver psychological services to reach all levels of health-care providers in timely, accessible formats. While virtual peer support groups were the most utilized resource among the support group options, other opportunities also provided unique benefits to learners whose education had been disrupted by the pandemic. Mental health must be prioritized for health-care workers in the event of future public health crises. Lessons learned from this pandemic indicate that it is critical to involve learners early on in the process in order to meet their educational needs and to increase access to evidence-based care. more...

Background: Despite the development of Checkpoint Inhibitor Treatments (Immunotherapy) and Targeted anticancer agents, cytotoxic (chemotherapy) agents remain the mainstay of breast cancer treatments. However, treatment failure is often encountered in breast cancers owing to innate or acquired chemoresistance. Real time monitoring of inherent or incipient chemoresistance is an unmet need to minimize or prevent treatment failures and improve outcomes. However, prior efforts to determine chemoresistance have used tumor tissue or explants and are hence not suitable for repetitive monitoring. We present findings from a large cohort perspective observational study which shows that Circulating Tumor Associated Cells (CTACs) be isolated in sufficient numbers from peripheral blood and can be profiled in vitro for chemoresistance characteristics. Methods: 15 ml of peripheral blood was obtained from 1410 breast cancer patients, of whom 719 were treatment naïve and 691 had received prior systemic therapies. Matched tumor tissue was obtained by a biopsy (post-blood collection) in a subset of 68 cases. Peripheral blood mononuclear cells (PBMCs) were isolated from all blood samples and treated with an epigenetically activating treatment medium which exerts selective cytotoxicity towards non-malignant hematolymphoid cells and allows survival of apoptosis resistant malignant CTACs, which were defined as cells which were EpCAM+, PanCK+ and CD45+/-. Viable Tumor Derived Cells (TDCs) were harvested from biopsied tumor tissue (N=68). CTACs and TDCs were treated in vitro with cytotoxic chemotherapy agents that are used in Standard of Care (SoC) treatment protocols for breast cancer as single agents or in combinations. In 68 cases, concordance in Chemoresistance Profiles (CRP) was determined between CTACs and corresponding TDCs. In 681 pretreated cases, CRP of CTACs evaluated cumulative (innate and acquired) resistance following prior exposure to chemotherapy agents. In 685 therapy naïve cases, CRP of CTACs evaluated innate chemoresistance towards chemotherapy agents. Results: Among the 68 paired samples of CTACs and TDCs, there were 733 unique combinations of CTAC-TDC-drug, among which 366 pairs (50%) were concordant for chemo-resistance, 336 pairs (46%) were concordant for absence of resistance, and 31 pairs (4%) showed absence of concordance leading to a cumulative concordance of 96% in CRP between TDC and CTACs. Among the 681 pretreated cases, resistance towards ≥1 anticancer agents was observed in 67% of the samples. Among the 685 therapy naïve cases, resistance towards ≥1 anticancer agents was observed in 39% of the samples. Conclusion: The present study shows that sufficient CTACs can be harvested from peripheral blood for meaningful non-invasive chemoresistance profiling and that the resistance profiles of CTACs are concordant with that of tumor tissue. The present approach can identify innate as well as acquired chemoresistance and can guide selection of appropriate therapies. This approach can facilitate real time monitoring of chemoresistance and therapeutic course correction to minimize the risk of treatment failures. Citation Format: Darshana Patil, Dadasaheb Akolkar, Sanket Patil, Vishakha Mhase, Sachin Apurwa, Sushant Pawar, Rutuja Bhave, Mahesh Ukade, Samruddhi Raut, Harshal Bodke, Shabista Khan, Raja Dhasarathan, Vineet Datta, Stefan Schuster, Cynthe Sims, Jatinder Bhatia, Chirantan Bose, Ajay Srinivasan, Rajan Datar. Non-invasive evaluation of chemoresistance in breast cancers using circulating tumor associated cells [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-36. more...

Background: Common modalities for breast cancer screening include self-breast examination (SBE) for detection of palpable lumps as well as Mammography scans for detection of suspicious nodules or masses. While both approaches have low specificity, SBE has lower sensitivity for early stage cancers while mammography is associated with radiation exposure risks. A blood-based non-invasive approach for determination of breast cancer risk in asymptomatic individuals can facilitate early detection and improve prognosis and survival. Circulating Ensembles of Tumor Associated Cells (C-ETACs) are heterotypic clusters of malignant cells which originate in a tumor and are ubiquitously detected in peripheral blood of individuals with solid organ cancers. We present findings from two large-cohort prospective observational studies showing the suitability of C-ETACs for non-invasive, non-radiological screening for breast cancer. Methods: 15 ml of peripheral blood was collected from 14,962 female volunteers among whom 832 were suspected cases of breast cancer and 14,962 were asymptomatic individuals with age-associated risk of breast cancer. The 832 suspected cases underwent a foundational (first diagnostic) biopsy following collection of blood while the 14,962 asymptomatic individuals underwent a mammography scan following collection of blood. Peripheral blood mononuclear cells (PBMCs) were isolated from all blood samples and treated with an epigenetically activating treatment medium which exerts selective cytotoxicity towards non-malignant hematolymphoid cells and allows survival of apoptosis resistant malignant cells and their clusters (C-ETACs). C-ETACs were defined as clusters of 3 or more cells which were EpCAM+, PanCK+ and CD45+/-. Results: Among the 832 suspected cases, 779 were eventually diagnosed with breast cancer and 53 with benign breast conditions. C-ETACs were detected in 701 / 779 cases of breast cancer (90.0% sensitivity) with comparable detection rates in metastatic (365/408 = 89.5%) as well as non-metastatic (336/371 = 90.6%). C-ETACs were also detected in 1 / 53 (1.9%) cases of benign breast tumor. Among the asymptomatic cohort of 14,130, C-ETACs were detected in 657 cases (4.7%), which included 509 / 10,859 (4.7%) individuals with BIRADS 1 and in 148 / 3,271 (4.5%) of individuals with BIRADS ≥2. These individuals have been advised clinical follow-up. Conclusions: We show that C-ETACs are ubiquitous in breast cancers and rare in individuals with benign conditions as well as asymptomatic individuals. Being derived from the tumor mass, C-ETACs are specific for cancer and thus provide direct visual evidence of malignancy in cancer cases and risk of malignancy in asymptomatic cases. The non-invasive nature of the approach is well suited for screening of large asymptomatic populations for breast cancer. Citation Format: Dadasaheb Akolkar, Darshana Patil, Pradip Fulmali, Pooja Fulmali, Revati Patil, Archana Adhav, Shoeb Patel, Sachin Apurwa, Sushant Pawar, Harshal Bodke, Vishal Ranjan, Rohit Chougule, Pradyumna Shejwalkar, Shabista Khan, Raja Dhasarathan, Pradip Devhare, Sanket Patil, Vineet Datta, Cynthe Sims, Stefan Schuster, Jatinder Bhatia, Chirantan Bose, Ajay Srinivasan, Rajan Datar. Non-invasive screening for breast cancer risk based on circulating ensembles of tumor associated cells [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS3-13. more...

