Development and use of low-fidelity, low-cost, animal tissue-based simulators for surgical training during the Covid-19 pandemic

BACKGROUND The Covid-19 pandemic severely affected surgical training as the number of surgeries being done was reduced to a bare minimum. Teaching and training of clinical skills on a simulator are desirable as they may have an even larger role during the Covid-19 pandemic. Commercially available simulators with optimum fidelity are costly and may be difficult to sustain because of their recurring cost. The development of low-cost simulators with optimum fidelity is the need of the hour. METHODS We developed animal tissue-based simulators for imparting skills training to surgical residents on some basic and advanced general surgical procedures. Porcine tissue and locally available materials were used to prepare these models. The models were pilot-tested. Standard operating procedures were developed for each skill that was shared with the participants well before the ‘hands-on’ exercise. An online pre-test was conducted. The training was then imparted on these models under faculty guidance adhering to Covid-19-appropriate behaviour. This was followed by a post-test and participant feedback. The entire exercise was paperless. RESULTS Sixty residents were trained in 10 sessions. Most of the participants were men (44; 73%). The mean pre-test and post-test scores were 40.92 (standard deviation [SD] 6.27) and 42.67, respectively (SD 4.06). Paired sample t-test suggested a significant improvement in the post-test score (p<0.001). The activity and the models were well appreciated by the residents. CONCLUSION The animal tissue-based indigenous models are easy to prepare, cost-effective and provide optimum fidelity for skill training of surgical residents. In addition to skill acquisition, training on such modules may alleviate the stress and anxiety of the residents associated with the loss of surgical training during a time-bound residency period.

Impact of oral hygiene training to Anganwadi and Accredited Social Health Activist workers on oral health of young children in tribal regions of Rajasthan State, India

Context: Early childhood caries is one of the most widespread diseases affecting children in urban and rural India. Community health workers can bring about a quantum of change in improving the oral health in children. Aims: The aim of the study was to assess the impact of oral health training imparted to Anganwadi and accredited social health activist (ASHA) workers on improving the oral hygiene of 148 children aged 1–6 years. Settings and Design: The preintervention followed by oral health training and postintervention assessment were done at three Anganwadi and ASHA centers of Rajasthan. Methodology: The preintervention data included Decayed, Missing, and Filled Teeth/decayed, extracted, and filled teeth, oral hygiene indices (Oral Hygiene Index-Simplified [OHI-S] and Oral Hygiene Index Simplified-Modified [OHIS-M]), plaque index, and caries activity using Oratest. The oral health training consisted of PowerPoint presentations, video presentations, live demonstrations on brushing technique, rinsing, plaque disclosure, and flossing technique. They were enlightened on deleterious oral habits, emergency protocol on trauma, etc. The postintervention data included outcome measures consisting of oral hygiene indices (OHI-S and OHIS-M), plaque index, and Oratest after 2 months to evaluate the impact of training. Statistical Analysis used: The data were analyzed using Chi-square test, Fisher's exact test, independent t-test, paired t-test, and one-way analysis of variance test. Results: There was a significant improvement in toothbrushing practices and rinsing (P < 0.05). There was a significant difference in debris index, calculus index, OHI-S/OHIS-M, plaque index, and Oratest after intervention (P < 0.05). Conclusion: Empowering Anganwadi and ASHA workers can be a feasible approach in India, where oral health is not a priority in primary health care as yet.

Drainage of External Jugular Vein into an Unusually Wider Internal Jugular Vein: A Rare Case Report.

The superficial veins are of utmost importanceclinically for cannulation, which is required fordiagnostic purposes and intravenous therapy. One suchsuperficial vein in the neck region is the externaljugular vein. The other vein, deeper in this region, isthe internal jugular vein. The internal jugular vein iscommonly used for central venous catheterization.Anomaly in the course and termination of bothexternal and Internal Jugular Veins (IJV) are critical asthey serve as an important route/site to perform variousdiagnostic or therapeutic procedures. Present caseshows a rare variation of termination of the rightexternal jugular vein into an unusually wider IJV.Variation as described in the present case, if found,would ease the clinicians' task to approach a lessaccessible IJV. Ultrasound-guided venouscatheterization would serve as a guide to perform theprocedure with ease and also to be familiar with suchvariations existing in the venous channels

Evaluation of prescription pattern and quality of life in postmenopausal osteoporosis: a cross sectional study

