Expert panel recommendations for topical hemostatic agent use in varied bleeding sites and situations during neuro-spine surgeries.

Intraoperative bleeding poses a substantial challenge, particularly in neuro-spine surgeries leading to complications such as hematomas, infections, and hemodynamic instability. Despite their proven efficacy, use of topical hemostatic agents (THAs) lacks comprehensive published literature and guidelines particularly in the Indian setting. The present study provides the first-ever Indian expert panel recommendations for effective adjunct THA use in different intraoperative bleeding sites and situations in neuro-spine surgeries. A comprehensive approach, encompassing a literature review, followed by experience sharing in a meeting using a survey helped integrate expert opinions in the form of practical algorithms to guide THA selection. Our survey results revealed a strong inclination towards specific THAs, flowable gelatin + thrombin being choice of THA for difficult to access and problematic bleeding situations during tumor removal/resection, transsphenoidal hypophysectomy and skull-based procedures. Both oxidized regenerated cellulose (ORC)/Fibrillar and flowable gelatin + thrombin were recommended for continuous oozing. ORC/Fibrillar was preferred for arteriovenous and cavernous malformations. This expert-panel guidance on THA use aims to optimize hemostat use practices and improve surgical outcomes in neuro-spine surgery.

Rehabilitation medicine in palliative care of chronic neurological conditions.

BACKGROUND: People living with long-term neurological conditions (LTNC) often require palliative care. Rehabilitation medicine specialists often coordinate the long-term care of these patients. OBJECTIVE: The aim of the present review was to undertake systematic literature searches to identify the evidence on palliative care for people with LTNC to guide rehabilitation medicine specialists caring for these patients in the UK. METHODS: We searched for evidence for (1) discussion of end of life, (2) planning for end-of-life care, (3) brief specialist palliative care interventions, (4) support for family and carers, (5) training of rehabilitation medicine specialists in palliative care, and (6) commissioning of services. The databases searched were MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database and Health Technology Assessment Database. Evidence was assimilated using a simplified version of the Grading of Recommendations Assessment, Development and Evaluation method. RESULTS: We identified 2961 records through database searching for neurological conditions and 1261 additional records through database searches for specific symptoms. We removed duplicate records and conference presentations. We screened 3234 titles and identified 330 potentially relevant abstracts. After reading the abstracts we selected 34 studies for inclusion in the evidence synthesis. CONCLUSIONS: From the evidence reviewed we would like to recommend that we move forward by establishing a closer working relationship with specialists in palliative care and rehabilitation medicine and explore the implications for cross-specialty training.

An atypical bilateral trifurcation of recurrent laryngeal nerve.

BACKGROUND: Thyroidectomy is a frequently performed surgery for benign and malignant conditions. Nevertheless, one of the most critical complications of thyroidectomy is recurrent laryngeal nerve (RLN) injury leading to vocal cord paralysis. A thorough knowledge of the anatomical variations of RLN and ligation of the related vessels close to their distal branches is critical to avoid injury. CASE PRESENTATION: Here, we report the first case of bilateral trifurcation of recurrent laryngeal nerve (RLN) in a 40-year old woman with multinodular goitre. Total thyroidectomy was performed and RLN was preserved bilaterally. Followed by a precise dissection, fine branches were traced penetrating the larynx. We did not observe any further post-operative complications and patient was discharged with desired outcomes. CONCLUSIONS: Anatomical variations of the RLN include-bifurcations, trifurcations, relation of RLN with inferior thyroid artery (ITA) and presence of non-recurrent laryngeal nerve. Only RLN dividing at a distance greater than 5 mm (branching point distance) before its entry into the larynx beneath the cricothyroid are said to bifurcate or trifurcate. Approximately 25% of nerves show branching [71%-unilateral and 18%-bilateral bifurcation]. Incidence of unilateral trifurcations have been noted be 0.9% and the rates of bilateral trifurcation and the divisions of the branches is yet to be ascertained. This is the first report of a bilateral trifurcation of RLN, detected in patient with multinodular goitre and hence warrants a precise analysis of variations of the RLN in patients undergoing thyroidectomy, which is critical to prevent RLN injury.

