Anaesthesia Management for Neurosurgery in a Patient With Congenital Lung Agenesis.

Congenital lung agenesis is a rare congenital abnormality associated with an absence or under-development of either one or both lungs, and its presentation in adulthood is even rarer. We describe a 40-year-old female patient with a history of congenital agenesis of the right lung and a high-grade glioma in the frontal region of the brain presenting for craniotomy and excision of the tumor in an MRI suite. Lung protective strategies of ventilation were utilized intraoperatively. The remote location of the MRI suite made access to extra manpower support challenging. The patient was managed uneventfully and discharged stable to the high-dependency unit. Our case describes how congenital lung agenesis poses a unique set of challenges for anaesthetic management, particularly in neurosurgical patients, and provides guidance to a multidisciplinary team approach.

Compacted Area with Effective Links (CAEL) for Data Dissemination in VANETs.

Vehicular ad hoc network (VANET) is a specialized form of wireless network that is solely intended for collaboration between vehicles. Several studies have shown that standard routing protocols cannot be implemented in VANETs because of their unique characteristics such as their significant count of vehicles on the network and the rapid evolution of the network's design. Because VANET communication links are broken very frequently, it is necessary to address the routing consistency of these highly dynamic networks. The transmission of VANET data may result in a substantial amount of overhead in the routing process; thus, it is vital to address the issue of overhead to enhance the overall network performance. The proposed protocol named compacted area with effective links (CAEL) is designed to focus on decreasing overhead to achieve an enhancement in PDR performance inside the network. The communication between selected nodes that have been judged to be dependable in terms of geographical location and appropriate existing links between vehicles is focused on achieving this goal. With the inclusion of the reliability factor, it is possible to complete the important step of removing extraneous nodes, with the selection of the trustworthy nodes being made based on the link expiration time during the whole routing procedure. When compared to our previously published protocols, i.e., Dynamic Trilateral Enrollment (DyTE) and Reliable Group of Vehicles (RGoV), the results of the simulations demonstrate that CAEL has achieved an overall improvement in the performance of the network.

Tonic pain alters functional connectivity of the descending pain modulatory network involving amygdala, periaqueductal gray, parabrachial nucleus and anterior cingulate cortex.

INTRODUCTION: Resting state functional connectivity (FC) is widely used to assess functional brain alterations in patients with chronic pain. However, reports of FC accompanying tonic pain in pain-free persons are rare. A network we term the Descending Pain Modulatory Network (DPMN) is implicated in healthy and pathologic pain modulation. Here, we evaluate the effect of tonic pain on FC of specific nodes of this network: anterior cingulate cortex (ACC), amygdala (AMYG), periaqueductal gray (PAG), and parabrachial nuclei (PBN). METHODS: In 50 pain-free participants (30F), we induced tonic pain using a capsaicin-heat pain model. functional MRI measured resting BOLD signal during pain-free rest with a 32 °C thermode and then tonic pain where participants experienced a previously warm temperature combined with capsaicin. We evaluated FC from ACC, AMYG, PAG, and PBN with correlation of self-report pain intensity during both states. We hypothesized tonic pain would diminish FC dyads within the DPMN. RESULTS: Of all hypothesized FC dyads, only PAG and subgenual ACC was weakly altered during pain (F = 3.34; p = 0.074; pain-free>pain d = 0.25). After pain induction sACC-PAG FC became positively correlated with pain intensity (R = 0.38; t = 2.81; p = 0.007). Right PBN-PAG FC during pain-free rest positively correlated with subsequently experienced pain (R = 0.44; t = 3.43; p = 0.001). During pain, this connection's FC was diminished (paired t=-3.17; p = 0.0026). In whole-brain analyses, during pain-free rest, FC between left AMYG and right superior parietal lobule and caudate nucleus were positively correlated with subsequent pain. During pain, FC between left AMYG and right inferior temporal gyrus negatively correlated with pain. Subsequent pain positively correlated with right AMYG FC with right claustrum; right primary visual cortex and right temporo-occipitoparietal junction CONCLUSION: We demonstrate sACC-PAG tonic pain FC positively correlates with experienced pain and resting right PBN-PAG FC correlates with subsequent pain and is diminished during tonic pain. Finally, we reveal PAG- and right AMYG-anchored networks which correlate with subsequently experienced pain intensity. Our findings suggest specific connectivity patterns within the DPMN at rest are associated with subsequently experienced pain and modulated by tonic pain. These nodes and their functional modulation may reveal new therapeutic targets for neuromodulation or biomarkers to guide interventions.

