Taurine treatment of retinal degeneration and cardiomyopathy in a consanguineous family with SLC6A6 taurine transporter deficiency.

In a consanguineous Pakistani family with two affected individuals, a homozygous variant Gly399Val in the eighth transmembrane domain of the taurine transporter SLC6A6 was identified resulting in a hypomorph transporting capacity of ~15% compared with normal. Three-dimensional modeling of this variant has indicated that it likely causes displacement of the Tyr138 (TM3) side chain, important for transport of taurine. The affected individuals presented with rapidly progressive childhood retinal degeneration, cardiomyopathy and almost undetectable plasma taurine levels. Oral taurine supplementation of 100 mg/kg/day resulted in maintenance of normal blood taurine levels. Following approval by the ethics committee, a long-term supplementation treatment was introduced. Remarkably, after 24-months, the cardiomyopathy was corrected in both affected siblings, and in the 6-years-old, the retinal degeneration was arrested, and the vision was clinically improved. Similar therapeutic approaches could be employed in Mendelian phenotypes caused by the dysfunction of the hundreds of other molecular transporters.

The Generalized Euler Characteristics of the Graphs Split at Vertices.

We show that there is a relationship between the generalized Euler characteristic Eo(|VDo|) of the original graph that was split at vertices into two disconnected subgraphs i=1,2 and their generalized Euler characteristics Ei(|VDi|). Here, |VDo| and |VDi| denote the numbers of vertices with the Dirichlet boundary conditions in the graphs. The theoretical results are experimentally verified using microwave networks that simulate quantum graphs. We demonstrate that the evaluation of the generalized Euler characteristics Eo(|VDo|) and Ei(|VDi|) allow us to determine the number of vertices where the two subgraphs were initially connected.

Structural, dielectric and electrical properties of Gd-substituted lithium nano-ferrites prepared by the WOWS sol-gel method.

To synthesize lithium ferrite with various Gd concentrations (Li0.5Fe2.5-xGdxO4), x = 0.00, 0.025, 0.05, 0.075, 0.1, solutes were dissolved in glycol, i.e. by using the without water and surfactant (WOWS) sol-gel method. X-ray diffraction (XRD) analysis confirmed that the material possessed an inverse spinel cubic structure and is single phase. Pellets of all samples were sintered at 700 °C and XRD confirmed that samples were crystalline, phase pure and had an inverse spinel cubic lattice. Scanning electron microscopy indicated that the grains were agglomerated and had a predominantly spherical shape. It is concluded that Gd acts as a grain refiner in lithium ferrite up to a Gd concentration of 0.05. AC conductivity and dielectric constant increased by increasing Gd concentration. The Maxwell-Wagner model and Johnsher's power law were used to explain the dielectric properties. DC conductivity was measured from 100 to 600 °C. DC conductivity was explained by the hopping mechanism. It is concluded that DC resistivity and dielectric constant values are related reciprocally in the prepared sample. AC electrical properties were also measured at a constant frequency of 1 MHz in the temperature range from 400 to 600 °C. Gd-substituted lithium ferrite showed high AC conductivity, high DC resistivity and constant dielectric values, but low dielectric loss values as compared to pure lithium ferrite.

Evaluation of physiological markers for assessing drought tolerance and yield potential in bread wheat.

