Revisiting the Anatomical Landmark-Guided Central Venous Access Device Insertion: A Retrospective Cohort Study.

BACKGROUND: Ultrasound (USG) guidance is superior to blind and open cut-down techniques for accurate puncture of the internal jugular vein (IJV) or subclavian vein, but it increases the cost and duration of the procedure. Here, we report our experience with the reliability and consistency of anatomic landmark-guided technique for Central Venous Access Device (CVAD) insertion in a low-resource setting. MATERIAL AND METHODS: A retrospective analysis of the prospectively maintained database of patients undergoing CVAD insertion through one of the jugular veins was performed. Central venous access was achieved using a standardized anatomic insertion landmark (apex of Sedillot's triangle). Ultrasonography (USG) and/or fluoroscopy assistance was taken as and when required. RESULTS: Over 12 months (October 2021 to September 2022), a total of 208 patients underwent CVAD insertion. Central venous access was successfully achieved using anatomic landmark-guided technique in all but 14 patients (6.7%), in whom USG guidance or C-arm was used. Eleven out of 14 patients who needed guidance for CVAD insertion had body mass index (BMI) of more than 25, one had thyromegaly while the remaining two had an arterial puncture during cannulation. CVAD insertion-related complications included deep vein thrombosis (DVT) in five, extravasation of chemotherapeutic agent in one, spontaneous extrusion related to a fall in one, and persistent withdrawal-related occlusion in seven patients. CONCLUSION: Anatomical landmark-guided technique of CVAD insertion is safe and reliable, and can reduce the need for USG/C-arm in 93% of the patients.

Long-term swallow outcomes and factors affecting swallowing dysfunction and quality of life among oral cancer patients: a prospective observational study.

BACKGROUND: Oral cancer is one of the most common cancers among the Indian population. India bears the most burden of oral cancer globally. Impairment of swallowing function is often seen after treatment for oral cancer. The oral phase of swallowing is disrupted in patients undergoing resection for oral cancer. The primary purpose of this study was to evaluate the long-term swallowing outcomes of oral cancer patients using a patient-reported outcome questionnaire. METHODOLOGY: All consecutive oral cancer patients in the cT2-T4 category undergoing curative-intent surgery and reconstruction at our institute from March 2020 to March 2022 were included in the study. The Sydney Swallow questionnaire (SSQ) and functional oral intake scale (FOIS) assessed swallowing outcomes six months after definitive treatment. WHO BREF quality-of-life questionnaire was used to assess health-related quality of life. RESULTS: A total of seventy patients with oral cancer were included. The median age was 49 years. The majority of them were males (90%). Tumors with cT4 constituted 62%; the rest, 48%, were cT2 and cT3 categories. The bulk of them were buccoalveolar tumors (64.3%. Almost two-thirds of the patients received multimodal treatment. Trismus and xerostomia were at 46% and 88%, respectively. The mean SSQ score was 257.4 ± 99.1. Swallowing outcomes are affected by T stage (p = 0.01), extent of resection (p = 0.01), multimodality treatment (p < 0.01), trismus (p = 0.05), and xerostomia (p = 0.01). Almost 69% of them required special food preparation for swallowing (FOIS 4&5). Patients with buccoalveolar disease (p = 0.05) had significantly poor quality of life. CONCLUSION: An advanced stage with extensive resection and receiving multimodal treatment has adverse swallowing outcomes. Post-treatment trismus and xerostomia also significantly affected swallowing results.

Postoperative acute pain management with duloxetine as compared to placebo: A systematic review with meta-analysis of randomized clinical trials.

BACKGROUND: Duloxetine has been used as an adjunct in multimodal analgesia for acute postoperative pain in clinical studies. This meta-analysis aims to conclude whether oral duloxetine, when given perioperatively, is any better than a placebo in managing postoperative pain. Effects of duloxetine on postoperative pain scores, time to first rescue analgesia, postoperative rescue analgesia consumption, side effects attributable to duloxetine, and patient satisfaction profile were assessed. METHOD: MEDLINE, Web of Science, EMBASE, Scholar Google, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched with keywords including "Duloxetine" AND "postoperative pain", "Duloxetine" AND "acute pain" and with "Duloxetine" till October 2022. This meta-analysis included randomized clinical trials in which perioperative duloxetine 60 mg per oral was administered not more than 7 days before surgery and for at least 24 after surgery but not more than 14 days after surgery. All RCTs in which the comparator is placebo and outcomes related to analgesic efficacy like pain scores, opioid consumption, and side effects of duloxetine until 48 h postoperatively were included. Data were extracted from the studies and a risk of bias summary was formed using the Cochrane Collaboration tool. Effect sizes were given as standardized mean differences for continuous outcomes and risk ratios (RR) by the Mantel-Haenszel test for the categorical outcome. Confirmation of publication bias was done by Egger's regression test (p < 0.05). If publication bias or heterogeneity was detected, the trim-and-fill method was used to calculate the adjusted effect size. Sensitivity analysis was done by leaving one out method after excluding the study with a high risk of bias. Subgroup analysis was done based on the type of surgery and gender. The study was prospectively registered in the PROSPERO under the registration number CRD42019139559. FINDINGS: 29 studies with 2043 patients met the inclusion criteria and were reviewed for this meta-analysis. Postoperative pain scores at 24 h [Std. Mean Difference (95% CI); -0.69 (-1.07, -0.32)] and at 48 h [-1.13 (-1.68, -0.58)] are significantly less with duloxetine (p-value < 0.05). Time to first rescue analgesia was significantly more in patients where duloxetine was administered [1.27 (1.10, 1.45); p-value > 0.05]. Opioid consumption up to 24 h [-1.82 (-2.46, -1.18)] and 48 h [-2.48 (-3.46, -1.50)] was significantly less (p-value < 0.05) in patients who received duloxetine. Complications and recovery profiles were similar in patients receiving either duloxetine or a placebo. INTERPRETATION: Based on GRADE findings, we conclude that there is low to moderate evidence to advocate the use of duloxetine for managing postoperative pain. Further trials are needed to replicate or refute these results based on robust methodology.