Design and Evaluation of a Button Sensor Antenna for On-Body Monitoring Activity in Healthcare Applications.

A button sensor antenna for on-body monitoring in wireless body area network (WBAN) systems is presented. Due to the close coupling between the sensor antenna and the human body, it is highly challenging to design sensor antenna devices. In this paper, a mechanically robust system is proposed that integrates a dual-band button antenna with a wireless sensor module designed on a printed circuit board (PCB). The system features a small footprint and has good radiation characteristics and efficiency. This was fabricated, and the measured and simulated results are in good agreement. The design offers a wide range of omnidirectional radiation patterns in free space, with a reflection coefficient (S11) of −29.30 (−30.97) dB, a maximum gain of 1.75 (5.65) dBi, and radiation efficiency of 71.91 (92.51)% in the lower and upper bands, respectively. S11 reaches −23.07 (−27.07) dB and −30.76 (−31.12) dB, respectively, with a gain of 2.09 (6.70) dBi and 2.16 (5.67) dBi, and radiation efficiency of 65.12 (81.63)% and 75.00 (85.00)%, when located on the body for the lower and upper bands, respectively. The performance is minimally affected by bending, movement, and fabrication tolerances. The specific absorption rate (SAR) values are below the regulatory limitations for the spatial average over 1 g (1.6 W/Kg) and 10 g of tissues (2.0 W/Kg). For both indoor and outdoor conditions, experimental results of the range tests confirm the coverage of up to 40 m.

Efficacy of SG Shield in reducing droplet contamination during collection of oropharyngeal swab culture specimens.

Introduction: Oropharyngeal swabs for diagnosis of COVID-19 often induce violent coughing, which can disperse infectious droplets onto providers. Incorrectly doffing personal protective equipment (PPE) increases the risk of transmission. A cheap, single-use variation of the face shield invented by a Singaporean team, SG Shield, aims to reduce this risk. This manikin study aimed to study the efficacy of the SG Shield in combination with standard PPE. Methods: A person attired in full PPE whose face and chest was lined with grid paper stood in front of an airway manikin in an enclosed room. A small latex balloon containing ultraviolet fluorescent dye was placed in the oral cavity of the manikin and inflated until explosion to simulate a cough. Three study groups were tested: (a) control (no shield), (b) face shield and (c) SG Shield. The primary outcome was droplet dispersion, determined quantitatively by calculating the proportion of grid paper wall squares stained with fluorescent dye. The secondary outcome was the severity of provider contamination. Results: The SG Shield significantly reduced droplet dispersion to 0% compared to the controls (99.0%, P = 0.001). The face shield also significantly reduced droplet contamination but to a lesser extent (80.0%) compared to the control group (P = 0.001). Although the qualitative severity of droplet contamination was significantly lower in both groups compared to the controls, the face shield group had more contamination of the provider's head and neck. Conclusion: The manikin study showed that the SG Shield significantly reduces droplet dispersion to the swab provider's face and chest.

Psychedelics for Brain Injury: A Mini-Review.

Objective: Stroke and traumatic brain injury (TBI) are among the leading causes of disability. Even after engaging in rehabilitation, nearly half of patients with severe TBI requiring hospitalization are left with major disability. Despite decades of investigation, pharmacologic treatment of brain injury is still a field in its infancy. Recent clinical trials have begun into the use of psychedelic therapeutics for treatment of brain injury. This brief review aims to summarize the current state of the science's relevance to neurorehabilitation, and may act as a resource for those seeking to understand the precedence for these ongoing clinical trials. Methods: Narrative mini-review of studies published related to psychedelic therapeutics and brain injury. Results: Recent in vitro, in vivo, and case report studies suggest psychedelic pharmacotherapies may influence the future of brain injury treatment through modulation of neuroinflammation, hippocampal neurogenesis, neuroplasticity, and brain complexity. Conclusions: Historical data on the safety of some of these substances could serve in effect as phase 0 and phase I studies. Further phase II trials will illuminate how these drugs may treat brain injury, particularly TBI and reperfusion injury from stroke.

