Impacts on functional and oncological outcomes of Robotic-assisted Radical Prostatectomy 10 years after the US Preventive Service Taskforce recommendations against PSA screening

ABSTRACT Objective: In the following years after the United States Preventive Service Task Force (USPSTF) recommendation against prostate cancer screening with PSA in 2012, several authors worldwide described an increase in higher grades and aggressive prostate tumors. In this scenario, we aim to evaluate the potential impacts of USPSTF recommendations on the functional and oncological outcomes in patients undergoing robotic-assisted radical prostatectomy (RARP) in a referral center. Material and Methods: We included 11396 patients who underwent RARP between 2008 and 2021. Each patient had at least a 12-month follow-up. The cohort was divided into two groups based on an inflection point in the outcomes at the end of 2012 and the beginning of 2013. The inflection point period was detected by Bayesian regression with multiple change points and regression with unknown breakpoints. We reported continuous variables as median and interquartile range (IQR) and categorical variables as absolute and relative percent frequencies. Results: Group 1 had 4760 patients, and Group 2 had 6636 patients, with a median follow-up of 109 and 38 months, respectively. In the final pathology, Group 2 had 9.5% increase in tumor volume, 24% increase on Gleason ≥ 4+3 (ISUP 3), and 18% increase on ≥ pT3. This translated to a 6% increase in positive surgical margins and 24% reduction in full nerve sparing in response to the worsening pathology. There was a significant decline in post-operative outcomes in Group 2, including a 12-month continence reduction of 9%, reduction in potency by 27%, and reduction of trifecta by 22%. Conclusions: The increasing number of high-risk patients has led to worse functional and oncologic outcomes. The initial rapid rise in PSM was leveled by the move towards more partial nerve sparing. Among some historical changes in prostate cancer diagnosis and management in the period of our study, the USPSTF recommendation coincided with worse outcomes of prostate cancer treatment in a population who could benefit from PSA screening at the appropriate time.

A Delphi survey-based development and validation of cognitive-communication assessment tool for Indian preschoolers

ABSTRACT Purpose To address the need for a standardized assessment tool for assessing cognitive-communication abilities among Indian preschoolers, the current study aimed at describing a Delphi based development and validation process for developing one such tool. The objectives of the research were to conceptualize and construct the tool, validate its content, and assess its feasibility through pilot testing. Methods The study followed a Delphi approach to develop and validate the tool across four phases i.e. conceptualization; construction; content validation; and pilot testing. The first three phases were performed with a panel of six experts including speech-language pathologists and preschool teachers while the pilot testing was done with 20 typically developing preschoolers. A literature review was also conducted with the Delphi rounds to support the developmental process. Results The first two rounds of the Delphi aided in the construction of a culturally and linguistically suitable story-based cognitive-communication assessment tool with the memory (free recall, recognition, and literary recall) and executive function (reasoning, inhibition, and switching) related tasks relevant for preschoolers. The content validation of the tool was continued with the experts till the revisions were satisfactory and yielded an optimum Content Validity Index. The pilot test of the finalized version confirmed its feasibility and appropriateness to assess developmental changes in the cognitive-communication abilities of preschoolers. Conclusion The study describes the Delphi-based conceptualization, construction, content validation, and feasibility check of a tool to assess cognitive-communication skills in preschool children.

Effect of inter-aural temporal envelope differences on inter-aural time difference thresholds for amplitude modulated noise