Background: Mental disorders are among the strongest predictors of suicide attempts. However, little is known regarding which disorders that is uniquely associated with suicidal behavior because of high levels of psychiatric co-morbidity. The present study was planned to undertake on suicidal intent in such deliberate self-harm patients. Aims: The aim is to determine the suicidal intent and to assess the relationship with psychiatric morbidity in patients of deliberate self-harm Settings: Patients of deliberate self-harm. Design: Cross-sectional study. Materials and Methods: The sample consisted of 50 patients of deliberate self-harm admitted during study period of 6 months in appropriate in-patient unit for observation and necessary intervention, who fulfils inclusion criteria. A semi structured pro forma was used for collection of socio-demographic data, case history and Beck's Suicide intent scale was used which is designed to assess the severity of intention to die associated with an episode of deliberate self-harm. Statistical Analysis Used: Descriptive statistics such as mean, standard deviation, and percentage was used to present the data. To assess the relationship between the suicidal intent and psychiatric morbidity, Chi-square test was used. A P < 0.05 were considered significant. Data analysis was performed using software SPSS v20.0. Results: Self poisoning (80%) was found to be the most common method employed in deliberate self-harm. 74% of the deliberate self-harm attempts were impulsive in nature. Altercation with the spouse (30%) was the most common precipitating factor. Psychiatric morbidity was found to be associated with suicidal intent (P = 0.0068). Conclusions: In conclusion, even with low intent to harm self we have to be careful while examining the patients of psychiatric morbidity. They are at risk of attempting harm to self. We cannot ignore the patients just on the basis of low intent to harm self. more...

Objectives To describe the demographics and evaluate the clinical outcomes of hypoxic coronavirus disease-2019 (COVID-19) patients treated with different immunomodulatory (IM) drugs in a resource-limited setting. Materials and methods We conducted a retrospective cohort study of these patients admitted to our hospital between March 22 and May 31, 2020. Data were abstracted from multiple electronic data sources or patient charts to provide information on patient characteristics, clinical, laboratory variables, and outcomes. Results A total of 134 patients met the inclusion criteria and were followed up till June 7, 2020. The median age of the patients was 55.6 years (range 20–89 years) and 68% were men. At least one comorbidity was seen in 72% of the patients with diabetes (44%) and hypertension (46%) being the most common. At triage, fever (82%), shortness of breath (77%), and cough (61%) were the most common presenting symptoms. A PaO2/FiO2 ratio less than 300 was seen in 60%, and 4.5% required invasive mechanical ventilation within 72 hours of hospital admission. Five immunomodulatory agents (hydroxychloroquine, methylprednisolone, colchicine, etoricoxib, and tocilizumab) were administered in different combinations. Overall, in-hospital mortality was 26.9%, and 32% required mechanical ventilation. Around 69% of patients were discharged home. Five variables (SpO2, PaO2/FiO2 ratio, leucocytosis, lymphopenia, and creatinine) on admission were found to be significant in the patients who died. Conclusion Our study provides the characteristics and outcomes of hypoxic COVID-19 patients treated with IM drugs in varied combination. Five independent variables were strong predictors of mortality. How to cite this article Mahale N, Rajhans P, Godavarthy P, Narasimhan VL, Oak G, Marreddy S, et al. A Retrospective Observational Study of Hypoxic COVID-19 Patients Treated with Immunomodulatory Drugs in a Tertiary Care Hospital. Indian J Crit Care Med 2020;24(11):1020–1027. more...

Background and Objectives There are two patient positions described for minimally invasive esophagectomy (MIE) for esophageal cancer, viz., left lateral and prone positions. To retain the benefits and overcome the disadvantages of these positions, a semi-prone position was developed by us. Our objective was to analyze the feasibility of performing MIE in this position. Materials and Methods A retrospective review of patients who underwent MIE at our center from January 2007 to December 2017 was done. A semi-prone position is a left lateral position with an anterior inclination of 45 degrees. Intraoperative parameters including conversion rate, immediate postoperative outcomes, and long-term oncological outcomes were analyzed. Statistical Analysis Statistical Package for the Social Sciences version 19 (IBM SPSS, IBM Corp., Armonk, New York, United States) was utilized for analysis. Survival analysis was done using Kaplan-Meier graph. Quantitative data were described as mean or median with standard deviation, and qualitative data were described as frequency distribution tables. Results Consecutive 224 patients with good performance status were included. After excluding those who required conversion (14 [6.6%]), 210 patients were further analyzed. Median age was 60 years (range: 27–80 years). Neoadjuvant treatment recipients were 160 (76%) patients. Most common presentation was squamous cell carcinoma (146 [70%]) of lower third esophagus (140 [67%]) of stage III (126 [60%]). Median blood loss for thoracoscopic dissection and for total operation was 101.5 mL (range: 30–180 mL) and 286 mL (range: 93–480 mL), respectively. Median operative time for thoracoscopic dissection alone was 67 minutes (range: 34–98 minutes) and for entire procedure was 215 minutes (range: 162–268 minutes). There was no intraoperative mortality. Median 16 lymph nodes were dissected (range: 5–32). Postoperative complication rate and mortality was 50% and 3.3%, respectively. Disease-free interval was 18 months (range: 3–108 months) and overall survival was 22 months (range: 6–108 months). Conclusion MIE with mediastinal lymphadenectomy in a semi-prone position is feasible, convenient, oncologically safe, which can combine the benefits of the two conventional approaches. Further prospective and comparative studies are required to support our findings. more...