Infectious crystalline keratitis induced by Citrobacter.

Background: Microbial keratitis is an important cause of ocular morbidity, with emerging organisms and drug resistance posing a real threat to vision of patients. Case presentation: A 30-year-old female presented with infective keratitis in the left eye. She had been using rose nectar as home remedy for her ailment. With no improvement in her symptoms, she presented to the eye emergency department, where she was started on empirical therapy with moxifloxacin, which was shifted to levofloxacin eye drops after the antimicrobial susceptibility test results came in. Microbiological examination revealed infection with rare gram-negative bacilli Citrobacter koseri. The patient responded well to the treatment with 1.5% levofloxacin eye drops and her vision improved from 20/120 to 20/30 over a course of 3 months. Conclusion: Treatment of microbial keratitis with those antibiotics that the organism is most sensitive to is of paramount importance today, where we often find patients on a cocktail of eye drops, which leads to further resistance and vision deterioration. Culturing of cornea scrapings and antimicrobial susceptibility testing of the isolated organism is now the standard guideline to be followed in the investigation of microbial keratitis.

Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy (PCNL) for managing renal calculi.

OBJECTIVE: To compare upper versus lower calyceal approaches in percutaneous nephrolithotomy for managing renal calculi. METHODS: The retrospective study was conducted in the Department of Urology, The Kidney Centre Post-Graduate Training Institute, Karachi, and comprised data of patients who underwent percutaneous nephrolithotomy from January 2014 to January 2015. Patients were divided into upper pole puncture group A and lower pole puncture group B. Data was analysed using SPSS 17. RESULTS: Of the 198 patients, 147(74.2%) were males and 51(25.8%) were females. The overall mean age was 40.64±14.02 years. Of the total, 69(34.84%) were in group A and 129(65.15%) were in group B. Inter-group difference was significant in pre- and post-operative haemoglobin (p<0.05). Post-operative outcomes showed that blood transfusion, stone clearance and complication like tube thoracostomy had significant association with both the groups (p<0.05). Complete clearance was seen in 152(76.8%) patients; 40(74.1%) in group A and 102(81.6%) in group B. CONCLUSIONS: The success rate was found to be better in lower calyceal puncture group than upper calyceal puncture group for the management of renal calculi.

Description and Early Results of the Kaiser Permanente Southern California COVID-19 Home Monitoring Program.

INTRODUCTION: The Southern California region of Kaiser Permanente developed a COVID-19 Home Monitoring program as an alternative to hospital admission to decrease hospital bed days and mitigate the adverse effects of a surge. To date, more than 15,000 patients have been enrolled and approximately 10% of enrolled patients have been escalated to hospital care for timely treatment. Our objective is to describe our COVID-19 Home Monitoring program and present early results. METHODS: We conducted an observational retrospective study of all patients enrolled in the COVID-19 Home Monitoring program between April 13, 2020 through February 12, 2021. Data analysis conducted includes patient demographics, enrollment, entry points, length of stay, mortality, additional treatment, utilization, adherence, satisfaction, and alert triggers. RESULTS: A total of 12,461 of 13,055 patients (95.5%) recovered and completed the program, 1387 patients (10.6%) were admitted to the hospital, and 20 patients (0.2%) died while they were being monitored at home. The mortality rate at 30 days from enrollment was 1.6%. Hospital length of stay for ambulatory patients receiving oxygen only was 5.4 days compared to 3.1 days for those ambulatory patients receiving oxygen, dexamethasone, and remdesivir. CONCLUSION: COVID-19 home monitoring appears to be safe and effective. Initial data suggest it can serve as an alternative to hospitalization, decreasing hospital length of stay when patients receive therapies in the ambulatory setting otherwise reserved for the hospital. Initial results of this Home Monitoring program appear to be promising, and a longer term prospective study is warranted.