ABSTRACT Purpose The inter-aural time difference (ITD) and inter-aural level difference (ILD) are important acoustic cues for horizontal localization and spatial release from masking. These cues are encoded based on inter-aural comparisons of tonotopically matched binaural inputs. Therefore, binaural coherence or the interaural spectro-temporal similarity is a pre-requisite for encoding ITD and ILD. The modulation depth of envelope is an important envelope characteristic that helps in encoding the envelope-ITD. However, inter-aural difference in modulation depth can result in reduced binaural coherence and poor representation of binaural cues as in the case with reverberation, noise and compression in cochlear implants and hearing aids. This study investigated the effect of inter-aural modulation depth difference on the ITD thresholds for an amplitude-modulated noise in normal hearing young adults. Methods An amplitude modulated high pass filtered noise with varying modulation depth differences was presented sequentially through headphones. In one ear, the modulation depth was retained at 90% and in the other ear it varied from 90% to 50%. The ITD thresholds for modulation frequencies of 8 Hz and 16 Hz were estimated as a function of the inter-aural modulation depth difference. Results The Friedman test findings revealed a statistically significant increase in the ITD threshold with an increase in the inter-aural modulation depth difference for 8 Hz and 16 Hz. Conclusion The results indicate that the inter-aural differences in the modulation depth negatively impact ITD perception for an amplitude-modulated high pass filtered noise.

Adrenal morphology and cortical function in patients with extrapulmonary tuberculosis: response to antituberculosis treatment

ABSTRACT Objective: Enlargement of the adrenal glands and variable adrenocortical function have been reported in patients with pulmonary tuberculosis and, in a few studies, in patients with extrapulmonary tuberculosis (EPTB). However, none of the studies have evaluated the course of the adrenal morphology in these patients. Subjects and methods: Prospective study including 37 patients with EPTB and 37 healthy age- and sex-matched controls. The adrenal function was evaluated by measurement of cortisol levels at baseline and after stimulation with ACTH (Acton Prolongatum) before and 6 months after antituberculosis treatment. The size of both adrenal glands was evaluated using 64-slice computed tomography (CT) scanning before and 6 months after treatment. The findings were compared with those in a group of healthy matched controls. Results: Clinical and biochemical parameters were comparable between groups. The mean baseline serum cortisol level was significantly lower in the EPTB group (397.1 ± 184.9 nmol/L) compared with the control group (696.3 ± 101.8 nmol/L). Compared with controls, patients with EPTB had significantly lower mean cortisol levels at baseline and 1 hour after ACTH, both before (397 ± 184.9 nmol/L and 750.7 ± 176.8 nmol/L, respectively) and after (529.7 ± 100.4 nmol/L and 1017.2 ± 119.7 nmol/L, respectively) antituberculosis treatment. Both the length and thickness of the right and left adrenal glands were greater in patients with EPTB than in controls but became comparable to those in controls after treatment completion. Conclusions: Patients with EPTB have an enlarged adrenal size and low baseline and stimulated serum cortisol levels. After treatment completion, cortisol levels increased significantly, and the adrenal size normalized in these patients.

Development and validation of a novel Context-Based Prospective Memory Task among neurotypical adults

ABSTRACT Purpose To address the paucity and potential of context-based prospective memory (PM) assessment tasks suitable to Indian ethnicity, the study aimed to develop a novel context-based PM task and determine its psychometric properties among neurotypical adults. Methods Rendered images in 2-D were extracted from a 3-D shopping mall, where PM and ongoing tasks were embedded within them to provide participants with a semi-immersive experience. The design and scoring of the novel task were constructed in alignment with the Memory for Intentions Screening Test. Fifty neurotypical adults in and around Mangaluru were recruited. The Memory of Intentions Test (MIST) and novel context-based PM task were administered. Results The validity of the novel task was established with a Content Validity Index of 0.98. The intraclass correlation for the test-retest reliability of the novel context-based PM task was 0.92 (p<0.001) and the inter-rater reliability was 0.98 (p<0.001). The internal consistency of the six subscales was high (Cronbach's α= 0.86), and the Spearman-Brown coefficient indicated a strong split-half reliability of 0.87. Spearman's correlation showed that the trials exhibited strong connections to the dichotomic characteristics of the subscales to which they belonged. Further, McNemar's test suggested similar profiles of the participants for the MIST and novel task. Conclusion The results of the present study suggest that the novel context-based PM task offers good validity and reliability measures, providing valuable insight into the mechanisms of PM, and therefore, could be ideal for inclusion in a battery of cognitive assessments.