Carbon isotope discrimination (Δ) has been recognized as a valuable phenotyping tool in wheat breeding. However, technical expertise and analysis cost restrict its large-scale use. We examined the associations of ash content (AC), minerals content (Ca, K, Mg, Fe and Mn) and leaf chlorophyll content (Chl) with grain Δ and grain yield (GY) to assess their potential as substitute to grain Δ. We evaluated 49 wheat genotypes under two water deficit regimes (W120 and W200) in a rain-out shelter. Leaf chlorophyll content (Chl) was strongly correlated with grain Δ and GY under moderate water deficit regime (W200). Significant and negative correlations (P < 0.01) of AC and potassium concentration (K) with grain Δ, and between AC and GY was observed under both water regimes, while manganese concentration (Mn) was negatively correlated with grain Δ under W120 regime only and magnesium concentration (Mg) correlated negatively under the W200 regime only. Grain Δ was correlated (P < 0.01) positively with photosynthesis rate (A), stomatal conductance (gs) and GY, while correlated negatively (P < 0.01) with intrinsic water use efficiency (iWUE) under both water regimes. Results confirm the role of grain Δ as an indirect selection criterion for drought tolerance under a wide range of drought conditions. Additionally, Chl is the most suitable trait to predict yield under moderate water deficit conditions. AC and K concentration in grain proved potentially useful and economical alternative criterion to grain Δ in the evaluation of differences in yield potential and drought tolerance in wheat under drought.

Effect of oral eplerenone in anatomical and functional improvement in patients with chronic central serous chorioretinopathy.

OBJECTIVE: To determine the efficacy of oral eplerenone in anatomical and functional improvement in patients with chronic central serous chorioretinopathy (CSCR). METHODS: This quasi experimental study was performed at PNS Shifa Hospital Karachi from September 2018 to February 2019. Study included 23 patients. Patients were included using consecutive sampling technique and informed consent was taken from all patients before staring treatment. 50 mg of oral eplerenone per day was given for three months. Subretinal fluid (SRF) height and visual acuity (VA) were noted at baseline, one month and three month follow-up. Structured Study performa was used for data collection. Data was analysed and assessed with SPSS version 23. P value of <0.05 was considered statistically significant. RESULTS: Mean age of patients was 40.7±7 years and mean duration of disease before treatment was 3.7±0.76 months. Mean baseline BCVA and SRF height was 0.39±0.02 logMAR and 123±12.5 µm respectively. Sixty-five percent patients responded at one month and 80% at three months with reduction in SRF height. Improvement in visual acuity was also statistically significant at 3 months (p<0.05). CONCLUSION: Use of eplerenone in chronic CSCR resulted in significant improvement in vision and decrease in mean SRF height.

AC dielectrophoretic manipulation and electroporation of vaccinia virus using carbon nanoelectrode arrays.

This paper reports the capture and detection of vaccinia virus particles based on AC dielectrophoresis (DEP) and electrochemical impedance measurements employing an embedded vertically aligned carbon nanofiber (VACNF) nanoelectrode array (NEA) versus a macroscopic indium-tin-oxide (ITO) transparent electrode in a "points-and-lid" configuration. The nano-DEP device was fabricated by bonding two SU-8 covered electrodes patterned using photolithography. The bottom electrode contains a 200 × 200 µm2 active region on a randomly distributed NEA and the top electrode contains a microfluidic channel in SU-8 spin-coated on ITO to guide the flow of the virus solution. The real-time impedance change was measured during DEP capture and validated with fluorescence microscopy measurements. The NEA was able to capture virus particles with a rather low AC voltage (∼8.0 V peak-to-peak) at 1.0 kHz frequency as the particles were passed through the fluidic channel at high flow velocities (up to 8.0 mm/s). A concentration detection limit as low as ∼2.58 × 103 particles/mL was obtained via impedance measurements after only 54 sec of DEP capture. At the low AC frequencies (50.0 Hz or less), the high electric field at the exposed VACNF tips induced electroporation of the DEP-captured virus particles, which was validated by fluorescence emission from the dyes staining lipophilic membrane and internal nucleic acid, respectively. This study suggests the possibility of integration of a fully functional electronic device for rapid, reversible and label-free capture and detection of pathogenic viruses, with a potential of generating electroporation to the captured the virus particles for further biochemical study.

Visual outcome of retinal vein occlusion in patients residing at high altitude.