Background: Osteoporosis (OP) is a silently progressing metabolic bone disease that results in loss of mineralized bone and subsequent fractures with minor trauma. Fracture related pain and physical inability to perform activities of daily living can lead to psychological consequences that impair Quality of Life (QoF). However, much less is known about Indian scenario. Hence, our study becomes imperative. Aim of this study to the drug utilization pattern and to analyze Quality of life of postmenopausal women suffering from osteoporosis.Methods: An analytical cross-sectional study was done on 91 post-menopausal osteoporotic women. Drug utilization pattern was evaluated. Pre-validated QUALEFFO-31 questionnaire was administered to each patient to record patient’s perceived QoL. Scores were calculated according to the algorithm. Higher scores indicated poor QoL. The collected data was analyzed with SPSS software (version 23)and p value ?0.05 was considered as statistically significant.Results: The mean age group of presenting patients was 56.2±6.6 years. All the patients received Calcium and vitamin D supplements and non-steroidal anti-inflammatory drugs for pain relief. But only 33% of the patients received any one of the bisphosphonates (BP). For analysis, patients were grouped into Group-1(n=60) who did not and Group-2 (n=31) who did receive a BP. QOL analysis showed that pain domain was affected the most. Also, patients in Group 2 reported worse score in all the domains in comparison to Group 1 (P<0.05). It is likely that BP might need more time to show considerable effect or because it was added only to those patients who already had more complaints and could afford the high cost.Conclusion: BP in spite of being the drug of choice for OP is used less commonly in India. OP causes pain and physical debilitation with detrimental effect on mental health. Longer duration prospective studies are needed to study the association of QoL and use of BP in OP patients.

Evaluation of clinical efficacy and safety of natural micronized progesterone in prevention of preterm labor: a prospective study at tertiary care teaching hospital in India

Background: Uterine relaxants (UR) are used in management of in Preterm labour (PTL), which is responsible for considerable morbidity and mortality in mother as well as preterm infant. Author are yet to discover an ideal UR which is highly effective yet safe. Literature supports the use of natural micronized progesterone (NP) during threatened PTL. However, little data exists for Indian population. Therefore, present study becomes imperative.Methods: A comparative clinical study was carried out on 78 patients (aged 19 to 35 years with singleton pregnancy and gestational age between 28 and 37 weeks with cervix ?4 cm dilated) who were diagnosed with threatened PTL were included. Those who refused treatment were allocated to control group (n= 29) and received only bed rest. NP was given orally 200 mg twice a day to 21 patients and 200 mg intra vaginal twice a day to 28 patients and was continued until delivery or 37 weeks of gestation whichever occurred first. The efficacy was proven if PTL was prevented and patient did not require an alternative UR for ?48 hours.Results: The mean age of patients was 23±3.2 years, majority being multipara. Author observed that both oral and vaginal formulation of NP was found to be highly effective (p <0.05) as primary UR and maintenance therapy in preventing PTL as compared to the control group. However, difference between them was not statistically significant. None of the patients were lost to follow-up and no adverse events linked to the treatment were reported.Conclusions: Although, the data obtained from this study was limited and the sample size was small, findings of this study support the use of NP in prolonging threatened PTL.

Caesalpinia bonduc Linn Extracts Exhibit Hepatoprotective Effect on HepG2 Cells against Paracetamol by Up-regulating Glutathione Related Genes

Background: Caesalpinia bonduc (CB) is said to ownvarious pharmacological and therapeutic applicationagainst a number of diseases. It is used widely in folkmedicine to treat liver diseases. In the present study,we have made a sincere effort to evaluate thehepatoprotective activity of CB leaf extracts againstParacetamol (PCM) induced toxicity and theirmechanism of hepatoprotection in the humanHepatocarcinoma cells (HepG2 cells) therebyproviding scientific evidence for the same. Materialand Methods:The hepatoprotective activity of CB wasassessed in-vitro by the estimation of glutathione(GSH) and Malondialdehyde (MDA), anti-apoptoticassay/Annexin V and the expressions of genes such asGlutathione Reductase (GS-R) and GlutamateCysteine Ligase, Catalytic (GCLC). Results: Theobtained results suggest that the aqueous extract of CBpossess significant hepatoprotective activity. Thisactivity may be due to the possible antioxidantproperty and the free radical scavenging ability of theextracts, which might clear the toxic metabolites ofPCM. Conclusion: The present study suggests that theaqueous extract of CB have potential hepatoprotectiveactivity, which may prevent the lipid peroxidation ofthe cell membrane by its antioxidant properties.