Communication-related aspects of prospective memory: an exploratory factor analysis of prospective memory questionnaires

ABSTRACT Purpose Prospective memory (PM) questionnaires are frequently used to evaluate perceptions of PM skills in daily life. This study aimed to systematically investigate communication-specific attributes using pre-existing PM self-rating questionnaires to inform clinicians and researchers about the role of PM in cognitive communicative evaluations. Methods PM-related items from three questionnaires (i.e., Prospective Memory Questionnaire, Comprehensive Assessment of Prospective Memory, and Prospective and Retrospective Memory Questionnaire) were compiled and embedded in Google Forms and distributed to 70 Speech-Language Pathologists (SLPs) with expertise in Cognitive Communicative Disorders across India. Participants first identified items related to communication, and were then contacted to rate the communication-related PM items using a Likert scale for their degree of appropriateness. Responses from 40 SLPs were obtained and subjected to item-content validity index (i-CVI) and exploratory factor analysis (EFA). Results Of the 114 PM items, 28 received ratings over 50% for their relevance to communication. Of the 28 items, 21 had an i-CVI score greater than 0.8. After the removal of overlapping content, 14 items were finalized and subjected to EFA, which resulted in four factors: PM failure due to loss of communicative content, PM failure due to loss of communicative intent, PM cost due to ongoing interference, and PM failure linked to the priority of communicative intent. Conclusion This study highlights communication-related aspects of PM that can be used as a framework for SLPs to assess and research PM skills.

Real-world utilization pattern of dydrogesterone in 7287 Indian women with obstetric and gynecological conditions: data from multicentric, retrospective study

Abstract Objective: Despite the literature on dydrogesterone, studies on dydrogesterone utilization patterns are largely lacking in Indian patients. Methods: This was a multi-center, retrospective, observational, cross-sectional, and descriptive study across 817 centers in India. Data of patients who received dydrogesterone in past and provided consent for future use of their medical record for research purpose was were retrieved and analyzed. Results: Data of 7287 subjects (aged 29.55±4.84 years) was analyzed. Threatened abortion was the most common indication for which the subjects received dydrogesterone (46.9%) followed by recurrent pregnancy loss. Polycystic ovary syndrome (PCOS), thyroid disorders and anemia were the most common comorbid conditions and prior pregnancy loss, advanced maternal age and obesity were the most common risk factors seen in subjects who received dydrogesterone. Total 27.5% of subjects received a loading dose of dydrogesterone, and majority (64%) received 40 mg as loading dose. 10 mg dose was used as maintenance or regular dose in 81.4% of the subjects. Twice daily (BID) was the most common dosing frequency (66.6%). The most common concomitant medications being taken by the subjects on dydrogesterone included folic acid (45.1%), iron supplements (30.3%) and calcium and vitamin D3 supplements (25.5%). Another progesterone preparation (oral, injection, vaginal, tubal) other than dydrogesterone was used concurrently in 7.8% of subjects. Conclusion: The study helped to identify the patient population that is benefitted by dydrogesterone and the preferred indications, risk factors, comorbid conditions and concomitant medication used in this patient population at real-life scenario.

Learning to switch gears — Steering palliative care into emergency medicine

Emergency care is largely seen as synonymous with resuscitation and saving lives. In most of the developing world where Emergency Medicine (EM) is still evolving, the concept of EM palliative care is alien. Provision of palliative care in such settings poses its own challenges in terms of knowledge gaps, socio-cultural barriers, dismal doctor-to-patient ratio with limited time for communication with patients, and lack of established pathways to provide EM palliative care. Integrating the concept of palliative medicine is crucial for expanding the dimension of holistic, value-based, quality emergency care. However, glitches in decision-making processes, especially in high patient volume settings, may lead to inequalities in care provision, based on socio-financial disparities of patients or premature termination of challenging resuscitations. Pertinent, robust, validated screening tools and guides may assist physicians in tackling this ethical dilemma.