OBJECTIVE: To study visual outcome in patients of high altitude retinopathy presenting with retinal venous occlusion. METHODS: The randomised clinical trial study was conducted at the Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan, from January 2013 to December 2015, and comprised eyes of lowlanders. Patients staying at high altitude (>8,000 feet above sea level) as part of their service duty and presented with retinal venous occlusive disease were included. Patients with history of diabetes, hypertension, glaucoma, any pre-existing retinal disease or age-related conditions responsible for decreased vision were excluded. Detailed ocular as well as systemic examination was carried out to establish the diagnosis of retinal venous occlusion. Patients were divided into two groups. First group was observed over a period of 6 months and labelled as control group, whereas the second group was treated with intravitrealbevacizumab and labelled as intervention group. Complete ocular examination was carried out in all patients at 4 weeks, 3 months and 6 months. SPSS 21 was used for data analysis. RESULTS: A series of 32 eyes of 28 male patients were included. The overall mean age was 31.40±3.40 years. The mean altitude of their temporary stay was 4,120±941 metres above sea level and the mean duration of stay was 6.80±4.13months. Besides, 21(75%) subjects were smokers. Moreover, 26(81.25%) eyes had central retinal vein occlusion while branch retinal vein occlusion was seen in 6(18.75%) eyes. The mean visual acuity in the control group was 0.70±0.56 on Logarithm of the Minimum Angle of Resolution chart at the presentation while it was 0.26±0.87, 0.20±0.32 and 0.15±0.23 after 4 weeks, 3 months and 6 months, respectively. The mean best corrected visual acuity in intervention group was 0.68 ± 0.46 before treatment and 0.15±0.11, 0.12±0.11 and 0.10±0.08 at 4 weeks, 3 months and 6 months, respectively. Significant post-intervention change was observed in best corrected visual acuity at 6 months (p<0.05) in patients who presented with severe visual loss. CONCLUSIONS: Treatment with intravitrealbevacizumab may be considered in patients with severe visual loss at presentation.

Efficacy of Platelet-Rich Plasma versus 5% Topical Monixidil for the Treatment of Androgenetic Alopecia.

OBJECTIVE: To compare the efficacy of platelet-rich plasma (PRP) versus 5% topical minoxidil for the treatment of androgenetic alopecia (AGA). STUDY DESIGN: Randomised-controlled trial. Place and Duration of the Study: Department of Dermatology, PNS Shifa Hospital, Karachi, Pakistan, from 1st November 2021 to 31st July 2022. METHODOLOGY: Seventy AGA patients aged between 18-60 years of either gender were randomly divided into two groups. Group A was given 5% topical minoxidil and Group B was given PRP. Both groups were followed up over a period of 6 months, and the final analysis was done with the help of global photography, hair pull test, and patient satisfaction score. RESULTS: At the end of 6th month, 27 patients (77%) in Group A had a negative hair pull test as compared to only 14 (40%) in Group B (p = 0.001). In Group A, 32 patients (91.4%) reported improvement in hair scalp from baseline. Whereas, in Group B, 26 patients (74.3%) reported improvement from baseline (p = 1.00). PRP was effective in 26 patients (74.5%) and 5% topical minoxidil in 15 patients (43.7%) (p = 0.007). CONCLUSION: PRP therapy can be a useful alternative to topical minoxidil in the treatment of AGA. KEY WORDS: Androgenetic alopecia, Global photography, Platelet-rich plasma, 5% Topical minoxidil, Treatment.

A Distinct Instance of Palindromic Rheumatism Disguised as Polymyalgia Rheumatica.

In this case report, we highlight a rare case of palindromic rheumatism (PR) presenting as polymyalgia rheumatica (PMR). Many challenges and complexities are associated with diagnosing and treating PR. Literature reviews showed only a few case reports of this unique presentation. PR has a distinct presentation that often goes unnoticed and is misinterpreted by medical professionals. A more thorough clinical approach is required to identify and treat this condition. We hope sharing such uncommon cases will help the medical community better understand PR and develop improved diagnostic and therapeutic options. This case also demonstrates the need for further research to better understand the pathogenesis of this uncommon condition.

Integrated computational and experimental evaluation of phenolic constituents of Apricot fruit L. for antiqourum sensing, antibiofilm, antioxidant, and 15-lox inhibitory properties.