Even today, the leading cause of visual impairment is age related cataract. Among the risk factors for cataract, tobacco is one of the modifiable risk factors. Association between smoking and increased oxidative stress among cataract patients has been shown by some studies. But studies related to smokeless tobacco use are not done. The aim of the study was to estimate oxidative stress by markers like enzymatic antioxidant Superoxide Dismutase (SOD) and lipid peroxiation product Malondialdehyde (MDA) in tobacco user age related cataract (ARC) subjects and compare them with tobacco nonuser age related cataract (ARC) subjects. This cross sectional study was performed in 120 subjects divided into 2 groups – 60 tobacco nonuser age related cataract subjects and 60 tobacco user age related cataract subjects. 60 tobacco user cataract subjects divided into 5 groups - tobacco smokers, tobacco chewers, tobacco mishri users, dual tobacco chewers with mishri users and dual smokers with smokeless tobacco users. Oxidative stress was assessed by estimation of erythrocytic SOD and serum MDA. The study showed that in tobacco user group age of cataract patients was significantly less than tobacco nonuser cataract patients (P more...

Increased awareness of von Willebrand Disease (VWD) has led to more frequent diagnostic laboratory testing, which insurers often dictate be performed at a facility with off-site laboratory processing, instead of a coagulation facility with onsite processing. Off-site processing is more prone to preanalytical variables causing falsely low levels of von Willebrand Factor (VWF) due to the additional transport required. Our aim was to determine the percentage of discordance between off-site and onsite specimen processing for VWD in this multicenter, retrospective study. We enrolled females aged 12 to 50 years who had off-site specimen processing for VWF assays, and repeat testing performed at a consulting institution with onsite coagulation phlebotomy and processing. A total of 263 females from 17 institutions were included in the analysis. There were 251 subjects with both off-site and onsite VWF antigen (VWF:Ag) processing with 96 (38IU/dL) being low off-site and 56 (22IU/dL) low onsite; 223 subjects had VWF ristocetin co-factor (VWF:RCo), 122 (55IU/dL) were low off-site and 71 (32IU/dL) were low onsite. Similarly, 229 subjects had a Factor VIII (FVIII) assay, and 67 (29IU/dL) were low off-site with less than half, 29 (13IU/dL) confirmed low with onsite processing. Higher proportions of patients demonstrated low VWF:Ag, VWF:RCo, and/or FVIII with off-site processing compared to onsite (McNemar's test P-value more...

Background and aim India is facing the pandemic of coronavirus disease (COVID-19) just like the whole world. The private sector is the backbone of a healthcare facility in India. Presently, only a few major hospitals in the country are actively dealing with the COVID-19 patients while others are facing troubles due to lack of manpower, management, and required experience to face the pandemic. Despite the lockdown, the cases are ever increasing and each and every hospital in the country should be prepared to face this pandemic the world has never seen before. As one of the largest multispecialty hospitals and a designated COVID center, we have developed and adopted some strategies for better preparedness to face the surge of this pandemic. We would like to share our experience and hope that the strategies laid down and adopted by us will help many other acute care facilities in many parts of India. Materials and methods Different strategies are adopted to deal with the crisis situation of the COVID-19 pandemic. Our adopted strategies were directed to mitigate the challenges of administration, hospital space organization, management of staff and supplies, maintenance of standard of care, and specific COVID care and ethics during this pandemic. Results Based on strategies adopted by us, we feel more confident and prepared to deal with COVID-19 pandemic. Conclusion Our approach for preparing for the COVID-19 pandemic may not be the best one but we believe that the basic managerial principles we adopted will guide many other institutions to find their path in tackling the pandemic in the best possible way. How to cite this article Jog S, Kelkar D, Bhat M, Patwardhan S, Godavarthy P, Dhundi U, et al. Preparedness of Acute Care Facility and a Hospital for COVID-19 Pandemic: What We Did! Indian J Crit Care Med 2020;24(6):385-392. more...

In pregnancy there is change in the physiological levels of hormones. It also brings about changes in other systems like circulatory, respiratory and also leads anatomical modifications in pelvis. These changes are essential for the mother to accommodate the foetus. It is essential to know the changes in pulmonary functions that occur normally in pregnancy and to differentiate it from abnormal values. Progesterone a hormone of pregnancy is known to cause certain degree of bronchodilatation. Hence forth this study was conducted to assess FVC and PEFR and to correlate with Progesterone levels in pregnancy. Materials and Methods: An observational and analytical study was conducted in 90 pregnant women (Primigravidae). The controls were non-pregnant women. All were in the age group between 18 and 25 years. Their pulmonary function parameters FVC and PEFR was analyzed using computerised RMS 401- Heliometer. Progesterone assay was done using CLIA. SPSS 21 version software was used for statistics. Significance was given to p value less than 0.05. Results: FVC and PEFR decreased significantly in pregnancy irrespective of trimester in comparison to controls. FVC did not show significant variation in all trimesters of pregnancy. In the third trimester of pregnancy PEFR showed significant decrease. Between the groups there was significant increase (p progesterone in first trimester of pregnancy. There was positive and significant correlation of FVC and Progesterone in third trimester of pregnancy. This study brings the knowledge about modifications in respiratory functional parameters and helps to identify the norms on predicted values in pregnancy. Keywords: Pregnancy, Forced Vital Capacity, Peak Expiratory Flow Rate, Progesterone. more...