Implication of photic sneeze reflex in ophthalmology

Background: Photic sneeze reflex (PSR) also known as autosomal dominant compelling helioophthalmic outburst is a rare condition characterized by uncontrolled sneezing in response to bright light. The exact mechanism causing this is poorly understood. However, various hypotheses have been proposed. Ophthalmic examination involves exposing the patient to bright light like slit lamp, indirect ophthalmoscopy and surgical microscope, which can trigger sneezing in PSR patients. Purpose: The purpose of this video is to draw light to this rare phenomenon and its implication in ophthalmic surgery. Synopsis: A 74?year?old male patient presented with diminution of vision in left eye. On routine slit lamp and IDO examination, patient had repeated sneezing. We diagnosed him to have photic sneeze reflex. He had pseudophakic bullous keratopathy in the right eye and senile immature cataract in the left eye. Taking into consideration his one eyed status and PSR, measures were taken accordingly and cataract surgery was performed uneventfully. We describe in this video the challenges encountered with this phenomenon and approach in such cases. Highlights: In this video, we tried to give an idea about photic sneeze reflex and its theories. Also, we tried to bring out the impact of PSR on ophthalmologic practice.

Comparison between stylet and bougie with the C-MAC D-blade in cervical simulated immobility. A prospective randomized controlled trial

Introduction The C-MAC D-blade was designed for difficult airway intubation scenarios. To facilítate easier and faster endotracheal intubation in the laryngoscopy paradox, an introducer is preferred. Hence, we decided to conduct a study to compare the 60° angled C-MAC stylet and the gum elastic bougie as aids to intubation while using the C-MAC D-blade laryngoscope in a simulated difficult airway setting. Objective To compare the ease of oral intubation with the use of the C-MAC stylet (60° angled stylet) versus intubation performed over a bougie inserted using the C-MAC D-blade guidance in patients with simulated restricted cervical mobility. Method Prospective, randomized controlled single-center study. Intubation using the C-MAC D-blade laryngoscope was performed in 48 surgical patients randomly assigned to 2 groups of 24 each: Stylet group, Group S (using 60° angled stylet) and Bougie group, Group B (using bougie) after providing manual in-line stabilization to restrict cervical mobility. The Mann-Whitney U test and the Chi square test were used as applicable. Results The use of stylet resulted in easier (Group S 75% vs. Group B 16.7%) and faster (Group S 26.83 ± 8.61s vs. Group B 47.18 ± 16.46s) intubation with fewer attempts compared to group B. Both groups experienced a similar hemodynamic stress response to intubation. Conclusions The 60° angled C-MAC Stylet is a more effective and time-saving intubation aid with C-MAC D-blade compared to bougie.

Introducción: El videolaringoscopio C-MAC D-blade se diseñó para los casos de intubación de la vía aérea difícil. Para facilitar una intubación más rápida y sencilla en la paradoja de la laringoscopía se prefiere un introductor. Por tanto, decidimos realizar un estudio para comparar el estilete de 60° C-MAC y el bougie elástico de goma como ayudas para la intubación utilizando el laringoscopio C-MAC D-blade en una situación simulada de vía aérea difícil. Objetivo: Comparar la facilidad de intubación oral mediante el uso del estilete del C-MAC (estilete angulado de 60°) con la intubación realizada sobre un bougie insertado con la guía del C-MAC D0-blade en pacientes con restricción simulada de la movilidad cervical. Métodos: Estudio prospectivo, aleatorizado y controlado realizado en un solo centro. Se realizó intubación utilizando el laringoscopio C-MAC D-blade D en 48 pacientes quirúrgicos asignados aleatoriamente a 2 grupos de 24 cada uno: grupo de estilete, grupo S (con el estilete angulado de 60°) y el grupo de bougie o grupo B (con bougie) después de establecer una estabilización manual del eje para restringir la movilidad cervical. Se aplicaron las pruebas U de Mann-Whitney U y de Chi cuadrado según correspondiera. Resultados: Con el estilete fue más fácil (Grupo S 75% vs. Grupo B 16.7%) y más rápida (Grupo S 26.83 ± 8.61s vs. Grupo B 47.18 ± 16.46s) la intubación, requiriéndose un menor número de intentos en comparación con el Grupo B. Los dos grupos experimentaron un estrés hemodinámico similar en respuesta a la intubación. Conclusiones: El estilete angulado de 60° C-MAC es una ayuda más efectiva y ahorra más tiempo con el C-MAC D-blade en comparación con el bougie.

