Outcome Analysis of Advanced Oral Cancers Requiring Large Composite Fibular Osteocutaneous Flap Reconstruction: Experience From a Tertiary Care Cancer Hospital.

BACKGROUND: Advanced oral cancer entailing extensive resection of large parts of the mucosa, bone, and skin require reconstructions with composite free flaps. Our aim was to analyze the outcomes of those oral squamous cell carcinomas requiring fibular osteocutaneous free flaps with large skin defects. METHODS: Perioperative course and histopathological and survival outcomes of 246 consecutive patients warranting composite fibular flaps from January 2010 to June 2015 at Tata Memorial Hospital, Mumbai, India, were retrospectively analyzed. RESULTS: Despite majority of T4 disease (88.2%) and stage IV disease (92%) patients, the 5-year overall survival was 52.1% and the 5-year recurrence-free survival was 48.6% with a median follow-up of 42 months with minimal complications. CONCLUSIONS: Reconstruction with composite fibular osteocutaneous flaps has comparable outcomes of survival with acceptable complications in mega oral squamous cell carcinomas requiring extensive resection.

Management of Chronic Insomnia Using Cognitive Behavior Therapy for Insomnia (CBT-I) During COVID-19 Pandemic: Does One Shoe Fit All?

Purpose: Insomnia is a highly prevalent disorder that is seen across all age groups causing significant morbidity to the patients. Its prevalence has further risen during COVID-19 pandemic. It is widely acknowledged that untreated insomnia can lead to significant health risks and socio-occupational dysfunction. Methods: A narrative review was conducted following focused search of databases. Results: Available guidelines mention two different approaches for the management of insomnia-pharmacological and non-pharmacological. Non-pharmacological therapies like multicomponent cognitive behavior therapy for insomnia (CBT-I) have been advocated for the management of acute as well as chronic insomnia in the literature as it has been found efficacious and useful. Multiple variants of CBT-I, e.g., digitally delivered CBT-I, brief CBT-I have been tested during pandemic owing to closure of clinics. However, there are certain issues to be considered while choosing CBT-I as therapy. For example, like other forms of psychotherapies, is there a need for assessing the candidature of patient before administering CBT-I; is CBT-I free of adverse effects as commonly thought; is CBT-I more efficacious than hypnotics; and at last, how to manage cases that are not candidate for CBT-I. Conclusion: This narrative review addresses the scientific robustness of evidence for issues related to adherence, efficacy and adverse effects of non-pharmacological therapies. Available literature suggests that data related to adherence and efficacy of CBT-I suffer from methodological shortcomings and careful selection of patient is important for the successful therapy. At the same time, attempts have been made to shed light to the areas where CBT-I can be helpful in the management of insomnia.

Management of chronic insomnia using hypnotics: a friend or a foe?

Epidemiological studies suggest that 10-15% adults meet the present criteria for the diagnosis of insomnia disorder; however, there may be geographical variations. Untreated insomnia disorders have a number of adverse health consequences in addition to economic burden caused by it. Available guidelines mention that CBT-I should be preferred over hypnotics. However, several patients of chronic insomnia are not candidate for CBT-I and for them, hypnotics are the only answer. This paper reviews the literature to answer following questions: What is the current understanding regarding place of hypnotics for in management of insomnia disorder? How many patients misuse or abuse hypnotics, especially benzodiazepines, as commonly believed? Do we have data from human studies regarding low-dose benzodiazepine dependence? What does hypnotics produce-withdrawal insomnia, rebound insomnia or end of dose phenomenon? Are adverse effects of benzodiazepines worse than other psychotropic medications? Is prescription of hypnotics more troublesome than untreated insomnia disorder? Available literature suggests that there is an unreasonable negative bias attached to the use of hypnotics. Only a sub-set of patients who are prescribed hypnotics, meet the criteria for "dependence" in long term. Other patients either discontinue it (as insomnia remits) or change to occasional use (since insomnia may be relapsing remitting disorder), or continue using it in low dose (since insomnia reappears as hypnotics are discontinued, similar to increase in blood sugar after hypoglycemics are discontinued). Meta-analysis shows that adverse effects of hypnotics are comparable to that of other psychotropic medications. Considering the consequences and risks associated with untreated insomnia disorder, even long-term use of hypnotics is justified, however with the careful watch that patients are not increasing the dose. This approach is especially important in geographical areas where trained CBT-I therapists are not available.