The present study investigated the antioxidant profile together with the antibacterial potential of Apricot L. with the aim to find a functional food based anti-infective lead. Additionally the study evaluated the biofilm and QS inhibitory potential of the plant using Pseudomonas aeruginosa (ATCC 15442) and Chromo bacterium Violaceum (DSM 30191) respectively. Several fractions of the peel of Apricot were subjected to initial antimicrobial and antibiofilm screening. Among all the fractions, methanol and ethyl acetate fractions displayed significant antimicrobial activity against the strains selected with MIC values 1.25 mg/dL and 1.68 mg/dL respectively. Similarly, while evaluating antiqourum-sensing potential, methanol extract showed remarkable zone of inhibition (14mm) with Violaceum inhibition (58%) while aqueous part presented moderately good inhibition (32%) with zone of inhibition of (4mm). N-hexane fraction was least active in this regard. In case of free radicals scavenging aptitudes, Ethanolic fraction displayed the highest free radicals scavenging potential (IC50µg/mL 13.76 ± 23.61) while Aqueous and ethyl acetate part exhibited moderate to good antioxidant behaviors with IC50µg/mL of 26.74 ± 22.00 and 19.49 ± 2.91 respectively. Then the selected compounds were screened for putative binding sites and molecular docking studies followed by enzyme inhibition assays. The negative binding energies and close proximity to residues in the binding pocket of selected targets including human α- soybean lox (PDB ID 1IK3), quorum sensing regulators LasR (2UV0) were observed which indicated high affinity and tight binding capacity of compounds 1 and 5 towards the active sites of LasR 2UV0 and 15-lipoxygenase. The physicochemical characteristics and toxicity expectation were computationally accomplished. Bioactivity prediction study revealed that all of the selected Phytoconstituents displayed incredible Bioactivity score. None of the selected chemical compound was found to be toxic as discovered by toxicity studies. Compound 4 exhibited the highest inhibition of 15-lipoxygenase in vitro (69%, at 0.037 mM final concentration) and that is accompanied by compound 5 (60%) whereas in the biofilm inhibition assay, compound 1 was most active (IC50 0.05 mM), followed by compound 3 (IC50 0.07 mM). It was therefore determined that compounds 1 and 3 had the highest biofilm inhibitory activity, whereas compounds 4 and 5 were potent 15-lipoxygenase inhibitors with potentially anti-inflammatory properties. Future investigations are suggested for the characterization and formulation development.

Association Between Venous Thromboembolism Prophylaxis and the Incidence of Thromboembolism Following Orthopedic Procedures: A Cross-Sectional Study.

INTRODUCTION: Venous thromboembolism (VTE) is a significant concern following orthopedic procedures, necessitating effective prophylactic measures. The rates of VTE prophylaxis, however, vary widely between institutions and nations, falling between 13% and 70% on average. In the absence of adequate thromboprophylaxis, pulmonary embolism, which accounts for 5% to 10% of mortality in hospitalized patients, is one of the leading causes of death. This study investigates the relationship between VTE prophylaxis and thromboembolism incidence, considering patient characteristics, risk assessment completion, anticoagulant prescription, and weight-bearing status. OBJECTIVES: To evaluate the knowledge gap by examining the relationship between VTE prevention and the prevalence of thromboembolism also to examine the anticoagulant prescription trends for patients being discharged from orthopedic operations and to investigate the connection between post-procedure weight-bearing status and the development of VTE problems. METHODOLOGY: A retrospective, cross-sectional design was employed, analyzing 200 orthopedic procedure patients from January to June of 2023 performed at Rehman Medical Institute. After getting ethical approval from the institutional ethical approval board, data were collected on the basis of variables encompassing patient attributes, surgery details, VTE risk factors, prophylaxis type, and VTE complications. Data was entered and analyzed via IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States), and the data were run through various tests including descriptive statistics, cross-tabulations, and chi-square. Results were then presented in the form of a table. RESULTS: Among 200 individuals 24 individuals experienced VTE, while 176 did not. Significant gender-based VTE differences were observed (p = 0.01). Hypertension (HTN) showed a significant association (p = 0.04) with VTE. Major surgeries were correlated with higher VTE incidence (p = 0.03). Pharmacological prophylaxis reduced the occurrence of VTE (p = 0.01). Early mobilization and Ted stockings were correlated with lower VTE incidence (p = 0.04, p = 0.12). CONCLUSION: This study reveals gender-specific VTE differences, emphasizes the role of HTN, surgical nature, and prophylaxis in VTE incidence, and supports tailored prophylactic strategies. Our findings align with previous research and emphasize the significance of tailored prophylaxis strategies. By examining multiple factors, including gender, co-morbidities, surgical characteristics, and prophylactic methods, our study contributes to the evidence base that supports clinical decision-making and enhances patient safety in orthopedic surgery.