STABILITY TOLERANCE OF SUNFLOWER OIL -IN-WATER EMULSION EMULSIFIED BY SOYA LECITHIN FOR FOOD GRADE ACIDS

Oil-in-water emulsion has promised values in food, pharmaceutical, drug, cosmetic and allied industries. The stable emulsion with long shelf life increases its utility. Many avouring agents are used to increase shelf life as preservative or commercial value. Food grade acids are used to in the emulsion preparation which enhances the taste or avour. The present study focuses the usage of acetic acid, phosphoric acid and oxalic acid. The emulsions for different acids are prepared ranging concentration from 0.001 to 0.003M using lecithin as emulsier and sunower oil. Experiments were done to study organoleptic properties with respect to basicity and dissociation constant values. The colour of the primary emulsion was creamy white and sustainable for acetic acid emulsion to 28 day at experimental temperature 10, 25 and 40 0C. Oxalic acid is recorded a low pH value 1.88 for 0.003 M emulsion solution in compare with acetic acid (3.63) and phosphoric acid (2.32).The relative conductance measurement for oxalic acid shows a very high value 5.6mS to acetic acid 0.257mS and phosphoric acid 0.247 mS. The rst dissociation constant value 5.6x10-2 of oxalic acid is larger relatively compare to phosphoric acid 7.5 x 10-3 and acetic acid 1.8 x10-5. Basicity of acids increases from acetic acid (mono basic), oxalic acid (dibasic) to phosphoric acid (tri-basic).These results strongly supports that basicity and dissociation constant values of acids conspicuously inuence the stability of the emulsion. Higher value of dissociation constant value and basicity, lower the stability of the emulsion.

Personal Protective Equipment Associated Symptoms amongst Frontline Health Care Workers in COVID-19 Pandemic � A Cross Sectional Study

Context : During COVID-19 Pandemic, frontline Health Care Worker (HCW) in hospitals were mandated to Personal Protective Equipment (PPE), while caring for suspected or confirmed COVID-19 patients, which involved the donning of close-fitting N95 Face Masks, Protective Eyewear, Gowns, Surgical Gloves and the use of Powered AirPurifying Respirators (PAPR). Aims : This study is to know the challenges faced during use of PPE among frontline HCW. Methods and Material : This is a cross-sectional study among HCW at our Tertiary Institution who were working in high-risk hospital areas during COVID-19. All respondents completed a self-administered questionnaire Statistical analysis used : Data were entered in Microsoft Excel and analyzed using SPSS version 23. Baseline characteristics were described using frequency and percentages. Association between predictors of PPE associated symptoms were assessed using Chi-square test with p-value of <0.05 considered as significant. Results : Total of 190 Health Care Workers participated in the study. Doctors- contributed most [143/189 (75.2%)]. Majority of the respondents reported usage of Masks, Eyewear, Shield and Gown [126/189 (66.7%)], in which most of them donned N-95 mask [152/189(80.5%)], and Goggles [110/189 (58.2%)] average for 6.32 (2.40) hours a day and 18.15(8.65) days in a month. 83 respondents reported a new onset headache associated with usage of PPE. Majority of the respondents localized Headaches as frontal (69.9%) which was statistically significant. Other symptoms were Tiredness (73.5%), Excess Sweating (45.4%) and Giddiness (20.6%). Conclusions : Prevalence and characteristics of PPE- associated symptoms in HCW working in high-risk areas in Tertiary Care Centers necessitates better measures and strategies for designing PPE and reducing the exposure time in HCW and also the impact on their work performance

Prevalence, Characteristics and Socio-Demographic Correlates of Self-Stigma among Leprosy Affected Persons - A Case Study