Evidence Map and Systematic Review of Disinfection Efficacy on Environmental Surfaces in Healthcare Facilities.

Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality with an estimated 1.7 million infections and 99,000 deaths costing USD $28-34 billion annually in the United States alone. There is little understanding as to if current environmental surface disinfection practices reduce pathogen load, and subsequently HAIs, in critical care settings. This evidence map includes a systematic review on the efficacy of disinfecting environmental surfaces in healthcare facilities. We screened 17,064 abstracts, 635 full texts, and included 181 articles for data extraction and study quality assessment. We reviewed ten disinfectant types and compared disinfectants with respect to study design, outcome organism, and fourteen indictors of study quality. We found important areas for improvement and gaps in the research related to study design, implementation, and analysis. Implementation of disinfection, a determinant of disinfection outcomes, was not measured in most studies and few studies assessed fungi or viruses. Assessing and comparing disinfection efficacy was impeded by study heterogeneity; however, we catalogued the outcomes and results for each disinfection type. We concluded that guidelines for disinfectant use are primarily based on laboratory data rather than a systematic review of in situ disinfection efficacy. It is critically important for practitioners and researchers to consider system-level efficacy and not just the efficacy of the disinfectant.

Chronic Noncancer Pain and Opioid Addiction: Diagnostic and Management Challenges.

Chronic pain is associated with higher rates of psychiatric comorbidity, including substance use disorders. Patients with chronic pain often require opioids for their pain relief. Often, clinicians are reluctant to prescribe opioids to patients with chronic pain due to fear of patients becoming dependent on opioids. Diagnosing opioid addiction in chronic pain with comorbid prescription opioid use is challenging, as some of the symptoms of addiction overlap with those of physical dependence. A 28-year-old female presented with a history of recurrent abdominal pain beginning at the age of 16 years. The patient was diagnosed with chronic pancreatitis and was prescribed tramadol orally or injections for pain. The patient started experiencing craving with repeated administration of tramadol. She started using it daily and increased her dose to about 6-7 ampoules per day. She also developed complications due to injections. She was not able to work due to her pain, as well as injection use. She would go to multiple chemist shops for getting herself injected with tramadol injections. She also developed depressive symptoms in this period. Due to abdominal pain, the patient was admitted in the gastroenterology ward, from where she was shifted to the psychiatry ward for the management of opioid misuse and depressive symptoms. The patient was diagnosed to be suffering from opioid dependence syndrome with depressive episodes, for which she was provided tablet buprenorphine 14 mg/day dose along with tablet sertraline 150 mg/day. The case demonstrates several challenges in the diagnosis and management of opioid dependence and chronic pain when they occur simultaneously.

A novel prototype 3/5 laparoscopic needle driver: A validation study with conventional laparoscopic needle driver.

INTRODUCTION: The challenges in laparoscopic suturing include need to expertise to suture. Laparoscopic needle holder is a" key" instrument to accomplish this arduous task. INSTRUMENT: The objective of this new invention was to develop a laparoscopic needle holder which would be adapted to avoid any wobble (with a shaft diameter same as a 5mm port), ensure accurate and dexterous suturing not just in adult patients but pediatric patients alike (with a short shaft diameter) and finally ensure seamless throw of knots with a narrow tip configuration. VALIDATION: We did an initial evaluation to evaluate the validity of the prototype needle holder and its impact on laparoscopic suturing skills by experienced laparoscopic surgeons and novice laparoscopic Surgeons. Both the groups of surgeons performed two tasks. The first task was to grasp the needle and position it in an angle deemed ideal for suturing. The second task was to pass suture through two fixed points and make a single square knot. At the end of the tasks each participant was asked to complete a 5- point Likert's scale questionnaire (8 items; 4 items of handling and 4 items of suturing) rating each needle holder. In expert group, the mean time to complete task 1 was shorter with prototype 3/5 laparoscopic needle holder (11.8 sec Vs 20.8 sec). The mean time to complete task 2 was also shorter with prototype 3/5 laparoscopic needle holder (103.2 sec Vs 153.2 sec). In novice group, mean time to complete both the task was shorter with prototype 3/5 laparoscopic needle holder. CONCLUSION: The expert laparoscopic surgeons as well as novice laparoscopic surgeons performed laparoscopic suturing faster and with more ease while using the prototype 3/5 laparoscopic needle holder.