Interactive effect of elevated tropospheric ozone and carbon dioxide on radiation utilisation, growth and yield of chickpea (Cicer arietinum L.).

An experiment was conducted in the Free Air Ozone and Carbon dioxide Enrichment (FAOCE) facility to study the impact of elevated O3, CO2 and their interaction on chickpea crop (cv. Pusa-5023) in terms of phenology, biophysical parameters, yield components, radiation interception and use efficiency. The crop was exposed to elevated O3 (EO:60ppb), CO2 (EC:550 ppm) and their combined interactive treatment (ECO: EC+EO) during the entire growing season. Results revealed that the crop's total growth period was shortened by 10, 14 and 17 days under elevated CO2, elevated O3 and the combined treatment, respectively. Compared to ambient condition, the leaf area index (LAI) under elevated CO2 was higher by 4 to 28%, whilst it is reduced by 7.3 to 23.8% under elevated O3. The yield based radiation use efficiency (RUEy) was highest under elevated CO2 (0.48 g MJ-1), followed by combined (0.41 g MJ-1), ambient (0.38 g MJ-1) and elevated O3 (0.32 g MJ-1) treatments. Elevated O3 decreased RUEy by 15.78% over ambient, and the interaction results in a 7.8% higher RUEy. The yield was 31.7% more under elevated CO2 and 21.9% lower in elevated O3 treatment as compared to the ambient. The combined interactive treatment recorded a higher yield as compared to ambient by 9.7%. Harvest index (HI) was lowest under elevated O3 (36.10%), followed by ambient (39.18%), combined (40.81%), and highest was under elevated CO2 (44.18%). Chickpea showed a positive response to elevated CO2 resulting a 5% increase in HI as compared to ambient condition. Our findings quantified the positive and negative impacts of elevated O3, CO2 and their interaction on chickpea and revealed that the negative impacts of elevated O3 can be compensated by elevated CO2 in chickpea. This work promotes the understanding of crop behaviour under elevated O3, CO2 and their interaction, which can be used as valuable inputs for radiation-based crop simulation models to simulate climate change impact on chickpea crop.

IVORY Guidelines (Instructional Videos in Otorhinolaryngology by YO-IFOS): A Consensus on Surgical Videos in Ear, Nose, and Throat.

OBJECTIVES/HYPOTHESIS: Otolaryngology instructional videos available online are often of poor quality. The objective of this article was to establish international consensus recommendations for the production of educational surgical videos in otolaryngology. STUDY DESIGN: DELPHI survey. METHODS: Twenty-seven international respondents participated in this study from 12 countries. Consensus was reached after three rounds of questionnaires following the Delphi methodology. The proposals having reached the 80% agreement threshold in the third round were retained. RESULTS: The main recommendations are as follows: 1) Ethics: patients must be anonymized and unrecognizable (apart from plastic surgery if necessary). A signed authorization must be obtained if the person is recognizable. 2) Technical aspects: videos should be edited and in high-definition (HD) quality if possible. Narration or subtitles and didactic illustrations are recommended. 3) Case presentation: name of pathology and procedure must be specified; the case should be presented with relevant workup. 4) Surgery: surgical procedures should be divided into several distinct stages and include tips and pitfalls. Pathology should be shown if relevant. Key points should be detailed at the end of the procedure. 5) Organ-specific: type of approach and bilateral audiometry should be specified in otology. Coronal plane computed tomography scans should be shown in endonasal surgery. It is recommended to show pre- and postoperative videos in voice surgery and preoperative drawings and photos of scars in plastic surgery, as well as the ventilation method in airway surgery. CONCLUSIONS: International recommendations have been determined to assist in the creation and standardization of educational surgical videos in otolaryngology and head and neck surgery. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E732-E737, 2021.

Long-term postnatal outcome of fetuses with prenatally suspected septo-optic dysplasia.