This study has determined the prevalence of self-stigma, its characteristics in terms of alienation, stereotype endorsement, perceived discrimination and social withdrawal and stigma resistance among leprosy-affected persons and its relationship and extent of this relationship with various socio-demographic features. This has been done by carrying out a cross-sectional survey of 120 active people affected by leprosy during 2020-21. An internationally validated and standardised instrument (ISMI) was used to measure self-stigma. Statistical techniques such as independent t-test, Pearson’s and point biserial correlation and regression analysis were used for data analysis. The study found significant correlations between ISMI self-stigma scores and socio- demographic variables with moderate to minor deviation across the four components of the ISMI scale. The high to low correlation of various components of the ISMI scale found is discrimination experience, followed by stigma resistance, stereotype endorsement and alienation. Overall, the highest self-stigma was found in disabled people affected by leprosy, followed by those whose age was less than 40 years, followed by unemployed and male people affected by leprosy. It was concluded that alienation was maximum among people affected by leprosy who were either disabled, aged less than 40 years or were males. Discrimination experience was reported mainly by unemployed, disabled, males and younger people affected by leprosy. The findings indicate that proper methodology and components of Cognitive Behavioural Therapy may help reduce self-stigma among leprosy-affected persons

Role of machine learning techniques in classification of peripheral pulse morphology

Recording of peripheral pulse serves as a very important and essential non-invasive tool used widely by doctors for the diagnosis of various diseases. The morphology of pulse is seen to vary as a function of time in a given individual and also from individual to individual. There are many variations in morphological patterns of peripheral pulse in different disease conditions, which lead to difficulty in accurate diagnosis. The peripheral pulse waveforms are extracted from radial arteries as time series data using a peripheral pulse analyzer which is designed on the principle of impedance plethysmography. It was first introduced by Nyober in the mid-nineteen hundreds and ameliorated further by Kubicek. It involves the recording of the instantaneous blood volume by the measurement of electrical impedance as a function of time. Therefore, the study of peripheral pulse morphology has gained much attention in the past few years among researchers. Physiological variability is one of the recent investigations added during the last two decades for the objective assessment of autonomic function and the assessment of prognosis in severe sicknesses namely myocardial infarction, diabetic neuropathy, etc. In addition to heart rate variability studied worldwide, few researchers have studied blood pressure variability and peripheral blood flow variability. In this computer era, artificial intelligence and machine learning techniques have become more important day-by- day, and different types of algorithms were used for the identification of hidden patterns from plethysmographic observations on the radial pulse such as support vector machine as well as crisp and fuzzy clustering. Eight patterns were classified with a yield of 80%–90% and helped with the diagnosis of disorders such as myocardial infarction, pulmonary tuberculosis, coronary artery disorders, cirrhosis of the liver, and bronchial asthma. This paper briefly describes the use of machine learning techniques for the classification of peripheral pulse morphologies.

Growth and Neurodevelopmental Outcomes of Very Low Birth Weight Infants From Southern India at Corrected Age of One Year

Objective: To assess the growth and neurodevelopmental outcome of very low birth weight (VLBW) infants at corrected age of one year. Methods: This prospective cohort study enrolled VLBW infants delivered in a tertiary care hospital, and followed up till oneyear corrected age. The WHO Anthropo version 3.2.2 software was used to calculate weight for age, length for age, and head circumference z-score during follow up. Neurodevelopmental assessment was done using Developmental Assessment Scale for Indian Infants (DASII) at the age of one year. Results: The mean (SD) z-scores at one-year for weight for age, length for age and head circumference were -2.1 (1.1), -1.4 (1.03) and -2.2 (1.2), respectively. The mean (SD) DASII motor and mental scores were 90.8 (13.4) and 96.5 (13.2), respectively. Major and minor developmental abnormalities were noted in 9.4% and 18.2%, infants, respectively. Cerebral palsy was noted in 5.8% infants. Conclusion: VLBW infants showed impaired growth and significant developmental abnormalities at the corrected age of one year.