Prevalence of Aortic Root Pathologies in Platypnea-Orthodeoxia Syndrome Secondary to Intra-Cardiac Shunts.

Background: Atrial septal defects can allow right to left shunting of venous blood which presents clinically as platypnea-orthodeoxia syndrome. It is believed that concomitant presence of aortic root pathologies increases the likelihood of shunting. Methods: The study included a review of 510 articles listed in PubMed of patients with platypnea-orthodeoxia syndrome. Case reports of patients with extra-cardiac etiologies of platypnea-orthodeoxia were excluded. Results: We reviewed 191 case reports, and 98 cases (51.3%) had evidence of concomitant aortic root pathology. Furthermore, of the remaining 93 case reports, 69 ones excluded any mention of the nature of the aortic root altogether, further suggesting that this is an underreported number. Conclusions: There is a high prevalence of aortic root pathologies in patients with platypnea-orthodeoxia syndrome secondary to intra-cardiac shunts. In patients with unexplained hypoxemia and incidental finding of aortic root pathology, it may be worthwhile to obtain postural oxygen saturation measurements to exclude intra-cardiac shunts as the potential cause.

Effectiveness of Autoinoculation in Patients with Multiple Warts Presenting at a Tertiary Care Hospital.

OBJECTIVE: To determine the effectiveness of autoinoculation in patients with multiple skin warts. STUDY DESIGN: A Quasi-experimental study. PLACE AND DURATION OF STUDY: Dermatology department of PNS Shifa Hospital, from April to October 2021. METHODOLOGY: Ninety-six patients with multiple warts were enrolled in this study after informed consent. Under strict aseptic measures and local anaesthesia, wart tissue was removed and crushed on a glass slide with the scalpel. Autoinoculation was done on flexor aspects of bilateral forearms after making a subcutaneous pocket which was then stitched. Patients were assessed at monthly intervals for 03 months and after 01 month of the last autoinoculation to see sustained response. Effectiveness was recorded according to ordinal scale; worsening of lesions/no response at <50% resolution/partial response at >50%- <100% resolution and complete response at 100% resolution. RESULTS: Complete response was observed in 88 (91.66%) of the cases, no response was observed in 2 (2.1%) cases where as 6 (6.3%) showed worsening. All patients were compliant with the follow-up. No new eruptions were observed. CONCLUSION: Autoinoculation is a minimally invasive and cost-effective procedure with excellent response to wart. It also decreases recurrence by generating viral-specific immunity. KEY WORDS: Viral warts, Autoinoculation, Multiple, Immunotherapy, Verrucous, Treatment, HPV, Resistant.

The Spectrum of Heart Failure Management.

Heart failure, a complex cardiovascular condition, is a huge burden on patients, caregivers, and healthcare systems and it is prevalent worldwide. Heart failure is caused by a wide variety of underlying conditions that include both cardiac and non-cardiac pathologies. Identifying the underlying cause enables us to apply etiology-based interventions. The spectrum of heart failure management ranges from classification to transplantation. In addition to its classification and monitoring, this article reviews various management strategies, including both conventional methods and the latest innovations. These include lifestyle interventions, pharmacotherapy, device therapy, transplantation, and regenerative medicine.

