To evaluate the analgesic effectiveness of bilateral erector spinae plane block versus thoracic epidural analgesia in open cardiac surgeries approached through midline sternotomy.

BACKGROUND: The efficacy of the erector spinae plane (ESP) block in mitigating postoperative pain has been shown for a range of thoracic and abdominal procedures. However, there is a paucity of literature investigating its impact on postoperative analgesia as well as its influence on weaning and subsequent recovery in comparison to thoracic epidural analgesia (TEA) in median sternotomy-based approach for open-cardiac surgeries and hence the study. METHODS: Irrespective of gender or age, 74 adult patients scheduled to undergo open cardiac surgery were enrolled and randomly allocated into two groups: the Group TEA (thoracic epidural block) and the Group ESP (bilateral Erector Spinae Plane block). The following variables were analysed prospectively and compared among the groups with regard to pain control, as determined by the VAS Scale both at rest (VASR) and during spirometry (VASS), time to extubation, quantity and frequency of rescue analgesia delivered, day of first ambulation, length of stay in the intensive care unit (ICU), and any adverse cardiac events (ACE), respiratory events (ARE), or other events, if pertinent. RESULTS: Clinical and demographic variables were similar in both groups. Both groups had overall good pain control, as determined by the VAS scale both at rest (VASR) and with spirometry (VASS) with Group ESP demonstrating superior pain regulation compared to Group TEA during the post-extubation period at 6, 9, and 12 h, respectively (P > 0.05). Although statistically insignificant, the postoperative mean rescue analgesic doses utilised in both groups were comparable, but there was a higher frequency requirement in Group TEA. The hemodynamic and respiratory profiles were comparable, except for a few arrhythmias in Group TEA. With comparable results, early recovery, fast-track extubation, and intensive care unit (ICU) stay were achieved. CONCLUSIONS: The ESP block has been found to have optimal analgesic effects during open cardiac surgery, resulting in a decreased need for additional analgesic doses and eliminating the possibility of a coagulation emergency. Consequently, it presents itself as a safer alternative to the potentially invasive thoracic epidural analgesia (TEA).

Smokeless tobacco products, supply chain and retailers' practices in England: a multimethods study to inform policy.

BACKGROUND: In England, many people of South Asian origin consume smokeless tobacco (ST). ST use can lead to oral cancer, which is disproportionately high in South Asians. Our aims were to assess the compliance of ST product retailers with statutory regulations and to explore the supply chain of ST. METHODS: We undertook a multimethods study between August 2017 and July 2019 in five English boroughs with a high proportion of ethnic South Asians. We purchased ST products and conducted field surveys with ST retailers at point of sale. Qualitative interviews were conducted with ST retailers and suppliers. ST packs were assessed for regulatory compliance, while quantitative and qualitative data triangulated information on retailers' practices and the ST supply chain. RESULTS: We collected 41 unique ST products, which included dry snuff, naswar, gutka, chewing tobacco and zarda. ST products were not registered, and demonstrated low compliance with health warning (14.6%) and packaging (56.1%) requirements. ST availability in surveyed boroughs was high (38.2%-69.7%); dry snuff, naswar and zarda were most commonly available. ST retailers demonstrated limited knowledge of regulations, and one-third were found to advertise ST at point of sale. Qualitative insights revealed illicit supply and distribution networks, as well as ST production in discreet locations. CONCLUSION: ST products are widely available in England, yet non-compliant with statutory regulations. In order to safeguard consumers, in particular ethnic South Asians, stronger efforts are needed to regulate the supply chain of ST at both national and international levels.

An Evaluation of the Practice for the Requisition of Blood Products and its Utilization in Neurosurgical Patients Undergoing Elective Surgery at a Tertiary Care Hospital.