Calcitonin gene-related peptide (CGRP) concentrations outside migraine attacks in peripheral blood as a potential biomarker for chronic migraine / Concentrações de peptídeo relacionado ao gene da calcitonina (CGRP) fora dos ataques de enxaqueca no sangue periférico como um potencial biomarcador para enxaqueca crônica

Introduction: Chronic migraine is a debilitating condition that affects a significant portion of the population. Accurate diagnosis and treatment of chronic migraine remain a challenge due to the lack of objective biomarkers. Calcitonin gene-related peptide (CGRP) is a neuropeptide involved in the pathophysiology of migraine and has been proposed as a potential biomarker for migraine. Methods: We measured CGRP levels in peripheral blood samples collected from 142 participants with chronic or episodic migraine and 24 healthy controls during ictal periods, i.e., outside migraine attacks. We compared CGRP levels between the three groups and assessed the correlation between CGRP levels and clinical features of chronic migraine. Conclusion: Our study provides evidence that CGRP levels in peripheral blood during ictal periods may serve as a potential biomarker for chronic migraine. Further studies are needed to validate these findings and to explore the clinical utility of CGRP as a biomarker for chronic migraine.

Introdução: A enxaqueca crônica é uma condição debilitante que afeta uma parcela significativa da população. O diagnóstico preciso e o tratamento da enxaqueca crónica continuam a ser um desafio devido à falta de biomarcadores objetivos. O peptídeo relacionado ao gene da calcitonina (CGRP) é um neuropeptídeo envolvido na fisiopatologia da enxaqueca e foi proposto como um potencial biomarcador para enxaqueca. Métodos: Medimos os níveis de CGRP em amostras de sangue periférico coletadas de 142 participantes com enxaqueca crônica ou episódica e 24 controles saudáveis ​​durante períodos ictais, ou seja, fora das crises de enxaqueca. Comparamos os níveis de CGRP entre os três grupos e avaliamos a correlação entre os níveis de CGRP e as características clínicas da enxaqueca crônica. Conclusão: Nosso estudo fornece evidências de que os níveis de CGRP no sangue periférico durante os períodos ictais podem servir como um potencial biomarcador para enxaqueca crônica. Mais estudos são necessários para validar estes resultados e explorar a utilidade clínica do CGRP como biomarcador para enxaqueca crónica.

Simulation-based training in ear, nose and throat skills and emergencies

Abstract Objectives: The aim of the study was to compare lecture-based teaching and simulation-based hybrid training for ENT induction and objectively assess the performance of trainees in a simulated environment. Methods: This is a prospective interventional study that included 60 interns in their rotatory internship with no prior exposure to ENT emergencies. The interns came in batches of 5-6 for their 15-days ENT postings. On the first day, a pre-test questionnaire, lecture-based teaching on three scenarios and then allocation into one of the three simulation groups- Group A (Tracheostomy group), Group B (Nasogastric tube group), and Group C (Epistaxis group) was done. Hands-on simulation training was given only to the assigned group. At the end of 15-days, post-test questionnaire and an objective assessment of the three scenarios in a simulated environment was conducted. The same training was repeated for each batch of participants who attended the posting. Results: The participants had significant improvement in the post-test scores in all three scenarios (p < 0.05), and these improvements were marked in those who had received simulated training. On comparing simulation scores, the participants who received hands-on training on a particular scenario outperformed other (p < 0.05). Conclusion: Simulation-based training improves cognition and overall confidence in managing ENT skills and emergencies. In simulation training, objective and standardized assessment is the key to achieve specific learning objectives to improve the psychomotor and cognitive skill. Level of evidence: II.

Bilateral variation in the branching pattern of the subclavian artery: an unusual finding with clinical implications / Variação bilateral no padrão de ramificação da artéria subclávia: um achado incomum com implicações clínicas

Abstract The subclavian artery is a significant branch of the aortic arch. We present a rare case of a bilateral variation in the branching pattern of the subclavian artery, observed in an adult male cadaver aged 70 years. On both the sides of the neck, all the branches of the subclavian artery took their origin from its first part. There was a rare occurrence of a cervicodorsoscapular trunk, which gave rise to superficial cervical, suprascapular, and dorsal scapular arteries. The same branching pattern was observed on the left side of the neck, with the presence of another cervicodorsoscapular trunk. Thyrocervical trunk and transverse cervical artery were both absent from the cervical region bilaterally. The inferior thyroid artery was a direct branch from the subclavian artery. Knowledge regarding variations of the subclavian artery is very important as lateral cervical region arteries are important for flap harvesting in plastic and reconstruction surgery. Preoperative radiologic evaluation of pedicles might help in choosing the optimal flap design, prevent ischemic complications, and help to improve overall treatment outcomes.