Comparative and analytical characterization of the oral bacteriome of smokeless tobacco users with oral squamous cell carcinoma.

Oral cavity squamous cell carcinoma (OSCC) is the most common type of head and neck cancer worldwide. Smokeless tobacco (SLT) has been well proven for its role in oral carcinogenesis due to the abundance of several carcinogens. However, the role of inhabitant microorganisms in the oral cavity of smokeless tobacco users has not yet been well explored in the context of OSCC. Therefore, the present investigation was conceived to analyze the oral bacteriome of smokeless tobacco users having OSCC (CP group). With the assistance of illumina-based sequencing of bacterial-specific V3 hypervariable region of 16S rDNA gene, 71,969 OTUs (operational taxonomic units) were categorized into 18 phyla and 166 genera. The overall analysis revealed that the oral bacteriome of the patients with OSCC, who were smokeless tobacco users, was significantly different compared to the healthy smokeless tobacco users (HTC group) and non-users (HI users). The appearance of 14 significantly abundant genera [FDR (false discovery rate) adjusted probability value of significance (p value) < 0.05] among the CP group showed the prevalence of tobacco-specific nitrosamines forming bacteria (Staphylococcus, Fusobacterium, and Campylobacter). The functional attributes of the oral bacteriome of the CP group can also be correlated with the genes involved in oncogenesis. This study is the first report on the oral bacteriome of Indian patients with OSCC who were chronic tobacco chewers. The results of the present study will pave the way to understand the influence of smokeless tobacco on the oral bacteriome of OSCC patients. KEY POINTS: • Oral bacteriome of OSCC patients differ from healthy smokeless tobacco (SLT) users and SLT non-users. • Smokeless tobacco influences the oral bacteriome of OSCC group. • Oral bacteriome specific diagnostics may be developed for pre-diagnosis of oral cancer.

Taxonomic profiling and functional characterization of the healthy human oral bacterial microbiome from the north Indian urban sub-population.

Poor oral health has broad consequences that can be seen at personal as well as societal levels, especially in developing countries like India. We have limited information on the healthy oral cavity's inhabitant microorganisms that play a crucial role in overall oral health. In a comprehensive culture-independent approach, the bacterial composition of healthy human oral cavities was determined from a sub-population of northern India. During this study, 20 mouthwash-derived metagenomes were explored for identifying bacterial diversity using the 16S rRNA hypervariable V3 region with the MiSeq Illumina platform. On the taxonomy assignment of operational taxonomic units (OTUs), 20 assigned phyla and 162 genera were recovered among the participants. The mean relative abundance revealed that Streptococcus was the dominant genera among the participants. However, at inter-individual analysis, Neisseria and Haemophilus exhibited first-order dominance among five and three healthy individuals, respectively. Correlation studies indicate that Streptococcus shares a strong relationship with Rothia, Corynebacterium, Prevotella, and Veillonella, whereas it was negatively correlated with Neisseria, Aggregatibacter, Porphyromonas, and Fusobacteria like Gram-negative bacteria. Bacterial diversity showed insignificant differences at the level of age and gender within and between the participants. The results support several of the major findings of previous reports on the healthy oral microbiome of the Indian population, however, the present investigation further illustrates that demographic region leaves an impact on overall bacterial composition. The study will assist in a better understanding of the oral microbiome from region-specific Indian population that was otherwise highly under-represented.

Discordance of COVID-19 guidelines for patients with cancer: A systematic review.