Sudden Cardiac Death in Athletes: Consensuses and Controversies.

Exercise is widely considered beneficial for cardiovascular health. However, on rare occasions, athletes experience sudden cardiac death without any preceding symptoms. The devastating nature of these events necessitates us to understand the underlying causes. In younger athletes (age <35), the underlying causes are usually hereditary/genetic, whereas in older athletes (age >35), coronary artery disease is prevalent. Sudden cardiac death in athletes can occur regardless of the presence of any structural abnormality in the heart. Despite divergence between guidelines, the majority of cardiology societies recommend at least taking a comprehensive history and performing physical examinations for initial screening for all athletes. This article reviews the consensuses and controversies regarding the incidence, causes, and prevention of sudden cardiac death in athletes.

Distributions of the Wigner reaction matrix for microwave networks with symplectic symmetry in the presence of absorption.

We report on experimental studies of the distribution of the reflection coefficients, and the imaginary and real parts of Wigner's reaction (K) matrix employing open microwave networks with symplectic symmetry and varying size of absorption. The results are compared to analytical predictions derived for the single-channel scattering case within the framework of random-matrix theory (RMT). Furthermore, we performed Monte Carlo simulations based on the Heidelberg approach for the scattering (S) and K matrix of open quantum-chaotic systems and the two-point correlation function of the S-matrix elements. The analytical results and the Monte Carlo simulations depend on the size of absorption. To verify them, we performed experiments with microwave networks for various absorption strengths. We show that deviations from RMT predictions observed in the spectral properties of the corresponding closed quantum graph and attributed to the presence of nonuniversal short periodic orbits does not have any visible effects on the distributions of the reflection coefficients and the K and S matrices associated with the corresponding open quantum graph.

Comparing Dermatoscopic Features With Slit Skin Smear and Histopathology in Diagnosis of Cutaneous Leishmaniasis.

OBJECTIVE: To evaluate dermatoscopic features of cutaneous leishmaniasis and to compare its diagnostic accuracy against slit skin smear and skin histopathology. METHODS:  This cross-sectional study was conducted at the Department of Dermatology, Pakistan Navy Station (PNS) Shifa Hospital, Karachi, Pakistan, from August 2021 to August 2022. A total of 200 lesions from 70 patients of cutaneous leishmaniasis diagnosed with slit skin smear for Leishmania-Donovan (LD) bodies and skin biopsy were included via non-probability consecutive sampling technique. Dermatoscopic evaluation was performed via a handheld dermatoscope (DELTA 20T; HEINE, Gilching, Germany) on 10x magnification. All dermatoscopic images were analyzed by two different observers who had command of dermatoscopy. Data analysis was done using Statistical Package for the Social Sciences SPSS version 27 (IBM Corp., Armonk, NY, USA). RESULTS: Common dermatoscopic findings were erythema 200 (100%), hyperkeratosis 140 (70%), crusting 50 (25%), ulceration 42 (21%), milia-like structure 58 (29%), tear drop-like structure 46 (23%), yellow tears 70 (35%), and white starburst pattern 68 (34%). Less common findings were yellow hue 28 (14%), orange areas 26 (13%) and scar seven (3.5%). Vascular structures frequently observed were linear vessels 109 (54.5%), dotted vessels 80 (40%), and hairpin vessels 61 (30.5%); less common findings were comma-shaped vessels 52 (26%), arborizing vessels 20 (10%), crown vessels nine (4.5%). Comparison of dermatoscopic features was done with slit skin smear for LD bodies (p value = 0.003 ) and histopathology (p value = 0.001). CONCLUSIONS: Dermatoscopy is a non-invasive technique that is helpful in diagnosing cutaneous leishmaniasis, saving time in making rapid diagnosis and saving the need to undergo extensive invasive investigation. Yield of dermatoscopy was comparable to slit smear for LD bodies and histopathology and was found to be effective in making rapid diagnosis with significant accuracy (p value <0.05).