Is there a link between inorganic polyphosphate (polyP), mitochondria, and neurodegeneration?

Mitochondrial dysfunction - including increased apoptosis, calcium and protein dyshomeostasis within the organelle, and dysfunctional bioenergetics and oxidative status - is a common, early feature in all the major neurodegenerative diseases, including Alzheimer's Disease (AD) and Parkinson's Disease (PD). However, the exact molecular mechanisms that drive the organelle to dysfunction and ultimately to failure in these conditions are still not well described. Different authors have shown that inorganic polyphosphate (polyP), an ancient and well-conserved molecule, plays a key role in the regulation of mitochondrial physiology under basal conditions. PolyP, which is present in all studied organisms, is composed of chains of orthophosphates linked together by highly energetic phosphoanhydride bonds, similar to those found in ATP. This polymer shows a ubiquitous distribution, even if a high co-localization with mitochondria has been reported. It has been proposed that polyP might be an alternative to ATP for cellular energy storage in different organisms, as well as the implication of polyP in the regulation of many of the mitochondrial processes affected in AD and PD, including protein and calcium homeostasis. Here, we conduct a comprehensive review and discussion of the bibliography available regarding the role of polyP in the mitochondrial dysfunction present in AD and PD. Taking into account the data presented in this review, we postulate that polyP could be a valid, innovative and, plausible pharmacological target against mitochondrial dysfunction in AD and PD. However, further research should be conducted to better understand the exact role of polyP in neurodegeneration, as well as the metabolism of the polymer, and the effect of different lengths of polyP on cellular and mitochondrial physiology.

Outcomes and impact of laparoscopic inguinal hernia repair versus open inguinal hernia repair on healthcare spending and employee absenteeism.

BACKGROUND: This study compares the impact of open (OIHR) versus laparoscopic (LIHR) inguinal hernia repair on healthcare spending and postoperative outcomes. METHODS: The TRUVEN database was queried using ICD9 procedure codes for open, laparoscopic, and robotic-assisted IHR, from 2012 to 2013. Patients > 18 years of age and continuously enrolled for 12 months postoperatively were included. Demographics, patient comorbidities, postoperative complications, pain medication use, length of hospital stay, missed work hours, postoperative visits, and overall expenditure were collected, and assessed at time of surgery and at 30-, 60-, 90-, 180-, and 365-days postoperatively. Statistical analysis was conducted using SAS, with α = 0.05. RESULTS: 66,116 patients were included (LIHR: N = 23,010; OIHR: N = 43,106). Robotic-assisted procedures were excluded due to small sample size (N = 61). The largest demographic was males between 55 and 64 years. LIHR had fewer surgical wound complications than OIHR (LIHR: 0.3%; OIHR: 0.5%, p = 0.007), less utilization of pain medication (LIHR: 23.3%; OIHR: 28.5%; p < 0.001), and fewer outpatient visits. In the 90-day postoperative period, LIHR had significantly fewer missed work hours (LIHR: 12.1 ± 23.2 h; OIHR: 12.9 ± 26.7 h, p = 0.023). LIHR had higher postoperative urinary complications (LIHR: 0.2%; OIHR: 0.1%; p < 0.001), consistent with the current literature. LIHR expenditures ($15,030 ± $25,906) were higher than OIHR ($13,303 ± 32,014), p < 0.001. CONCLUSIONS: The results highlight the benefits of laparoscopic repair with regard to surgical wound complications, postoperative pain, outpatient visits, and missed work hours. These improved outcomes with respect to overall healthcare spending and employee absenteeism support the paradigm shift toward laparoscopic inguinal hernia repairs, in spite of higher overall expenditures.

Non-invasive Motor Cortex Neuromodulation Reduces Secondary Hyperalgesia and Enhances Activation of the Descending Pain Modulatory Network.