This review was aimed to systematically evaluate the available literature on the impact of COVID-19 on cancer care and to critically analyze the diagnostic and therapeutic strategies suggested by various healthcare providers, societies, and institutions. Majority guidelines for various types of cancers favored a delay in treatment or a nonsurgical approach wherever feasible. These guidelines are based on a low level of evidence and have significant discordance for the role and timing of surgery, especially in early tumors.

Insights into the human oral microbiome.

Human oral cavity harbors the second most abundant microbiota after the gastrointestinal tract. The expanded Human Oral Microbiome Database (eHOMD) that was last updated on November 22, 2017, contains the information of approximately 772 prokaryotic species, where 70% is cultivable, and 30% belong to the uncultivable class of microorganisms along with whole genome sequences of 482 taxa. Out of 70% culturable species, 57% have already been assigned to their names. The 16S rDNA profiling of the healthy oral cavity categorized the inhabitant bacteria into six broad phyla, viz. Firmicutes, Actinobacteria, Proteobacteria, Fusobacteria, Bacteroidetes and Spirochaetes constituting 96% of total oral bacteria. These hidden oral micro-inhabitants exhibit a direct influence on human health, from host's metabolism to immune responses. Altered oral microflora has been observed in several diseases such as diabetes, bacteremia, endocarditis, cancer, autoimmune disease and preterm births. Therefore, it becomes crucial to understand the oral microbial diversity and how it fluctuates under diseased/perturbed conditions. Advances in metagenomics and next-generation sequencing techniques generate rapid sequences and provide extensive information of inhabitant microorganisms of a niche. Thus, the retrieved information can be utilized for developing microbiome-based biomarkers for their use in early diagnosis of oral and associated diseases. Besides, several apex companies have shown keen interest in oral microbiome for its diagnostic and therapeutic potential indicating a vast market opportunity. This review gives an insight of various associated aspects of the human oral microbiome.

Adjuvant radiotherapy versus observation following lumpectomy in ductal carcinoma in-situ: A meta-analysis of randomized controlled trials.

The role of adjuvant radiotherapy (RT) following lumpectomy for ductal carcinoma in-situ (DCIS) was addressed in four major randomized controlled trials (RCTs) which were conducted two to three decades ago. Initial results of these trials suggested the protective role of RT in reducing the ipsilateral breast recurrences. Long-term results of all these four trials, based on more than 10-years follow-up data, have recently been published. A meta-analysis of four published RCTs which have addressed the role of adjuvant RT following lumpectomy for DCIS was conducted. Review manager (Cochrane Collaboration's software) version RevMan 5.2 was used for analysis. Evaluated events were ipsilateral breast recurrences (both DCIS and invasive), regional recurrences, contralateral breast events, distant recurrences, and overall mortality. The events were entered as dichotomous variable. The present meta-analysis included four RCTs and a total of 3680 patients - 1710 received adjuvant RT following lumpectomy while 1970 patients did not receive any adjuvant treatment. Patients who received RT had almost half of risk of ipsilateral breast recurrence (RR = 0.53, 95% CI = 0.45-0.62) and regional recurrence (RR = 0.54, 95% CI = 0.32-0.91) compared to those who did not receive adjuvant treatment - there was absolute risk reduction in 15% (95% CI = 12%-17%) for ipsilateral breast recurrences in adjuvant RT treated patients. There was no significant difference in distant recurrence (RR = 1.06, 95% CI = 0.74-1.53), contralateral breast events (RR = 1.22, 95% CI = 0.98-1.52) and overall mortality (RR = 0.93, 95% CI = 0.79-1.09). Though addition of postoperative RT to lumpectomy does not reduce overall mortality, the present meta-analysis confirms that it decreases the ipsilateral breast and regional recurrence by almost half.

Adult Bochdalek Hernia with Organo-Axial Gastric Volvulus: Misdiagnosed as Hydropneumothorax.

Bochdalek hernia (BH) in an adult may manifest clinically with a myriad of abdominal or chest symptoms or a combination of them. Diagnosis of an adult BH is usually delayed in view of rarity of the lesion and its varied presentation. A 30-year-old adult gentleman presented to us with a left thoracostomy which was draining pus and ingested food particles. The tube thoracostomy had been performed in another hospital for an apparent left hydropneumothorax before he arrived in our hospital. Computed tomography of Chest and abdomen revealed a left diaphragmatic defect with herniation of stomach, spleen and omentum into the chest with organo-axial volvulus of the stomach. A thoracostomy tube was seen to be traversing through the stomach with its tip located close to the left pulmonary artery. The patient underwent left thoraco-abdominal exploration with dissection and reposition of the hernial contents in the abdominal cavity. The gastric perforations and the diaphragmatic defect were repaired. This case reiterates a well-known fact that an adult type BH must find a place in the differential diagnosis of a hydropneumothorax. Though the adult BH is a rare diagnosis, unawareness or reluctance to consider the possibility of adult BH may prolong the suffering of the patient as it happened in our patient who had iatrogenic perforation of the stomach due to tube thoracostomy.