Circulating ensembles of tumor‐associated cells (C‐ETACs) which comprise tumor emboli, immune cells and fibroblasts pose well‐recognized risks of thrombosis and aggressive metastasis. However, the detection, prevalence and characterization of C‐ETACs have been impaired due to methodological difficulties. Our findings show extensive pan‐cancer prevalence of C‐ETACs on a hitherto unreported scale in cancer patients and virtual undetectability in asymptomatic individuals. Peripheral blood mononuclear cells (PBMCs) were isolated from blood samples of 16,134 subjects including 5,509 patients with epithelial malignancies in various organs and 10,625 asymptomatic individuals with age related higher cancer risk. PBMCs were treated with stabilizing reagents to protect and harvest apoptosis‐resistant C‐ETACs, which are defined as cell clusters comprising at least three EpCAM+ and CK+ cells irrespective of leucocyte common antigen (CD45) status. All asymptomatic individuals underwent screening investigations for malignancy including PAP smear, mammography, low‐dose computed tomography, evaluation of cancer antigen 125, cancer antigen 19‐9, alpha fetoprotein, carcinoembryonic antigen, prostate specific antigen (PSA) levels and clinical examination to identify healthy individuals with no indication of cancer. C‐ETACs were detected in 4,944 (89.8%, 95% CI: 89.0–90.7%) out of 5,509 cases of cancer. C‐ETACs were detected in 255 (3%, 95% CI: 2.7–3.4%) of the 8,493 individuals with no abnormal findings in screening. C‐ETACs were detected in 137 (6.4%, 95% CI: 5.4–7.4%) of the 2,132 asymptomatic individuals with abnormal results in one or more screening tests. Our study shows that heterotypic C‐ETACs are ubiquitous in epithelial cancers irrespective of radiological, metastatic or therapy status. C‐ETACs thus qualify to be a systemic hallmark of cancer., What's new? Circulating Ensembles of Tumor Associated Cells (C‐ETACs) comprised of tumor emboli, immune cells, and fibroblasts pose well‐recognized risks of thrombosis and aggressive metastasis. However, the detection and characterization of C‐ETACs have been impaired by methodological difficulties. Here, the authors have developed a label‐free non‐mechanical process that permits enrichment of viable apoptosis‐resistant C‐ETACs from peripheral blood. They show that heterotypic C‐ETACs are not merely incidental findings in cancer but rather a systemic manifestation of malignancy. C‐ETACs are present in a significant proportion of all solid organ malignancies and are rare in asymptomatic individuals. Monitoring of C‐ETACs could help inform cancer management. more...

Distal radius fractures (DRF) are one of the most common fractures treated by orthopaedic surgeons around the globe. It has been estimated that the National Health Services (NHS) spends an average of £1375.34 per patient for surgical fixation of DRF with a volar locking plate as a day case. This figure climbs to £1983.39 if the same patient stays at the hospital overnight. Inpatient physiotherapy costs the NHS a staggering £82.03 per day, while each outpatient session with physiotherapy is £40.70 for the NHS. This means that a substantial amount is spent by the NHS on rehabilitation and physiotherapy for each DRF, whether fixed surgically or non-surgically. Post-operative rehabilitation involving initial immobilization followed by physiotherapy/hand therapy is an indispensable part of the total management concept of DRF. Most of the conservative management protocols also advocate a five-week immobilization followed by physiotherapy/hand therapy. Due to the fact that more than 50% of the patients with DRF are still employed, the impairment caused by a restriction of range of motion, duration of the sick leave and the effects of DRF on quality of life play a very important socio-economical role in the broadest sense. Patients are routinely referred to physiotherapists/hand therapists following DRF to improve the range of motion (ROM), manage pain, strengthen the wrist and develop full functionality to pre-injury levels. However, the real impact of supervised exercises and active physiotherapy in restoring mobility and strength to the fractured wrist is still not well understood. This article aims to review the existing literature and evidence base regarding the efficacy of immobilization and physiotherapy in improving the functional outcome of surgically treated DRFs. more...

Because medical illness is associated with increased inflammation and an increased risk for treatment-resistant major depressive disorder, anti-cytokine therapy may represent a novel, and especially efficacious, treatment for depression. We hypothesized that blockade of the interleukin (IL)-6 signaling pathway with tocilizumab would decrease depression and related symptomatology in a longitudinal cohort of allogeneic hematopoietic stem cell transplantation (HCT) patients, a medically ill population with a significant inflammation and psychopathology. Patients undergoing allogeneic HCT received either a single dose of tocilizumab one day prior to HCT (n = 25), or HCT alone (n = 62). The primary outcome included depressive symptoms at 28 days post HCT; anxiety, fatigue, sleep, and pain were assessed at pretreatment baseline and days +28, +100, and +180 post HCT as secondary outcomes. Multivariate regression demonstrated that preemptive treatment with tocilizumab was associated with significantly higher depression scores at D28 vs. the comparison group (β = 5.74; 95% CI 0.75, 10.73; P = 0.03). Even after adjustment for baseline depressive symptoms, propensity score, and presence of acute graft-versus-host disease (grades II–IV) and other baseline covariates, the tocilizumab-exposed group continued to have significantly higher depression scores compared to the nonexposed group at D28 (β = 4.73; 95% CI 0.64, 8.81; P = 0.02). Despite evidence that IL-6 antagonism would be beneficial, blockade of the IL-6 receptor with tocilizumab among medically ill patients resulted in significantly more—not less—depressive symptoms. more...

Cardiac transplantation is widely accepted as a treatment of choice for patients with end-stage heart failure. Successful outcomes depend on many factors including proper patient selection, donor optimization, coordination and timing, optimized strategies for immunosuppression, and detailed perioperative care. In this chapter, we highlight patient selection, monitoring, and intraoperative and postoperative management of heart transplants. more...

Pulmonary thromboendarterectomy is being applied with increasing frequency to patients suffering from symptomatic chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is defined as a persistent mean pulmonary arterial pressure greater than 25 mmHg for 6 months after an inciting embolic event. CTEPH is progressive in nature and carries a poor prognosis due to the limited efficacy of medical therapy. Surgical intervention by pulmonary thromboendarterectomy (PTE) or lung transplantation are the only effective cures. However, the scarcity of available organs limits the viability of transplantation as a therapeutic option and the mortality rate of untreated CTEPH approaches 90% after 3 years. Therefore, PTE is becoming the therapy of choice for patients with CTEPH and a suitable distribution of pulmonary artery occlusive disease on imaging studies. more...