Central sensitization is a driving mechanism in many chronic pain patients, and manifests as hyperalgesia and allodynia beyond any apparent injury. Recent studies have demonstrated analgesic effects of motor cortex (M1) stimulation in several chronic pain disorders, yet its neural mechanisms remain uncertain. We evaluated whether anodal M1 transcranial direct current stimulation (tDCS) would mitigate central sensitization as measured by indices of secondary hyperalgesia. We used a capsaicin-heat pain model to elicit secondary mechanical hyperalgesia in 27 healthy subjects. In an assessor and subject-blind randomized, sham-controlled, crossover trial, anodal M1 tDCS decreased the intensity of pinprick hyperalgesia more than cathodal or sham tDCS. To elucidate the mechanism driving analgesia, subjects underwent fMRI of painful mechanical stimuli prior to and following induction of the pain model, after receiving M1 tDCS. We hypothesized that anodal M1 tDCS would enhance engagement of a descending pain modulatory (DPM) network in response to mechanical stimuli. Anodal tDCS normalized the effects of central sensitization on neurophysiological responses to mechanical pain in the medial prefrontal cortex, pregenual anterior cingulate cortex, and periaqueductal gray, important regions in the DPM network. Taken together, these results provide support for the hypothesis that anodal M1-tDCS reduces central sensitization-induced hyperalgesia through the DPM network in humans.

Qualifications and Characteristics North American Dental Deans Seek in Department Chairpersons.

The aim of this study was to determine whether deans of North American dental schools perceived that one category of department chairperson skills (leadership or management) was more important than the other for their chairpersons to be successful. A secondary purpose was to determine the professional qualifications and personal characteristics these deans perceived contributed most to the success of department chairpersons and whether those differed by the research emphasis of the school. An email survey was sent in 2016 to all 75 deans of U.S. and Canadian dental schools with graduating classes. Section one of the survey was an open response section asking deans to list the five most essential characteristics of a successful department chairperson. Section two asked deans to rank the importance of eight listed professional qualifications, and the last section asked deans to rate the importance of four leadership and four management traits that could contribute to the success of their chairpersons. Questions about characteristics of the deans and the schools were also included. A response rate of 46.7% was obtained. The most frequent characteristics listed in the open response section were in the categories of vision, academic expertise, and integrity. The three most highly ranked professional qualifications were previous teaching experience, previous administrative experience, and history of external research funding. Four of the eight professional qualifications were ranked differently by deans of high compared to moderate research-intensive schools (p<0.05). Overall, the respondents rated leadership skills more highly than management skills (p=0.002) as important for departmental chairpersons.

Outcome of 980 nm diode laser vaporization for benign prostatic hyperplasia: A prospective study.

Purpose: To evaluate the initial experience and outcome of photo-selective vaporization of the prostate (PVP) for benign prostatic hyperplasia (BPH) in Pakistan with the use of a 980 nm diode laser. Materials and Methods: A prospective study was performed from November 2016 to December 2017. A total of 100 patients diagnosed with bladder outlet obstruction secondary to BPH who planned for PVP were enrolled in the study. PVP was carried out with a diode laser at 980 nm (Biolitec Diode 180W laser) in a continuous wave with a 600 nm (twister) fiber. Baseline characteristics and perioperative data were compared. Postoperative outcomes were evaluated by International Prostate Symptom Score (IPSS), post void residual (PVR) and maximum urinary flow rate (Qmax) at 3 and 6 months after surgery. Results: The mean age was 65.82±10.42, mean prostate size was 67.35±16.42, operative time was 55.85±18.01 and total energy was 198.68±49.12 kJ. At 3 months and 6 months, significant improvements were noted (p<0.001) in IPSS 7.04±1.69 (-18.92), Qmax 19.22±4.75 mL/s (+13.09) and and PVR 18.89±5.39 mL (-112.80). Most frequent problems were burning micturition (35%) and terminal dysuria (29%). No significant difference in postoperative hemoglobin was seen in patients who were on anti-platelet drugs. Conclusions: PVP with a diode laser is a safe and effective procedure for the treatment of BPH and is also safe in patients who are on anti-platelet agents.

Postoperative Pain Score of Bupivacaine versus Placebo in Patients Undergoing Percutaneous Nephrolithotomy.