Optimization of sentinel lymph node identification techniques in the Indian setting: A randomized clinical trial

INTRODUCTION: The recommended technique of sentinel lymph node biopsy (SLNB) in breast cancer is a combination of blue dye and radiotracer. In the Indian scenario, SLNB is still not routinely practiced due to lack of nuclear medicine facilities and unavailability of isosulfan blue or patent blue violet (PBV). This study was conducted for optimizing SLN identification techniques by comparing the identification rate using PBV and methylene blue (MB) in combination with radiotracer. MATERIALS AND METHODS: Single-blinded two-arm parallel design randomized control trial was conducted at an apex teaching and research medical institute in India. Patients with axillary LN–negative breast cancer were included. Blue dye and radio tracer were injected preoperatively, and SLNB was performed using a combination technique. Frozen section was performed. Demographic, clinical, radiological, operative, and histopathological data were recorded. Descriptive statistics were used to represent patient characteristics. Baseline characteristics for entire cohort and between groups were compared using Student's t-test for quantitative variables and Chi-square test for qualitative variables. RESULTS: A total of 119 patients were randomized for mapping with MB and 118 patients with PBV between 2011 and 2015. SLN was identified in 116 patients with MB and 115 with PBV. SLN identification proportions were 97.4% (MB) and 96.6% (PBV). In patients undergoing axillary lymph node dissection, concordance with SLNB was 98.5% and 96.61% in MB and PBV, respectively. False-negative proportion for MB was 2.56% and 7.69% for PBV, respectively. The cost of MB is about INR 15 per ~10-mL vial. The cost of PBV is approximately ~$91 per ampoule (equivalent to approximately INR 8190). CONCLUSION: SLNB using MB can be recommended as the technique of choice in low-resource settings.

Persistent fetal superficial middle cerebral vein: an anatomical study / 대한해부학회지

The superficial middle cerebral vein (SMCV) drains the venous blood from most of the superolateral surface of the brain and drains typically into the cavernous sinus as mentioned in standard textbooks. But the drainage of the SMCV is variable as indicated by various radiological studies. Although variations in the drainage of the SMCV exist, there is a shortage in the literature providing cadaveric evidence for the same. The present study was designed to identify the variations in the drainage pattern of the SMCV in fetal cadavers. During the dissection of formalin-fixed full-term fetuses, deviation in the drainage of the SMCV was observed in five out of 30 cases. In three out of 30 specimens (10%), SMCV was observed draining into superior petrosal sinus; and in two specimens (6.6%) into the transverse sinus. In the remaining specimens, the SMCV drained directly into the cavernous sinus. Knowledge of the variations noted in the present study is essential, not only for diagnosing several diseases involving the cavernous sinus or paracavernous sinuses but also in surgeries of paracavernous sinus lesions and endovascular treatment of arteriovenous fistulas. The SMCV and superior petrosal sinus can be a venous refluxing route in patients with arteriovenous fistulas.

Comparison of resection margins and cosmetic outcome following intraoperative ultrasound-guided excision versus conventional palpation-guided breast conservation surgery in breast cancer: A randomized controlled trial

INTRODUCTION: Use of intraoperative ultrasound (IOUS) has been shown to help achieve satisfactory cosmesis and negative margins in breast conserving surgery (BCS). This study has been done to compare the oncological and cosmetic outcomes following BCS using conventional palpatory method and IOUS. MATERIALS AND METHODS: This is a prospective randomized controlled trial conducted at a tertiary care teaching and research institute in India. Patients with early operable breast cancer willing for BCS were included. Tumors were excised with 1 cm margin. In palpatory group, tumor was palpated and 1 cm margin was taken with a measuring scale while in the second group, IOUS was used to mark the margins. Histopathological evaluation was done to assess margins and cosmesis was assessed by patient, resident doctor, and nurse independently. RESULTS: Sixty patients were included, 32 in the ultrasonography-guided and 28 in palpation-guided wide local excision. The mean age of patients was 48.78 years. In both groups, mean tumor size was 3.18 cm. Margin thickness and positivity was higher in palpatory group (though P > 0.05). Most patients were satisfied with cosmesis. There was no significant difference in complications and specimen volume in both groups. Presence of ductal carcinoma in situ component and expression of Her2neu by tumor cells had a significant impact on margin positivity. CONCLUSIONS: Intraoperative use of ultrasound offers a real-time assessment of margin status and may reduce the margin positivity rate compared to conventional palpation-guided method.

Harmonic scalpel versus conventional diathermy: Is one really better than the other?