OBJECTIVES: Septo-optic dysplasia (SOD) is a clinical syndrome characterized by varying combinations of optic nerve hypoplasia, pituitary gland hypoplasia and abnormal cavum septi pellucidi. It is suspected on prenatal imaging when there is non-visualization or hypoplasia of the septal leaflets. Long-term postnatal outcomes of fetuses with prenatally suspected SOD have been documented poorly. The aims of this study were to describe the natural history of deficient septal leaflets, to quantify the incidence of postnatally confirmed SOD and to document the visual, endocrine and long-term neurodevelopmental outcomes of these infants. METHODS: This was an observational retrospective study of all fetuses with prenatal imaging showing isolated septal agenesis, assessed at a single tertiary center over an 11-year period. Pregnancy, delivery and neonatal outcomes and pre- and postnatal imaging findings were reviewed. Neonatal evaluations or fetal autopsy reports were assessed for confirmation of SOD. Ophthalmologic, endocrine, genetic and long-term developmental evaluations were assessed. Imaging findings and outcome were compared between infants with and those without postnatally confirmed SOD. RESULTS: Of 214 fetuses presenting with septal absence on prenatal ultrasound and magnetic resonance imaging (MRI), 18 (8.4%) were classified as having suspected isolated septal agenesis suspicious for SOD. Uniform prenatal MRI findings in cases with suspected SOD included remnants of the leaflets of the cavum septi pellucidi, fused forniceal columns, normal olfactory bulbs and tracts and a normal optic chiasm. Twelve fetuses were liveborn and five (27.8%) had postnatally confirmed SOD. Only two of these five fetuses had additional prenatal imaging features (pituitary cyst, microphthalmia and optic nerve hypoplasia) supporting a diagnosis of SOD. The other three confirmed SOD cases had no predictive prenatal or postnatal imaging findings that reliably differentiated them from cases without confirmed SOD. Visual and endocrine impairments were present in two (40%) and four (80%) cases with confirmed SOD, respectively. In those with visual and/or endocrine impairment, developmental delay (median age at follow-up, 2.5 (interquartile range, 2.5-7.0) years) was common (80%) and mostly severe. Neonates with isolated septal agenesis and a lack of visual or endocrine abnormalities to confirm SOD had normal development. CONCLUSIONS: Only a quarter of fetuses with isolated septal agenesis suggestive of SOD will have postnatal confirmation of the diagnosis. Clinical manifestations of SOD are variable, but neurodevelopmental delay may be more prevalent than thought formerly. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Human leukocyte antigen (HLA) class II association in chronic hepatitis B patients with hepatocellular carcinoma in a Malay population: A pilot study.

Asian countries account for almost three quarter of hepatocellular carcinoma (HCC) reported globally and chronic hepatitis B infection is one of the main contributors. Clinical observations show that Malay patients with chronic hepatitis B and HCC tend to have a worse outcome, when compared to other two major races in Malaysia. The objectives of this study was to determine the frequency of human leukocyte antigen (HLA) class II alleles in chronic hepatitis B patients with HCC among Malays compared to the general population to identify potential associations of HLA alleles with this disease. HLA class II typing was performed in chronic hepatitis B patients with hepatocellular carcinoma (n=12) by -polymerase chain reaction, sequence specific primer (PCR-SSP) method. There were higher allelic frequencies of certain HLA-DQB1 and HLA-DRB1 alleles; HLA-DQB1*03 (07) (41.7%), and HLA-DRB1*12 (41.7% vs 28.6%) and compared to controls (41.7% vs 29.7%). However, there was no significant statistical correlation found when compared with the normal healthy general population. This study provides an insight into the HLA Class II association with chronic hepatitis B and hepatocellular carcinoma in Malays. However, findings from this study should be validated with a larger number of samples using a high resolution HLA typing.

Viscoelastic effects on residual oil distribution in flows through pillared microchannels.