OBJECTIVE: To compare postoperative mean pain score of bupivacaine versus placebo in patients undergoing percutaneous nephrolithotomy. STUDY DESIGN: An experimental study. PLACE AND DURATION OF STUDY: Department of Urology, The Kidney Centre, Postgraduate Training Institute (PGTI), Karachi, from November 2014 to December 2015. METHODOLOGY: A total of 94 patients who underwent standard percutaneous nephrolithotomy, clinically diagnosed renal stone by CT scan, KUB, X-ray or ultrasound were included in the study. Patients were randomly divided into two groups. Forty-seven patients in group A were treated with 20ml/50mg of 0.25% bupivacaine; and 47 patients in group B were treated with normal saline. Postoperatively, visual analog score was used to assess the pain at 6, 12 and 24 hours. Data was analysed using SPSS version 20.0 and student t-test was applied for comparison between the groups. RESULTS: The average age of the patients was 37.23 ±11.31 years. Mean pain score in 24 hours was low in group A as compared to group B (5.22 ±0.76 vs. 7.85 ±0.78; p<0.001). CONCLUSION: Bupivacaine infiltration into the nephrostomy tract is a highly effective and safe in postoperative pain management for patients undergoing standard PCNL.

Predictive Factors for Intraoperative Blood Loss during Percutaneous Nephrolithotomy.

OBJECTIVE: To evaluate the factors that may increase bleeding during Percutaneous nephrolithotomy (PCNL) and correlate them with outcome. STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: The Kidney Centre postgraduate Training Institute, Karachi, Pakistan, from July to December 2016. METHODOLOGY: Consecutive patients who underwent PCNL from July to December 2016 were prospectively enrolled. Drop in hemoglobin was divided into three groups: mild <1 gm/dl, moderate 1-2 gm/dl and major >2 gm/dl. Factors such as age, gender, comorbidities, body mass index (BMI), operative time, creatinine levels, renal cortical thickness, stone size, its characteristics and location, puncture type and site, and need for blood transfusion were assessed by Chi-square/ Fisher exact test and Kruskal Wallis test. Predictive factors were assessed by multinomial logistic-regression analyses. RESULTS: Total 305 patients were enrolled in the study. Median age was 37 (27.5-49.1) years with predominantly males (n=217, 71.8%). Median BMI was 27.3 (24.6-31.4) Kg/m2 and mean stone size was 2.7 (2.1-3.4) cm. Two hundred and ninety-seven (97.7%) stones were radio-opaque. Operative time was 95 (60-127) minutes. There were 50.8% patients who had moderate drop in hemoglobin (1-2 gm/dl). Stone size, BMI and operative time were strongly associated with significant drop in hemoglobin. Complete stone clearance was achieved in 256 (84%) patients. Thirty (9.8%) patients needed blood transfusion. None of the patients required angioembolisation. CONCLUSION: BMI, stone size, and operative time were strongly associated with intraoperative blood loss during PCNL.

Awareness of risk factors and fallacies associated with urinary bladder cancer in our population: A prospective survey.

OBJECTIVE: To determine the awareness of risk factors for bladder cancer and false beliefs associated with this disease. METHODS: This cross-sectional study was conducted at the Kidney Centre, Karachi, from January to February 2015, and comprised subjects who presented to the various in-house clinics. The subjects were interviewed using a questionnaire comprising demographic parameters, level of education and awareness of smoking hazards, knowledge and false beliefs associated with bladder cancer. A pilot study was performed prior to the main study and the questionnaire was redesigned accordingly. SPSS 20 was used for data analysis. RESULTS: Of the 1,000 respondents, 593(59.3%) were males and 407(40.7%) were females. Moreover, 229(22.9%) respondents were aware of the association between smoking and bladder cancer compared to 858(85.8%) who knew that there is an association between smoking and lung cancer. Besides, 479(47.9%) respondents said that smoking caused tuberculosis. Patients with a higher level of education were statistically more likely to be aware of the association between smoking and bladder cancer, i.e. 91(9.1%) uneducated, 208(20.8%) primary, 182(18.2%) secondary, 222(22.2%) intermediate and 352(35.2%) graduates (p=0.0001). Most common fallacy associated with bladder cancer was low intake of water 504(50.4%), followed by multiple sexual partners 362(36.2%). CONCLUSIONS: Most patients were unaware of the relationship between bladder cancer and tobacco smoking.