Breast cancer is on the rise and so are the surgeries done for the same. Mastectomy and breast conservation surgery remain the common surgical modalities practiced for treatment of primary tumor. Axillary lymph node dissection and sentinel lymph node biopsy are the commonest surgical modalities used for the treatment of axilla. Flap necrosis, seroma, wound infection, and postoperative neuralgia as well as numbness over the lateral aspect of arm are the common postoperative complications. All these lead to increased patient morbidity and hospital stay, and development of techniques that lead to reduction of these have remained common areas of research. One such modality is the use of ultrasonic energy of harmonic scalpel in surgeries of the breast and axilla done for breast cancer.

A Cadaveric Study Of The Internal Occipital Crest And Vermian Fossa With Its Clinical Significance

Background: The anatomical variabilities of the internal occipital crest (IOC) and vermian fossa (VF) may influencethe related dural venous sinuses and further effect the flow of the cerebrospinal fluid. It is also associated withthe pathologies around the foramen magnum like Arnold Chiari malformation, certain cases of cerebellar corticaldysplasia.Aim: The present study was designed to explore and evaluate the morphological and morphometric details of theIOC and VF.Materials and Methods: The study was conducted on 40 adult cadavers (23 males & 17 females). The morphologyand morphometry of IOC and VF were studied. Based on the observations, the VF was classified into five types:Type 1- classical (well defined fossa), Type II-short triangular, Type III- elongated triangular, Type IV-quadrangularand Type V-deviated.Results: The IOC was found to be variable both in terms of morphology and morphometry. The morphologicalobservations included varied shapes, i.e., sharp (65%), blunt (30 %) and ill-defined (5 %). The length of the IOCwas also variable with a mean length of 2.97 ± 0.16 cm. The mean width at upper, middle and lower levels were0.9 ± 0.10 cm, 0.75 ± 0.17 cm, 1.10 ± 0.12 cm respectively.The incidence of the VF was found to be about 80%. The VF was classified into types based on its varied shape:classical (Type I ;56.25 %), short triangular (Type II ;21.87%), elongated triangular (Type III;12.5%) and quadrangular(Type 1V;6.25 %) respectively. In one specimen, the VF was deviated to the left side (type V ;3.12%). The mean lengthand width of the fossa were 1.67±0.34 cm and 1.80±0.34 cm respectively.Conclusion: The present study on the morphology and morphometry of the IOC and the VF may serve as databaseand further help clinicians to improve the diagnosis and therapeutic performances in the posterior cranialfossa.

A bacteriological study of acute exacerbation of chronic obstructive pulmonary disease over a period of one year.

Background: The aim of our study was to analyse the hospital data on AECOPD in patients with special reference in males and female cases, the pathogens involved, antibiotic susceptibility pattern. Methods: 107 patients (72 males, 35 females) aged between 45 and 85 years were included in the study. A detail history was elicited and complete examination was done. The sputum specimen was collected using sterile sputum cups and subjected to Gram’s stain, culture and biochemical reactions. Results: Our study shows 44 positive sputum cultures out of total 107 cases. Out of 107 cases 67% were males and 33% were females. The predominant clinical feature observed in our study was cough with expectoration, exertional dyspnoea and production of mucopurulent sputum. The prevalence of Gram negative bacteria was 55% and Gram positive bacteria was 45%. Klebsiella pneumoniae was the commonest bacteria isolated (38%) followed by Staphylococcus aureus (18%). The drug sensitivity reveals that 79.55% of the isolates were sensitive to amikacin followed by 68.18% sensitive to amoxyclavulinic acid and 54.55% of the isolates were sensitive to ciprofloxacin. Conclusions: In a developing country like India AECOPD is more common in adults more than 55 years of age due to smoking habits and high indoor pollution. This leads to a major impact on the quality of life of patients with the condition. They are a major cause of hospital admission and health care utilization.

Biliary Ascariasis: Our Experience and Review of Literature.

Background/Aim: Ascariasis is endemic in the tropics especially amongst those living in poor sanitary conditions. Although most commonly it infests the small intestine, it can sometimes migrate to the biliary tract. We herein aimed to study the clinical manifestations, complications, diagnostic modalities and the most appropriate treatment modality for this condition. Materials and Methods: Fifteen cases of hepatobiliary ascariasis presenting over a period of 1.5 years were studied. All the patients were adults and presented to the emergency with acute biliary symptoms. Results: In this study, biliary ascariasis was found to be more common in middle aged females. The common presentations included upper abdominal pain and jaundice. Complications observed included acute pancreatitis and cholangitis. Ultrasonography could establish the diagnosis in 86.67% cases. Medical management could successfully treat 86.67% patients with ERCP being required in the remainder. Conclusion: In endemic countries, ascariasis should be considered as a differential diagnosis in patients presenting with acute biliary symptoms. Ultrasonography is a useful non invasive test to diagnose the condition and medical management remains a reasonable first line treatment option.