The tumor also called as neoplasm, a growth in the abnormal tissue can be distinguished by its composition from the embracing tissue. A tumor prompts a cancer, a notable leading cause of death and responsible for about 13 % of all deaths worldwide. The incidence rate of cancer is rising at an unprecedented pace across the globe. Incredible radiological knowledge and expertise is required for accurate detection of tumors in medical imaging. Tumor detection automation is needed as there could be a shortage of professional radiologists during an era of unimaginable need. This paper examines the processes and techniques used as part of tumor detection in light of the results of magnetic resonance imaging (MRD in medical imaging. The techniques are considered based on computer vision can discern tumors in various kinds of medical imaging that aid with the diagnosis of myriad diseases, almost at a specialist level. more...

Background Obesity is a major public health challenge, and recent literature sheds light on the concept of “normalization” of obesity. Objective We aimed to study the worldwide pattern of web-based information seeking by public on obesity and on its related terms and topics using Google Trends. Methods We compared the relative frequency of obesity-related search terms and topics between 2004 and 2019 on Google Trends. The mean relative interest scores for these terms over the 4-year quartiles were compared. Results The mean relative interest score of the search term “obesity” consistently decreased with time in all four quartiles (2004-2019), whereas the relative interest scores of the search topics “weight loss” and “abdominal obesity” increased. The topic “weight loss” was popular during the month of January, and its median relative interest score for January was higher than that for other months for the entire study period (P Conclusions Despite a worldwide increase in the prevalence of obesity, its popularity as an internet search term diminished over time. The reason for peaks in months should be explored and applied to the awareness campaigns for better effectiveness. These patterns suggest normalization of obesity in society and a rise of public curiosity about image-related obesity rather than its medical implications and harm. more...

Spontaneous premature closure of the human fetal ductus arteriosus is an uncommon event that often results in significant morbidity and mortality. We present a case of a neonate with prenatal previously not detected intrauterine closure of the ductus arteriosus in a 21-year-old ,G3P1A2L1 mother with type 2 consanguinity at 39 weeks of gestation, with previous scans showing placenta previa grade 1 at 21weeks and Doppler study showing pericardial effusion at 36weeks.Caesarean section was performed in view of absent progression of labour. A male newborn weighing 4100gm, required bag and mask and intubation. With an excellent neonatal outcome. Finally we suggest that fetal echo in third trimester & maternal education programs to avoid self-medication and provide training for good diet is necessary. more...

PURPOSE: To describe the impact of adding a psychologist (the intervention) to a co-located perinatal psychiatry clinic (PPC) in terms of effects on clinical quality improvement (QI) metrics. METHODS: Six-month pre- and post-intervention study design with measurement of QI metrics: number of unique patients treated; number of new and established visits; percent no-shows for new and established visits; and mean wait time to new visit. RESULTS: Number of unique patients treated by the psychiatrist increased by 30%, from 90 pre-intervention to 118 post-intervention (p=0.06). Total number of visits completed by the psychiatrist increased by 20% from 174 pre-intervention to 208 post-intervention. Mean wait time for new visits for a physician decreased from 20 days pre-intervention to 14 days post-intervention, with a mean difference of 6.4 days (p=0.0015). Percentage of no-shows for new visits increased slightly from 23% pre-intervention to 26% post-intervention (p=0.72). The percentage of no-shows for established visits decreased significantly from 22% pre-intervention to 10% post-intervention (p more...

Introduction: The horseshoe kidney (HSK) is the most common type of renal fusion anomaly. The incidence and characteristics of kidney stones in patients with HSK are not well studied. The aim of this meta-analysis was to evaluate the incidence and types of kidney stones in patients with HSK. Methods: A systematic literature search was performed using MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews from the databases' inception through November 2016. Studies assessing the incidence and types of kidney stones in patients with HSK were included. We applied a random-effects model to estimate the incidence of kidney stones. The study protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42016052037). Results: A total of 14 observational studies with 943 patients (522 adults and 421 pediatric) with HSK were enrolled. The estimated pooled incidence of kidney stones was 36% (95% confidence interval [CI], 15%–59%) in adults with the HSK. Kidney stones were less common in pediatric patients with HSK with an estimated pooled incidence of 3% (95% CI, 2%–5%). The mean age of adult stone formers with HSK was 44.9 ± 6.2 years, and 75% were males. Within reported studies, 89.2% of kidney stones were calcium-based stones (64.2% calcium oxalate [CaOx], 18.8% calcium phosphate [CaP], and 6.2% mixed CaOx/CaP), followed by struvite stones (4.2%), uric acid stones (3.8%), and others (2.8%). Conclusions: Kidney stones are very common in adult patients with HSK with an estimated incidence of 36%. Calcium-based stones are the most prevalent kidney stones in adults with HSKs. These findings may impact the prevention and clinical management of kidney stones in patients with HSK. more...

Ectopic lacrimal gland encompasses all lacrimal tissue that is outside the lacrimal gland fossa, excluding the accessory glands of Krause and of Wolfring. The bulbar conjunctiva and limbus are most commonly involved regions while retrobulbar region is unusual. This tissue may undergo neoplastic transformation, the commonest tumour being pleomorphic adenoma. A 30 year old male presented with painless loss of vision and mild proptosis of the right eye since 5 months. MRI disclosed a well-defined, lobulated contrast enhancing mass in the right retrobulbar region measuring 2 X 2 X 2 cm and a differential diagnosis of vascular or glial neoplasm was entertained. Excision biopsy revealed an encapsulated mass away from the lacrimal fossa. Histopathology showed features of pleomorphic adenoma which was confirmed on IHC. more...