BACKGROUND: Neurosurgical procedures are associated with profound blood loss that necessitates need for intraoperative and postoperative blood transfusion. Excessive ordering of blood based on physicians' habitual practice may lead to unintentional misuse of blood bank services. For the optimal use of blood resources, transfusion practices have to be appropriate. AIMS: The aim of this study is to study the cross match to transfusion ratio and to review the blood utilization practices (transfusion index and maximal surgical blood order schedule) in elective neurosurgical procedures. SETTINGS AND DESIGN: A prospective, observational study comprising 740 patients undergoing elective neurosurgical procedures. MATERIALS AND METHODS: Blood requisition forms and patient records were analyzed of patients undergoing elective neurosurgical procedures from December 2017 to December 2018. A review and note was made of the patient's age, sex, and diagnosis. The number of units prepared, cross matched, and transfused were noted. STATISTICAL ANALYSIS: Statistical analysis was performed with the IBM SPSS software version 21.0. Blood utilization indices were computed and expressed as percentage. RESULTS: A total of 740 patients underwent elective surgical procedures. Among these, 346 patients were requested to prepare 614 units of blood. Out of these 740 patients, there were 56 patients who were in the pediatric age group. A total of 178 units were transfused in 102 patients. One hundred and forty-two units were transfused in the intraoperative period, whereas as 36 units were transfused in the postoperative period. CONCLUSION: There is an efficient usage of blood for patients undergoing surgery for meningiomas, posterior fossa tumors, spinal dysraphism, and craniovertrebral junctional anomalies. However, the blood resources were poorly utilized in patients undergoing surgery for subarachnoid hemorrhage and pituitary tumors. A revision of blood transfusion policy within the hospital is needed.

Post-thoracotomy ipsilateral shoulder pain: What should be preferred to optimize it - phrenic nerve infiltration or paracetamol infusion?

Background: Post thoracotomy ipsilateral shoulder pain (PTISP) is a distressing and highly prevalent problem after thoracic surgery and has not received much attention despite the incidence as high as 85%. Objectives: To study the effect of phrenic nerve infiltration with Ropivacaine compared to paracetamol infusion on PTISP in thoracotomy patients with epidural analgesia as standard mode of incisional analgesia in both the groups. Study Design: Prospective Randomised and Double Blind Study. Methods: 126 adult patients were divided randomly into 2 groups, "Group A (Phrenic Nerve Infiltration Group) received 10 mL of 0.2% Ropivacaine close to the diaphragm into the periphrenic fat pad" and "Group B (Paracetamol Infusion Group) received 20mg/kg paracetamol infusion" 30 minutes prior to chest closure respectively. A blinded observer assessed the patients PTISP using the VAS score at 1, 4, 8, 12 and 24 hours (h) postoperatively. The time and number of any rescue analgesic medication were recorded. Results: PTISP was relieved significantly in Group A (25.4℅) as compared to Group B (61.9℅), with significantly higher mean duration of analgesia in Group A. The mean time for first rescue analgesia was significantly higher in Group A (11.1 ± 7.47 hours) than in Group B (7.40 ± 5.30 hours). The number of rescue analgesic required was less in Group A 1.6 ± 1.16 as compared to Group B 2.9 ± 1.37 (P value <0.5). Conclusions: Phrenic Nerve Infiltration significantly reduced the incidence and delayed the onset of PTISP as compared to paracetamol infusion and was not associated with any adverse effects.

Radiation Therapy and its Effects Beyond the Primary Target: An Abscopal Effect.

Radiation therapy (RT) has been used for the treatment of various malignancies since decades with curative or palliative intent. RT for primary disease is often used with curative intent while its use in metastatic settings has been essentially palliative. However, in certain malignancies with metastatic disease, RT to primary disease has led to the regression of not only the primary site but also of the metastatic sites, a phenomenon known as "abscopal effect." Keeping in view the positive effects of RT beyond the primary site, we review the clinical utility of RT regarding its abscopal effect.

Primary Sino-nasal Neuroendocrine Carcinoma: A Rare Tumor.

Primary sino-nasal neuroendocrine carcinomas (PSNNECs) are rare, with a wide spectrum of histological differentiation. Advanced tumors may invade the surrounding structures, such as the skull base, orbit, or brain. Here, we present a rare case of PSNNEC and its management by concurrent chemoradiation (CCRT) followed by adjuvant chemotherapy with the radiological resolution of the tumor mass.

Bowel sounds in the chest: An uncommon presentation of adult hernia.