Multiple variations in the branches of the coeliac trunk / 대한해부학회지

Here we present a unique case of variation in the branching pattern of the coeliac trunk. In the present case, the coeliac trunk was replaced by two separate arterial trunks. The first arterial trunk bifurcated into the left gastric and the left hepatic arteries. The second arterial trunk bifurcated into a splenic artery and a hepato-gastroduodenal trunk. The hepato-gastroduodenal trunk presented an unusual course and termination. The right hepatic artery arising from the hepato-gastroduodenal trunk also showed a variant course. Such rare variations are important for gastroenterological surgeons and interventional radiologists due to increase in number of transplantation surgeries and live donor liver transplantations.

Human cadaveric study of the morphology of the basilar artery

<p><b>INTRODUCTION</b>Nourishment for the brain, a highly vascular organ, is derived from a unique structure called the 'circle of Willis', which is formed by the terminal branches of the internal carotid arteries (ICAs) and basilar arteries (BAs). The circle of Willis forms an anastomotic link between the carotid and vertebrobasilar systems in the arterial supply of the brain, while the BA forms an important component of the brain's posterior circulation and supplies its many vital parts.</p><p><b>METHODS</b>A study was performed on 20 brain specimens used for routine dissections at the Anatomy Department, Kasturba Medical College, in order to examine the morphology of BAs in the brain.</p><p><b>RESULTS</b>In most specimens, the position of the termination of BA was normal, although variations were present in the mode of termination. In one specimen, the BA terminated by dividing into two superior cerebellar arteries. The posterior cerebral arteries (PCAs) arose from ICAs on both sides in this specimen, and a communicating branch was present between the terminal point of the BA and PCA on the left. In another specimen, unilateral variation was seen, with the PCA arising from the ICA on the right and a posterior communicating artery arising from the PCA, connecting it with the BA. The anatomy on the left side was normal.</p><p><b>CONCLUSION</b>We highlight the morphological aspects of the BA, the knowledge of which would help neurosurgeons safely diagnose, as well as plan and execute vascular bypass and shunting procedures for the treatment of stenosis, aneurysms and arteriovenous malformations in the posterior cranial fossa.</p>

An unusual communication between the mylohyoid and lingual nerves in man: Its significance in lingual nerve injury.

The mylohyoid nerve is the branch of the inferior alveolar nerve (IAN) which arises above the mandibular foramen. An abnormal communication between the mylohyoid nerve and lingual nerve (LN) was noted during the routine dissection of a male cadaver. Communicating branches between IAN and LN have been identified as a possible explanation for the inefficiency of mandibular anesthesia. The communication between mylohyoid and lingual nerve was found in this case after the LN passes in close relation to third molar tooth, which makes it more susceptible to injury during third molar extractions.

Termination of the facial vein into the external jugular vein: an anatomical variation / Terminação da veia facial na veia jugular externa: uma variação anatômica

Different patterns of variations in the venous drainage have been observed in the past. During routine dissection in our Department of Anatomy, an unusual drainage pattern of the veins of the left side of the face of a middle aged cadaver was observed. The facial vein presented a normal course from its origin up to the base of mandible, and then it crossed the base of mandible posteriorly to the facial artery. Thereafter, it joined with the anterior division of retromandibular vein to form the common facial vein, which drained into the external jugular vein directly. Sound anatomic knowledge of the above variation in facial veins is essential to the success of surgical procedures in this region.

Padrões distintos de variações na drenagem venosa já foram observados. Durante a dissecção de rotina em nosso Departamento de Anatomia, observou-se um padrão incomum de drenagem das veias do lado esquerdo da face de um cadáver de meia idade. A veia facial apresentava curso normal de sua origem até a base da mandíbula, e então atravessava a base da mandíbula posteriormente à artéria facial. A seguir, juntava-se à divisão anterior da veia retromandibular para formar a veia facial comum, que drenava diretamente para a veia jugular externa. Um bom conhecimento anatômico da variação descrita acima nas veias faciais é essencial para garantir o sucesso que procedimentos cirúrgicos nessa região.