Objective: This multicenter, parallel-group, randomized trial examined the effects of an animal-assisted intervention on the stress, anxiety, and health-related quality of life for children diagnosed with cancer and their parents. Method: Newly diagnosed patients, aged 3 to 17 years (n = 106), were randomized to receive either standard care plus regular visits from a therapy dog (intervention group), or standard care only (control group). Data were collected at set points over 4 months of the child’s treatment. Measures included the State-Trait Anxiety Inventory™, Pediatric Quality of Life Inventory, Pediatric Inventory for Parents, and child blood pressure and heart rate. All instruments were completed by the child and/or his/her parent(s). Results: Children in both groups experienced a significant reduction in state anxiety ( P < .001). Parents in the intervention group showed significantly decreased parenting stress ( P = .008), with no changes in stress among parents in the control group. However, no significant differences between groups over time on any measures were observed. Conclusions: Animal-assisted interventions may provide certain benefits for parents and families during the initial stages of pediatric cancer treatment. more...

Objective Propranolol has recently become the treatment of choice for management of subglottic and airway hemangiomas. This literature review aimed to determine the success rate of propranolol for managing these lesions as well as the rate of rebound growth following propranolol treatment cessation. Study design Literature search involving MEDLINE and Scopus to identify English-language articles. Methods Studies were identified using hemangioma, subglottic or airway, and propranolol for search terms. Studies were eligible for inclusion if they reported the treatment used, individual deidentified patient data, and contained patients without medical or surgical treatment prior to propranolol therapy RESULTS: Initial review included 107 abstracts. Twenty-four articles including case reports and case series met inclusion criteria and were included in the qualitative analysis. Forty-nine patients were included. Twenty-eight (57%) were treated with propranolol alone, and 20 (41%) were treated with a combination of propranolol and a corticosteroid. Thirty-seven (76%) of patients were treated with a dose of 2 mg/kg/d of propranolol. The initial treatment was successful in 43 (88%) of patients. Rebound growth occurred in four (9%) patients. Overall, six (12%) patients underwent surgical resection. Conclusions Propranolol is efficacious for treating subglottic hemangiomas. Rebound growth does occur in a small subset of patients during the propranolol wean. Close observation for children during weaning of propranolol therapy for subglottic hemangioma is essential. Adjunctive management strategies need to be used in patients with rebound growth. Laryngoscope, 127:2665-2672, 2017. more...

Introduction: Little is known about protease, anti-protease markers in chronic obstructive pulmonary disease (COPD) patients. Objectives: The objective of present study was to identify and try to correlate serum markers of protease and anti-protease with pulmonary functions in different stages of patients with COPD and to determine the ratio of neutrophil elastase/alpha-1-antitrypsin in different stages of COPD patients. Methods: This prospective observational study was carried out in patients with stable COPD. Activities of serum alpha-1-antitrypsin and neutrophil elastase were measured in 220 stable COPD patients and in 60 healthy controls by ELISA method. 220 COPD patients were divided into 4 stages according to severity: stage I, II, III and IV. Results: An increase in serum neutrophil elastase and neutrophil elastase/alpha-1-antitrypsin ratio was observed in COPD patients with the advancement of the stage. In contrast to that, decreased activity of alpha-1-antitrypsin in serum was observed in different stages of COPD and is correlated positively with lung function parameters. Conclusion: From these findings we conclude that as the severity increases there is decrease in alpha-1-antitrypsin resulting in concomitant increase in neutrophil elastase activity causing imbalance between protease-antiprotease in COPD patients and this imbalance is associated with impairment of lung function. The neutrophil elastase/ α-1-antitrypsin ratio can tell us the severity of the chronic obstructive pulmonary disease it may be in terms of increased fibrosis of the lung. Though the magnitude of neutrophil elatase/alpha-1-antitrypsin ratio is minute, still it can be a good marker of pulmonary function in term of severity of the COPD. more...

Advances in computer modeling and simulation technologies have the potential to provide facial plastic surgeons with information and tools that can aid in patient-specific surgical planning for rhinoplasty. Finite element modeling and computational fluid dynamics are modeling technologies that have been applied to the nose to study structural biomechanics and nasal airflow. Combining these technologies with patient-specific imaging data and symptom measures has the potential to alter the future landscape of nasal surgery. more...

Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious immune-mediated condition, seen 3–5 weeks after COVID-19. Maternal SARS-CoV-2 may potentially cause a similar hyperinflammatory syndrome in neonates due to transplacental transfer of antibodies. We reviewed the perinatal history, clinical features, and outcomes of 20 neonates with features consistent with MIS-C related to maternal SARS-CoV-2 in Kolhapur, India, from 1 September 2020 to 30 April 2021. Anti-SARS-CoV-2 IgG and IgM antibodies were tested in all neonates. Fifteen singletons and five twins born to eighteen mothers with a history of COVID-19 disease or exposure during pregnancy presented with features consistent with MIS-C during the first 5 days after birth. Nineteen were positive for anti-SARS-CoV-2 IgG and all were negative for IgM antibodies. All mothers were asymptomatic and therefore not tested by RTPCR-SARS-CoV-2 at delivery. Eighteen neonates (90%) had cardiac involvement with prolonged QTc, 2:1 AV block, cardiogenic shock, or coronary dilatation. Other findings included respiratory failure (40%), fever (10%), feeding intolerance (30%), melena (10%), and renal failure (5%). All infants had elevated inflammatory biomarkers and received steroids and IVIG. Two infants died. We speculate that maternal SARS-CoV-2 and transplacental antibodies cause multisystem inflammatory syndrome in neonates (MIS-N). Immunomodulation may be beneficial in some cases, but further studies are needed. more...

Polycystic ovarian syndrome (PCOS) is a complex endocrine disorder characterized by insulin resistance which in turn leads to elevated levels of androgens, anovulation, amenorrhea or oligomenorrhea, obesity and polycystic ovaries. Objectives: To evaluate efficacy of herbal formulations-Nishamalaki and Kanchanar Guggulu in animal model of PCOS. Material and Methods: Six female rats of Group I served as control (No Letrozole, no treatment), Letrozole was given 1mg/kg /day for 28 days to induce PCOS in remaining female wistar rats which were then divided into 6 groups of 6 animals each Group II- PCOS disease control, Group III – Clomiphene citrate, Group IV- Nishamalaki, Group V- Metformin, Group VI- Nishamalaki & Metformin and Group VII- Kanchanar Guggulu. Animals were treated orally according to groups for 56 days. Body weight, food intake, Insulin, blood glucose levels and lipid profile checked before and after treatment. Vaginal smear was done daily to study estrous changes. Results: Along with dyslipidaemia, Rats with PCOS showed increase in body weight and insulin levels. Significant reduction in body weight, lipid profile, Blood sugar and insulin was seen in Nishamalaki treated animals but not in Kanchanar Guggulu group. Kanchanar Guggulu and Nishamalaki regularized the cycles in 1st and 3rd weeks respectively. Conclusion: Nishamalaki effectively corrected all changes in PCOS whereas Kanchanar Guggulu only regularized the estrous cycles. more...