We report a case of a 65-year-old male, who presented with respiratory complaints of cough and breathlessness, managed initially as respiratory tract infection. However, the patient did not improve, and a thorough examination and imaging revealed herniation of a gut segment into the thorax. The patient was operated and respiratory symptoms improved dramatically.

Breast specific functional and symptom analysis in female breast cancer survivors.

CONTEXT: The disease and surgery of the breast not only evoke a fear of mutilation and loss of feminity but is also responsible for psychosocial, behavioral, and sexual problems. AIM: To analyze prospectively the time trends in "breast specific functional and symptom scale scores in female breast cancer survivors." SETTINGS AND DESIGN: The prospective study was conducted in the Department of Radiation Oncology at Tertiary Referral Hospital. MATERIALS AND METHODS: A total of 154 operated (mastectomy) female breast cancer patients who were referred to the Department of Radiation Oncology for chemoradiation ± target therapy (trastuzumab) ± hormonal therapy (tamoxifen) were included in the study. Seven patients were excluded from the final analysis due to their refusal to consent. The patients were assessed by using European Organization for Research and Treatment of Cancer Quality of Life-BR23 questionnaire module (which incorporates five multi-item and three single items scales) at 1st visit (0 month), 6, 12, and 24 months interval, respectively. RESULTS: The symptom scores and future perspectives scale showed improvement with time, but body image and sexual functioning and enjoyment scales showed the deteriorating trend. P < 0.05 was considered as significant. CONCLUSION: The female breast cancer survivors failed to improve their body image, sexual functioning, and sexual enjoyment scales but did well in other BR23 scales. Besides the family and spousal/marital support these patients got closer to their religion which has been seen to influence their psychosocial well-being optimistically and need further studies to establish the role of religious practices/beliefs.

Nasopharyngeal Carcinoma: A 15 Year Study with Respect to Clinicodemography and Survival Analysis.

Nasopharyngeal carcinoma (NPC) is a rare malignancy in Kashmir with distinct pattern, hence we planned to study its clinicodemographic and survival profile. Kashmir has unique lifestyle and dietary habits which may be the source of carcinogenic compounds, most likely implicated in causation of NPC. A total of 148 patients of NPC registered from January 2000 to December 2014 were analyzed. The Mean ± SD age was 45.15 ± 17.092 years (range 11-85 years). The males were 72.3 % (N = 107) with male: female ratio of 2.61:1. Most of the patients were from rural area 81.90 % (N = 95) and non-smokers were 53.44 % (N = 62). Neck swelling was commonest presentation. WHO Type III NPC was commonest histopathological diagnosis 65.3 % (N = 92). Stage IV 36.1 % (N = 51) was commonest stage followed by stage III was 32 % (N = 46). Majority of the patients of NPC received CCRT 68.7 % (N = 78) followed by SCRT 13 % (N = 15) and Induction + CCRT 13 % (N = 15). The overall mean survival of NPC was 49.56 months. There was no significant correlation of age, gender, smoking, histopathology and treatment on the overall survival. However the stage was the only strong predictor of overall survival. Also the patients with intracranial extension had low survival which is turn depicts the advanced stage of disease. NPC survival is directly related to the stage of the disease irrespective of the treatment modality received. The negative EBV status in our patients implies that there are other risk factors involved in the causation of NPC for which further studies are needed to establish the etiological insult.

Improving a Dental School's Clinic Operations Using Lean Process Improvement.

The term "lean production," also known as "Lean," describes a process of operations management pioneered at the Toyota Motor Company that contributed significantly to the success of the company. Although developed by Toyota, the Lean process has been implemented at many other organizations, including those in health care, and should be considered by dental schools in evaluating their clinical operations. Lean combines engineering principles with operations management and improvement tools to optimize business and operating processes. One of the core concepts is relentless elimination of waste (non-value-added components of a process). Another key concept is utilization of individuals closest to the actual work to analyze and improve the process. When the medical center of the University of Kentucky adopted the Lean process for improving clinical operations, members of the College of Dentistry trained in the process applied the techniques to improve inefficient operations at the Walk-In Dental Clinic. The purpose of this project was to reduce patients' average in-the-door-to-out-the-door time from over four hours to three hours within 90 days. Achievement of this goal was realized by streamlining patient flow and strategically relocating key phases of the process. This initiative resulted in patient benefits such as shortening average in-the-door-to-out-the-door time by over an hour, improving satisfaction by 21%, and reducing negative comments by 24%, as well as providing opportunity to implement the electronic health record, improving teamwork, and enhancing educational experiences for students. These benefits were achieved while maintaining high-quality patient care with zero adverse outcomes during and two years following the process improvement project.