Greater palatine nerve neuropraxia after laryngeal mask insertion: A rare occurrence.

With the more frequent use of the laryngeal mask airway (LMA) over endotracheal tubes for general anaesthesia, various cranial nerve injuries have been reported recently. We report a rare occurrence of greater palatine nerve (GPN) palsy subsequent to the use of LMA Supreme™ in a young female scheduled for hand surgery. Although the exact mechanism of a nerve injury is still a matter of further research, we postulate pressure neuropraxia of GPN as a causative factor in the development of numbness over the hard palate after the removal of LMA in the post operative period.

Protocol for a single-centre, randomised controlled study of a preoperative rehabilitation bundle in the frail and elderly undergoing abdominal surgery.

INTRODUCTION: Frail patients have decreased physiological reserves and consequently, they are unable to recover as quickly from surgery. Frailty, as an entity, is a risk factor of increased morbidity and mortality. It is also associated with a longer time to discharge. This trial is undertaken to determine if a novel prehabilitation protocol (10-day bundle of interventions-physiotherapy, nutritional supplementation and cognitive training) can reduce the postoperative length of stay of frail patients who are undergoing elective abdominal surgery, compared with standard care. METHODS AND ANALYSIS: This is a prospective, single-centre, randomised controlled trial with two parallel arms. 62 patients who are frail and undergoing elective abdominal surgery will be recruited and randomised to receive either a novel prehabilitation protocol or standard care. Participants will receive telephone reminders preoperatively to encourage protocol compliance. Data will be collected for up to 30 days postoperatively. The primary outcome of the trial will be the postoperative length of stay and the secondary outcomes are the postoperative complications and functional recovery during the hospital admission. ETHICS AND DISSEMINATION: This study has been approved by the Singapore General Hospital Institutional Review Board (CIRB Ref: 2016/2584). The study is also listed on ClinicalTrials.gov (Trial number: NCT02921932). All participants will sign an informed consent form before randomisation and translators will be made available to non-English speaking patients. The results of this study will be published in peer-reviewed journals as well as national and international conferences. The data collected will also be made available in a public data repository. TRIAL REGISTRATION NUMBER: NCT02921932 (ClinicalTrials.gov).

High Frequency Migraine Is Associated with Lower Acute Pain Sensitivity and Abnormal Insula Activity Related to Migraine Pain Intensity, Attack Frequency, and Pain Catastrophizing.

Migraine is a pain disorder associated with abnormal brain structure and function, yet the effect of migraine on acute pain processing remains unclear. It also remains unclear whether altered pain-related brain responses and related structural changes are associated with clinical migraine characteristics. Using fMRI and three levels of thermal stimuli (non-painful, mildly painful, and moderately painful), we compared whole-brain activity between 14 migraine patients and 14 matched controls. Although, there were no significant differences in pain thresholds nor in pre-scan pain ratings to mildly painful thermal stimuli, patients did have aberrant suprathreshold nociceptive processing. Brain imaging showed that, compared to controls, patients had reduced activity in pain modulatory regions including left dorsolateral prefrontal, posterior parietal, and middle temporal cortices and, at a lower-threshold, greater activation in the right mid-insula to moderate pain vs. mild pain. We also found that pain-related activity in the insula was associated with clinical variables in patients, including associations between: bilateral anterior insula and pain catastrophizing (PCS); bilateral anterior insula and contralateral posterior insula and migraine pain intensity; and bilateral posterior insula and migraine frequency at a lower-threshold. PCS and migraine pain intensity were also negatively associated with activity in midline regions including posterior cingulate and medial prefrontal cortices. Diffusion tensor imaging revealed a negative correlation between fractional anisotropy (a measure of white matter integrity; FA) and migraine duration in the right mid-insula and a positive correlation between left mid-insula FA and PCS. In sum, while patients showed lower sensitivity to acute noxious stimuli, the neuroimaging findings suggest enhanced nociceptive processing and significantly disrupted modulatory networks, particularly involving the insula, associated with indices of disease severity in migraine.