Diagnosis of suspected cases of gliomas such as intracranial space-occupying lesions (ICSOLs) is based on histopathologic analysis of tumor tissue obtained by invasive biopsies, which are, however, associated with risk of serious complication, high rates of mortality, procedural expenses, sequelae, and other risks. Liquid biopsy (LB)-based noninvasive approaches for diagnosis of gliomas based on circulating tumor biomarkers in peripheral blood have hence gained considerable interest. We describe the discovery of a unique 20 exosomal mRNA signature that can discern gliomas from healthy individuals. We obtained 15 mL of peripheral blood by venous draw from 222 individuals, among whom 47 had confirmed diagnosis of gliomas and 175 were asymptomatic. Exosomes were enriched from peripheral blood and were used for isolation of mRNAs. Exosomal mRNAs were used for expression analysis of 20,802 gene transcripts, including 18,574 coding genes and 2,228 noncoding genes based on University of California Santa Cruz (UCSC) hg19 annotation. Differentially expressed mRNAs were analyzed using a machine learning algorithm to identify transcripts that were unique to or uniquely absent in known cases of gliomas and in healthy individuals. The machine learning algorithm identified a 20-mRNA signature that discerned gliomas from healthy individuals with high sensitivity (87%) and specificity (95%) with an overall accuracy of 94%. The differentially expressed transcripts included MST4, RARRES3, TARP, IL32, PPP3CC, RSL1D1, RSL24D1, EIF4B, ARHGEF3, DENND2D, EVL, SEC11A, RPL22L1, HIST1H1C, IRF8, SOS2, GLTSCR2, GIMAP7, HIST1H4D, and CDK11. These differentially expressed transcripts are potentially involved in various functions such as tumor suppression, protein phosphorylation-dephosphorylation, signal transduction (ligand binding), and cell cycle regulation. Our data indicate that exosomal mRNA profiling is a viable approach for discerning suspected cases of gliomas from healthy individuals. The noninvasive nature of this approach coupled with high sensitivity and specificity favor potential clinical application. Citation Format: Sachin Apurwa, Pooja Fulmali, Dadasaheb Akolkar, Darshana Patil, Sushant Pawar, Sneha Puranik, Vipul Todarwal, Akshay Ainwale, Pradip Devhare, Vineet Datta, Cynthe Sims, Ajay Srinivasan, Rajan Datar. An mRNA signature that accurately discerns gliomas from healthy individuals [abstract]. In: Proceedings of the AACR Special Conference on Advances in Liquid Biopsies; Jan 13-16, 2020; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(11_Suppl):Abstract nr B17. more...

Introduction: Tobacco usage is mainly in the form of smoking and smokeless tobacco. Some studies commented that smokeless tobacco has high nicotine and toxic effect, but the studies with depictive data have been limited. Cotinine is one of the nicotine metabolite, which is used as a marker to quantify tobacco exposure. Aim: To estimate serum cotinine (CTN) levels in tobacco smokers and smokeless tobacco users and to compare them with tobacco non-users. Materials and Methods: This cross-sectional study was performed in 240 study subjects divided into four groups- only tobacco smokers (G1), only smokeless tobacco users (G2), dual tobacco smokers and smokeless tobacco users (G3), and tobacco non-users (G4). G2 was divided into G2a, G2b, and G2c. Serum CTN levels were estimated using enzyme linked immunosorbant assay (ELISA) kit. Chi-square test, unpaired t-test, ANOVA and regression analysis were used for statistical analysis. Results: The mean serum CTN levels in groups G1, G2a, G2b, G2c, G3 and G4 were found to be 117.45 ng/mL, 138.09 ng/mL, 72.35 ng/mL, 100.34 ng/mL, 145.21 ng/mL and 5.28 ng/mL respectively. When the mean values were compared between the groups the values were found to be statistically highly significant. The finding suggests significantly higher CTN levels in tobacco users compared with tobacco non-users, also in tobacco chewers compared with tobacco smokers, as well as for dual tobacco smokers and smokeless tobacco users compared with smokers. Conclusion: Dual tobacco smokers and smokeless tobacco users tend to have relatively high level of serum CTN, which suggests tobacco dependence. more...

Non-psychiatric providers are increasingly called upon to provide medical treatment for their patients suffering from neuropsychiatric illnesses. If pharmacotherapy is elected as a mode of treatment, this chapter will aid clinicians in selecting the most appropriate medication. The choice of medication requires that the provider consider the patient’s medical comorbidities as well as any other medications that the patient may be taking to avoid untoward iatrogenic adverse events. An appreciation of potential side effects related to the various types of medications commonly prescribed to address psychiatric conditions is also imperative and outlined in the chapter. more...

Introduction Chimeric antigen receptor (CAR) T-cell therapy is a promising novel T-cell immunotherapy in cancer treatment that has shown clinical efficacy in treating refractory CD19+ B-cell malignancies. However, its use is associated with severe immune-mediated toxicities, including cytokine release syndrome (CRS) and CAR T-cell-related encephalopathy syndrome (CRES). CRS is a systemic inflammatory immune response resulting in symptoms ranging from constitutional to profound organ dysfunction; CRES is a neurotoxicity that can occur concurrently or separately from CRS. Objective This case report and discussion provide an overview of CRES and CRS and highlight special considerations for consultation-liaison (CL) psychiatrists. Method We describe a case of a woman treated with CAR T-cell therapy who developed CRES and CRS, including neuropsychiatric manifestations. We reviewed the literature using “Pubmed” search terms of “CAR T-cell therapy” and “CRS” or “CRES”. Discussion We provide an overview of CRS and CRES. We also highlight special considerations for the CL psychiatrist including completing a delirium workup, weighing risks/benefits of psychotropic agents to treat neuropsychiatric manifestations of CRES, and recognizing the potential for long-term behavioral health symptoms related to CRES, CRS, or their treatments. Conclusion CAR T-cell immunotherapy is becoming more prevalent. It is imperative that CL psychiatrists become familiar with this immunotherapy's toxicities including pathophysiology, neuropsychiatric manifestations, and evaluation and management to ensure optimal patient care. Finally, since immune activation, inflammation, and cytokine activation - as occurs with CRES - are known to affect cognitive and/or emotional functioning, CL psychiatrists must remain vigilant for these potential long-term psychiatric complications. more...