Implementation of World Health Organization behaviorally anchored rating scale and checklist utilization: promising results for LMICs.

Background: Operating teams can decrease the likelihood of patient risk by using the WHO Surgical Safety Checklist. To ascertain the impact of demographic factors on behaviorally anchored ratings and investigate operating room (OR) staff attitudes toward checklist administration, we set out to better understand how OR personnel use the checklist in a tertiary care hospital in Pakistan. Materials and methods: A monocentric sequential mixed-methods study employing a quantitative approach of using World Health Organization Behaviorally Anchored Rating Scale (WHOBARS) assessments of surgical cases by OR personnel and two independent observers, who were certified surgeons having extensive experience in the rating of the WHOBARS scale for more than 1 year, followed by a qualitative approach of staff interviews were carried out in a tertiary care setting. In June and July 2022, over the period of 8 weeks, an intervention (training delivery) was implemented and evaluated. The information, skills, and behavior adjustments required to apply the checklist were taught in the course using lectures, videos, small group breakouts, participant feedback, and simulations. Results: After the introduction of WHOBARS, 50.81% of respondents reported always using the checklist, with another 30.81% using it in part. Participants' years in practice, hospital size, or surgical volume did not predict checklist use. Checklist use was associated with always counting instruments (51.08%), patient identity (67.83%), difficult intubation risk (39.72%), the risk of blood loss (51.08%), prophylactic administration of an antibiotic (52.43%), and the use of pulse oximeter (46.75%). Interviewees felt that the checklist could promote teamwork and a safe culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone. Conclusion: The use of a multi-disciplinary course for checklist implementation resulted in 50.81% of participants always using the checklist and an increase in counting surgical instruments. Successful checklist implementation was not predicted by the participant's length of medical service, hospital size, or surgical volume. If reproducible in other countries, widespread implementation in LMICs becomes a realistic possibility.

Diffuse Coronary Artery Disease - A Challenge To Revascularize And The Role Of Coronary Endarterectomy.

Coronary endarterectomy is a useful adjunct procedure in patients with diffuse coronary artery disease when isolated coronary artery bypass grafting does not permit adequate revascularization. The primary aim of this procedure is to enable ample blood flow by removing the obstructing plaque. Herein we discuss the case of a middle-aged patient who underwent coronary endarterectomy.

Airway Management of a Patient With Tracheoesophageal Fistula and Tracheal Stent.

A 69-year-old male patient, a known case of squamous cell carcinoma of the esophagus on palliative care and Do Not Attempt Resuscitation (DNAR) status, presented for urgent laparoscopic gastrostomy tube insertion under general anesthesia. The patient had developed an iatrogenic tracheoesophageal fistula (TEF) because of the tracheal stent, which was placed for tracheal stenosis. A preoperative assessment was done, and a plan of airway management via one-lung ventilation (OLV) through an endobronchial tube was devised by the anesthesia team and discussed with the surgery team. The airway was secured via asleep fiberoptic right endobronchial intubation using a microlaryngeal tube (MLT) size 6 since there was uncertainty regarding adequate patency of the airway due to the invasion by the tumor and the presence of the stent. The patient remained hemodynamically stable. After surgical incision and insufflation of CO2 in the abdominal cavity, the patient's airway pressures were increased and we were unable to deliver adequate tidal volumes. Surgery was stopped; the presence of a kink in the circuit or endotracheal tube (ETT), the possibility of laryngospasm/bronchospasm, and pneumothorax were ruled out. Fiberoptic bronchoscopy (FOB) revealed that the endobronchial tube was abutting the secondary carina. We pulled the MLT by 2 cm. The rest of the procedure was uneventful and we extubated the patient at the end of the procedure under vision using a fiber optic bronchoscope. The patient was discharged after two days of stay in the hospital. Our patient with TEF and tracheal stent posed a significant challenge for airway management. A thorough plan was drawn up and a team briefing was done. Perioperatively, the difficulty in ventilation was identified, and various other etiologies were ruled out with the successful identification and management of the problem.