Resumo A artéria subclávia é um ramo significativo do arco da aorta. Apresentamos um caso raro de variação bilateral do padrão de ramificação da artéria subclávia, observada em um cadáver adulto do sexo masculino de 70 anos. Em ambos os lados do pescoço, todos os ramos da artéria subclávia originavam-se de sua primeira parte. Houve rara ocorrência de tronco escapular cervical dorsal, que deu origem às artérias cervical superficial, supraescapular e escapular dorsal. O mesmo padrão de ramificação foi observado no lado esquerdo do pescoço, com a presença de tronco escapular cervical dorsal. O tronco tireocervical e a artéria cervical transversa estavam ausentes em ambas as regiões cervicais direita e esquerda. A artéria tireóidea inferior consistia em um ramo direto da artéria subclávia. O conhecimento das variações da artéria subclávia é fundamental, pois as artérias da região cervical lateral são importantes para a obtenção de retalhos em cirurgias plásticas e reconstrutivas. A avaliação radiológica pré-operatória dos pedículos pode ajudar na escolha do desenho ideal do retalho, prevenir complicações isquêmicas e ajudar a melhorar o resultado geral do tratamento.

Outcome of a Simple Novel Technique to Reduce Soft Tissue Complications in Open Tendoachilles Injury: A Series of 20 Patients

@#Introduction: Open tendoachilles injuries are rare and associated with significant soft tissues complications. The objective of the present study was to assess the clinical outcome and safety of a simple and minimally invasive technique, with a goal to assess if it may help minimise flap and wound related complications in open tendoachilles injuries. Materials and methods: This prospective study of four years duration included 20 patients with open tendoachilles injuries managed with a simple minimally invasive tunnel technique. The primary outcome variable was occurrence of a major soft tissue complication. The secondary outcome variables included functional outcome measured using AOFAS Ankle hind foot score, re-rupture of tendoachilles and need for revision surgery. Results: None of the patients in the present series developed a serious soft tissue complication. Based upon the AOFAS hind foot scoring system, good to excellent outcome was achieved in 19 (95%) patients. All the patients were able to perform tip toe walking at six months post-surgery. None of the patients had a re-rupture of the tendoachilles and no patient needed a revision surgery. The complications encountered include thickening of the tendon at the repair site (15%), superficial wound infection (5%), stitch granuloma (5%) and hypertrophic scar (5%). Conclusion: This technique seems to be promising in reducing the soft tissue complications associated with the surgical management of open tendoachilles injuries. Most patients had a good final clinical outcome. The technique is safe, simple and reproducible. However, further randomised control studies with a larger sample size assessing the technique are recommended.

Laryngeal mask airway bougie ultrasonography guided intubation in a morbidly obese patient with difficult airway / 世界急诊医学杂志（英文）

@#Airway management of morbidly obese patients is challenging due to inherent anatomical and physiological variations.[1] The frequent association of compromised hemodynamics, hypoxemia, or acidosis in an emergency department (ED) setting adds to the difficulty of the procedure. Rapid airway management position (RAMP), awake fiber-optic guided intubation, use of intubating laryngeal mask airway (ILMA), and video-laryngoscope are a few techniques that have been described to tackle difficult airways in these patients.[2] Studies have shown that the availability of fiber-optic scopes (3%-60%), video-laryngoscopes (39%-88%), and laryngeal mask airways (LMA) (65%-83%) varies in different ED settings.[3,4] Furthermore, a lack of adequate training and the need for time-bound resuscitation make implementation of the above techniques challenging. Supraglottic airway devices (SADs) are potential rescue airway devices with a fast-learning curve. Point-of-care ultrasound (POCUS) is an easily available, convenient adjunct for airway management in emergency and critical care settings. Various studies have shown the utility of POCUS in the confirmation of correct endotracheal tube placement in real time.[5,6]