HYPOTHESIS: Multiphase flow through porous media is important in a number of industrial, natural and biological processes. One application is enhanced oil recovery (EOR), where a resident oil phase is displaced by a Newtonian or polymeric fluid. In EOR, the two-phase immiscible displacement through heterogonous porous media is usually governed by competing viscous and capillary forces, expressed through a Capillary number Ca, and viscosity ratio of the displacing and displaced fluid. However, when viscoelastic displacement fluids are used, elastic forces in the displacement fluid also become significant. It is hypothesized that elastic instabilities are responsible for enhanced oil recovery through an elastic microsweep mechanism. EXPERIMENTS: In this work, we use a simplified geometry in the form of a pillared microchannel. We analyze the trapped residual oil size distribution after displacement by a Newtonian fluid, a nearly inelastic shear thinning fluid, and viscoelastic polymers and surfactant solutions. FINDINGS: We find that viscoelastic polymers and surfactant solutions can displace more oil compared to Newtonian fluids and nearly inelastic shear thinning polymers at similar Ca numbers. Beyond a critical Ca number, the size of residual oil blobs decreases significantly for viscoelastic fluids. This critical Ca number directly corresponds to flow rates where elastic instabilities occur in single phase flow, suggesting a close link between enhancement of oil recovery and appearance of elastic instabilities.

A rational approach to the management of obstructive sleep apnea syndrome.

Snoring & obstructive sleep apnea syndrome (OSAS) is a globally prevalent problem which is on the rise in recent times. The treatment modalities include medical appliances and surgery. It is mandatory to have a rational approach in the management of OSAS, by meticulously analyzing both anatomical and physiological parameters causing the disorder. To define a rational approach for the management of OSAS, by devising a comprehensive protocol with assessment of anatomical level of obstruction by dynamic MRI and physiological factors by Epworth sleepiness scale (ESS) and Polysomnography. A prospective study in 110 patients was conducted over a period of 2 years, at our institute. All patients in the study group were evaluated with dynamic MRI and ESS and Polysomnography. As per the management protocols defined in the study, surgery was advocated in 46 patients (Group 1) with severe compromise in airway, while another group of 64 patients (Group 2) were provided continuous positive airway pressure support (CPAP). Successful outcomes among these 110 patients were analyzed at the end of the study period. A few patients required multimodal therapy which included surgery and CPAP support. Among 46 patients, surgical treatment proved successful in 41 patients in whom AHI reduced from 46.96 to 12.88 (improved by 62%) and ESS improved by almost ten points. Among 64 patients in CPAP group, AHI reduced from 54.2 to 11.3 (improved by 79%) and ESS improved by 11 points in all the patients, but six of them had poor compliance. Five patients among the surgical group had persistence of symptoms. Inferences derived from the above results proved the success of formulating a rational approach in the management of OSAS. Critical analysis of the anatomical and physiological factors inducing obstructive episodes and an appropriate treatment plan is vital, to produce successful outcomes in patients with OSAS. Failure of surgical procedures, are often due to improper case selection. A small group of patients may require multimodal therapy with surgery and CPAP.

Endolymphatic Sac Tumour: A Neoplastic Cause for Meniere's Syndrome.

Patients with intractable vertigo often present a diagnostic dilemma to the treating physician. A wide spectrum of diseases, ranging from those of the labyrinth onto the central nervous system, may present predominantly with vertigo. In some cases, it requires the clinical acumen of an experienced neuro-otologist, to decipher these vertiginous symptoms and arrive at a definitive diagnosis. Meniere's syndrome is one such phenomenon, where the endolymphatic hydrops may be attributable to varied aetiology. We report a case of sporadic (non-syndromic) Endolymphatic Sac Tumor which presented to us, mimicking a classical Meniere's syndrome. We discuss its clinical presentation, diagnostic modalities, operative technique and histo-pathological features. The case is reported along with a review of the world literature on this tumor, highlighting the diagnostic and management protocols advocated for this rare entity. Endolymphatic sac tumor is a rare entity which may masquerade as a classical case of Meniere's syndrome, wherein the triad of symptoms (as in endolymphatic hydrops) may not be alleviated by the usual treatment protocols. Tracing the aetiology of these symptoms, remains the most crucial factor in treating such patients.

Rectal lipoma associated with genital prolapse.