Clinicoepidemiological analysis of female breast cancer patients in Kashmir.

AIM: The aim of this study was to analyze the demographic features, reproductive history and stage at disease presentation among the female breast cancer patients. DESIGN AND SETTING: The present prospective hospital-based study was conducted in Department of Radiation Oncology, University Teaching and Tertiary Referral Hospital. MATERIALS AND METHODS: After approval from the Institute's ethical committee, 132 female breast cancer patients surgically treated either by mastectomy or breast conserving surgery (BCS) and then referred to the department of radiation oncology for further management and/or follow-up as per the hospital protocol, were enrolled in the study (January 2010 to December 2011) after obtaining a written informed consent from the patients. The patients were diagnosed by histology [fine needle aspiration cytology (FNAC), true cut or excision biopsy], mammography and ultrasonography (USG). The patients were analyzed as per the demographic and reproductive history and the stage of disease at presentation. The data collected were expressed as percentage (%), mean, median and standard deviation (SD). RESULTS: The mean age at presentation was 46.6 ± 10.2 years. The majority of patients were from rural areas, married, multiparous and post-menopausal. The commonest stage at disease presentation was IIb. CONCLUSION: In comparison to the rest of Indian scenario, more awareness related to breast cancer among post-menopausal and the rural females is needed. The role of peri-menopausal status, which represent 10% (n = 14) patients needs to be established in relation to breast cancer.

Quality of life assessment in survivors of breast cancer.

AIM: The aim was to assess the health-related quality of life (HRQOL) and its temporal variation at first visit and subsequent visits among breast cancer patients. DESIGN AND SETTING: The prospective study was carried out in Outpatient Department of Radiation Oncology, University Teaching and Tertiary Referral Hospital. MATERIAL AND METHODS: After clearance from the ethical committee and EORTC group, 81 surgically treated female breast cancer patients referred to the Outpatient Department of Radiation Oncology for chemoradiation and hormonal therapy were included in the study after informed written consent, irrespective of the age and stage of disease. The patients were interviewed as per the EORTC QLQ-C30 Questionnaire module at four levels at the first visit and at subsequent follow-up visits at 6, 12, and 24 months, respectively, and are still on follow-up. STATISTICAL ANALYSIS: The data collected were expressed as mean/raw score (RS), standard deviation (SD), and percent mean/scale score expressed on the linear transformation scale, derived as per the calculations and equations of the EORTC QLQ-C30 Scoring Manual. Intragroup comparison (IGC) was done at four levels/visits, a, b, c and d. A P-value of <0.05 was considered significant. RESULTS: The mean age at presentation was 46.6 ± 10.2 years. The study showed that the physical functioning, role functioning, cognitive functioning, emotional functioning, social functioning, global health status, and symptomatology showed statistically significant improvement over time (P < 0.001). CONCLUSION: The survivors of female breast cancer over the long-term follow-up showed significant improvement and coping mechanisms involved in a majority of HRQOL parameters.

Clinical study of maxillofacial trauma in Kashmir.

The present study of 206 cases admitted with maxillofacial trauma reveals that road traffic accidents account for 67 cases (32.52%) followed by missile injury 55 cases (26.70%) fall 39 cases (18.93%) bear slap 21 cases (10.19%) assault 14 cases (6.80%) and others 10 cases (4.86%) The cases of maxillofacial trauma were also analysed according to age and sex distribution and type of injury.It was found that road traffic accidents was the commonest cause of injury in males (34.21%) and in females the commonest cause of injury was fall (35.18%). Maximum number of cases 72 (34.95%) were found in the age group of 21-30 years and the mixed type of injury was common (60.68%) and mostly involving the middle third of face. Difficulty in chewing was the commonest presentation in road traffic accident.