Essentials Cancer patients receiving anticoagulants for venous thromboembolism have an elevated bleeding risk. This secondary analysis of CATCH assessed characteristics of clinically relevant bleeding (CRB). CRB occurs in 15% of cancer patients with thrombosis using therapeutic doses of anticoagulation. After multivariate analysis, risk factors for CRB were age >75 years and intracranial malignancy. Summary Background Cancer patients with acute venous thromboembolism (VTE) receiving anticoagulant treatment have an increased bleeding risk. Objectives We performed a prespecified secondary analysis of the randomized, open-label, Phase III CATCH trial (NCT01130025) to assess the rate and sites of and the risk factors for clinically relevant bleeding (CRB). Patients/Methods Patients with active cancer and acute, symptomatic VTE received either tinzaparin 175 IU kg-1 once daily or warfarin (target International Normalized Ratio [INR] of 2.0-3.0) for 6 months. Fisher's exact test was used to screen prespecified clinical risk factors; those identified as being significantly associated with an increased risk of CRB then underwent competing risk regression analysis of time to first CRB. Results Among 900 randomized patients, 138 (15.3%) had 180 CRB events. CRB occurred in 60 patients (81 events) in the tinzaparin group and in 78 patients (99 events) in the warfarin group (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.45-0.89). Common bleeding sites were gastrointestinal (36.7%; n = 66), genitourinary (22.8%; n = 41), and nasal (10.0%; n = 18). In multivariate analysis, the risk of CRB increased with age > 75 years (HR 1.83, 95% CI 1.14-2.94) and intracranial malignancy (HR 1.97, 95% CI 1.07-3.62). In the warfarin group, 40.4% of CRB events occurred in patients with with an INR of 75 years and intracranial malignancy. more...

Dear Editor, Piriformis syndrome (PS) comprises symptoms like pain in the region of the sacroiliac joint, greater sciatic notch, piriformis muscle (PM), and occasionally sciatica [1]. Walking/stooping/lifting exacerbate the symptoms. Signs include piriformis tenderness, PM stretch pain, positive straight leg raise sign, gluteal atrophy and weakness [2]. PS accounts for 6–8% of low back pain cases [3]. Proposed mechanisms for PS include PM contracture/spasm from trauma/overuse/hypertrophy. Steroid/botulinum toxin injections form the mainstay of therapy [1]. We propose that gemelli and obturator internus (OI) are also part of myofascial pain syndrome (MPS) causing PS. We report the success of ultrasound-guided dry needling (USGDN) of gemelli and OI in relieving PS symptoms in a patient who had remained unresponsive to repeated piriformis injections. A 72-year-old radiologist presented with continuous pain (8–9 on Numerical Rating Scale [NRS]) in right buttock, radiating to ankle within 1–2 minutes of sitting/standing/assisted walking. Piriformis stretch test was positive and palpation showed right buttock tenderness. His symptoms had started with mobilization after 3 months of bed rest for L5 vertebral osteomyelitis following surgery for lumbar canal stenosis of 3 years with foot drop. Pain was unrelieved by neuromodulators (pregabalin, gabapentin), analgesics (100 mg extended-release tramadol, paracetamol 500 mg tds), computed tomography (CT), and ultrasonography (USG)-guided piriformis injections with steroid. His Patient Health Questionnaire (PHQ) [4] score was 10, indicating major depressive disorder and painDETECT [5] score was 16, indicating definite neuropathy. Magnetic resonance imaging showed discogenic, facetogenic, and failed back surgery syndrome (FBSS) pathologies, normal hip, and healed osteomyelitis. He was offered three treatment options: a medial branch block test followed by radiofreqency (RF) neurotomy for facet arthropathy, epidural injection for radiculopathy, and USGDN for MPS causing PS. He chose USGDN. High-frequency linear 6–13 MHz transducer of Sonosite TM … more...

Background: Pneumoperitoneum to facilitate laparoscopic surgery produces hemodynamic changes that can be harmful for the elderly as well as patients with cardiovascular compromise. Clonidine is an alpha- 2 agonist that can attenuate these changes. Methods: This study of 100 patients was a single blind prospective randomized controlled study. Patients were randomly divided into two groups of 50 each. The clonidine group received 2 microgm/kg iv clonidine in 10 ml normal saline 15 minutes prior to induction. The placebo group received only normal saline. Hemodynamic parameters and incidence of vomiting and shivering were noted. Results: Data was analysed by Pearson’s chi-square test. Clonidine significantly attenuated the rise in heart rate, and the blood pressure. The incidence of postoperative nausea and vomiting was less in the clonidine group. It also reduced shivering. Conclusions: 2 microgm/kg of clonidine iv can be reasonably recommended as a premedicant for laparoscopic procedures in otherwise healthy patients. However further study is required to test its efficacy in patients with compromised cardiovascular function. more...

Prominent ears affect approximately 5% of the population and can have a significant psychological impact on patients. A wide variety of otoplasty techniques have been described, all sharing the goal of re-creating the normal appearance of the ear and achieving symmetry between the 2 sides. Recent trends in otoplasty techniques have consistently moved toward less invasive options, ranging from nonsurgical newborn ear molding to cartilage-sparing surgical techniques and even incisionless, office-based procedures. Herein, we review anatomy of the external ear, patient evaluation, the evolution of nonsurgical and surgical otoplasty techniques, otoplasty outcomes, and future trends for treatment of prominent ears. more...