Lipomas are the tumors of mature lipocytes with its occurrence most often on the torso, neck, upper thighs, upper arms, and armpits, but they can occur almost anywhere in the body. They are the rare tumors of intestine, more frequently located in large intestine compared to small intestine. We present the case of a 58-year-old post-menopausal lady presenting with rectal bleeding and utero-vaginal prolapse. The prolapsing mass was excised, and histopathological examination diagnosed the lesion to be a lipoma.

Prevalence of helicobacter pylori infection among patients undergoing upper gastrointestinal endoscopy in a medical college hospital in kerala, India.

BACKGROUND: Helicobacter pylori related gastritis is a major health ailment in developing nations. There is high morbidity and mortality ranging from chronic gastritis to gastric malignancies. Prevalence of H. pylori infection varies markedly from country to country and in a country, region to region. AIM: To study the prevalence of H. pylori gastritis in patients undergoing endoscopy and its association with the development of gastrointestinal diseases. SUBJECTS AND METHODS: The study was carried out in a Medical College Hospital in Kerala, India. Patients presenting with dyspeptic symptoms were subjected to upper gastrointestinal endoscopy and investigated for H. pylori infection through histopathological examination and rapid urease test of biopsy specimen. Diagnosis of H. pylori infection was made if one or both diagnostic test results were positive. Data analysis was carried out using the statistical package for social sciences, for Windows version 16.0 (SPSS 16; Chicago, IL, USA). RESULTS: H. pylori infection was diagnosed in 62.0% (329/530) of patients screened. There was no statistically significant difference in sex and age related distribution (<50 year age group and >50 year age group) of H. pylori infection. However, a statistically significant association of H. pylori infection with the presence of endoscopic abnormalities, peptic ulcer, and dysplasia/cancer was seen. CONCLUSION: The prevalence of H. pylori infection is significantly high in rural and suburban population of Ernakulam district, Kerala. Early detection and prompt treatment are essential for prevention of serious complications.

Prevalence of sleep abnormalities and their association among hypothyroid patients in an Indian population.

OBJECTIVE: To estimate the prevalence of sleep abnormalities and their association with hypothyroidism and metabolic risk factors in a relatively lean urban South Indian population. METHODS: This population-based, cross-sectional study was carried out in the urban population of Chennai, one of the largest metropolitan cities of India. Phase 1 was conducted in the field and involved a door-to-door survey of 26,000 individuals. In phase 2, every tenth subject recruited in phase 1 (n=2600) was invited to our centre for detailed anthropometric and biochemical measurements. For the current study, a subset of 358 subjects with positive family history of hypothyroidism was randomly selected. A validated questionnaire assessing various sleep abnormalities (snoring, daytime sleepiness, lack of refreshing sleep and number of hours of sleep) was administered. Anthropometric and biochemical measurements were obtained to assess metabolic risk factors including thyroid status. RESULTS: Snorers were more often male, older, smokers and had higher BMI, neck circumference, blood pressures, and hypothyroidism. Out of 358 patients, 133 had impaired thyroid function (37.1%) and 64 patients had both snoring and impaired thyroid function (17.8%). Subjects with daytime sleepiness had higher BMI and neck obesity. The overall prevalence of snoring and daytime sleepiness was 52% and 64%, respectively. Both sleep measures were associated with hypothyroid status. Metabolic syndrome was significantly associated with snoring even after adjusting for age, sex, family history of hypothyroidism, physical activity, smoking and alcohol. CONCLUSIONS: The prevalence of snoring and daytime sleepiness is high among urban South Indians who are relatively lean. Both disorders are associated with hypothyroidism, although these associations were stronger in those with obesity. Based on our case prevalence and the other reports cited previously, we can reasonably conclude that thyroid screening of sleep clinic patients is essential.

Morphological and functional correlates in Goldmann-Favre syndrome: a case series.

The purpose of this study is to describe the correlation of findings between results from spectral domain optical coherence tomography (SD-OCT) and microperimetry in a case series regarding patients with Goldmann-Favre syndrome. Goldmann-Favre syndrome is a rare autosomal recessive hereditary vitreo-retinal degeneration that impacts the functionality of vision in subjects. Three men with this condition were assessed and subjected to microperimetry and SD-OCT. Two of the men were brothers. This study finds that the retinoschisis and macular cystoid changes noted in the SD-OCT matched the scotomas revealed by the microperimetry. The findings of each of the individual cases are reported herein.

Suprapubic percutaneous sclero-embolization of symptomatic female pelvic varicocele under local anesthesia.

PURPOSE: To evaluate the safety and feasibility of supra-pubic percutaneous sclero-embolization (SE) in the treatment of symptomatic female pelvic varicocele (FPV), performed under local anesthesia. MATERIALS AND METHODS: The authors selected 28 patients screened by transabdominal and transvaginal ultrasound, with venous Doppler signal. Clinicians performed SE by transfemoral catheterization, under local anesthesia, using of a mix of 2 ml of lauromacrogol 400 (Atossisclerol 3%, Chemische F. Kreussler, Wiesbaden, Germany) and 2 ml of air, in a mixed foam fashion. RESULTS: The total operative time for SE was 7.6 +/- 2.1 min. Intra-surgical blood loss was 40 +/- 14 ml. No migration of sclerosant material occurred and postoperative analgesic request during a 48 hr period occurred in 6 patients. Technical success was 100%. The Authors embolized 8 women bilaterally (28.5%), 18 on the left ovarian vein (OV) (64.2%) and 2 only in the right OV (7.1%): 7 women complained of transitory flank pain (25%), which disappeared in few minutes. The major complications in 10 days after SE were: fever (> 38 degrees C for two days) in 2 patients (7.1%) and pelvic pain for 3 days in eight patients (28.5%). After 30 days only 6 women suffered of FPV lower symptoms which disappeared in 180 days. A substantial reduction in size of pelvic varicosities was noted in all patients. CONCLUSIONS: SE is a safe and feasible procedure. It reduces significantly the mean time of scopies, the intensity of radiation emission, and it is performed under local anaesthesia. This minimally invasive procedure could be proposed to all women with supra-pubic FPV for its reproducibility and feasibility.

Magnet migration in a cochlear implantee - a serendipitous diagnosis.

The successful outcome of a cochlear implant habilitation program depends upon a multitude of vital factors, including the avid cooperation of the cochlear implantee, committed participation of the parents/family members and total dedication of the habilitation team of implant audiologists and auditory verbal therapists. In a rare situation, where the implantee's performance is suboptimal or poor inspite of successful implantation, anxious moments engulf the parents and the implant team, with the morbid fear of a device failure lingering at the back of their minds. We report such an incident in a 13-year-old cochlear implantee, who was an excellent cochlear implant performer for 8 years, following which she had rapid deterioration of her auditory verbal skills within the next few weeks. The hidden etiology, was the inconspicuous migration of the internal magnet of the Receiver-Stimulator Coil placed in the mastoid temporal bone of her skull, due to unexplained reasons. We share our experience with the diagnosis and management of this condition and review the existing world literature on this rarely reported entity.

Totally implantable hearing aid surgical technique and the first Indian experience with Envoy esteem.

Hearing aids are the principal means of auditory rehabilitation for patients with moderate to severe sensorineural hearing loss. Although technical improvements and modifications have improved the fidelity of conventional aids, hearing aids still have many limitations. Implantable hearing aids offer patients with hearing loss several potential advantages over conventional hearing aids. This presentation will highlight our first experience, the indications, the procedure, the advantages and the current status of totally implantable hearing aids.

Melioidosis.

Melioidosis is an emerging infectious disease in India acquired through percutaneous inoculation or contaminated water. Known risk factors include diabetes mellitus, renal failure, cirrhosis, and malignancy. Melioidosis presents with a febrile illness, with protean manifestations ranging from septicemia to localized abscess formation. We present the case of a 42-year-old male from a non-endemic region who presented with fever of 2 months duration, sepsis, persistent pneumonia, right hip joint pain and hepatic and splenic abscesses. Aspiration of the joint and soft tissue fluid collection and subsequent culture yielded gram negative bacilli identified as Burkholderia pseudomallei. The epidemiology, clinical features, and laboratory diagnosis of this rare infection and its treatment is reviewed.