Toxic Epidermal Necrolysis After COVID-19 Vaccination: A Case Report and Review of Literature.

Following vaccination for COVID-19, various cutaneous adverse reactions (CARs) are reported. Here is an Asian male in late 50's who developed necrotic skin with mucosal involvement 10 days following booster dose of ChAdOx1 nCov-19 vaccination. Based on disease course and morphology, toxic epidermal necrolysis (TEN) was suspected. The patient developed respiratory distress and was intubated, intravenous immunoglobulin (IVIG) administered at 2 g/kg body weight following which skin lesions healed in fourth week, the patient was discharged after 50 days of intensive care unit (ICU) stay. Severe CARs are rare following vaccination, of two components in ChAdOx1nCoV-19 adenoviral vector vaccine, virotopes cause T-cell mediated granulysin and granzyme B release leading to epidermal detachment and mucosal involvement of conducting airways causing respiratory failure. CARs can also occur in whom first and second dose was uneventful. Supportive therapy and prevention of sepsis are mainstay of management. Though the use of IVIG has shown conflicting results, our case was successfully managed with IVIG.

Analgesic efficacy of stellate ganglion block in head and neck cancer pain: A case series.

Patients with head and neck cancer (HNC) have ongoing pain but Stellate ganglion block which is a sympatholytic block may be a viable therapy for treating it. The data were retrospectively collected from five histopathologically confirmed HNC patients who had completed chemotherapy and radiation doses. Stellate ganglion block was given to these patients and was subsequently monitored for 3 months to assess pain alleviation and overall satisfaction. Over a 3-month period, there was a decrease in the pain levels with a better quality of life so the stellate ganglion block can be a promising modality for reducing the pain of HNC.

Postoperative Delayed Facial Nerve Palsy: A Surgeon's Nightmare.

The facial nerve supplies motor, sensory, and parasympathetic innervation to the head and neck, and its paralysis can have significant physical and psychological impacts. This study discusses a compelling case involving a 21-year-old male who developed delayed facial nerve palsy (DFNP) on the eighth day after cortical mastoid surgery. Through conservative management, the patient achieved a full recovery by the 52nd day. Our experience underscores the importance of approaching DFNP with patience, emphasizing the need for thorough counseling of both the patient and their family members.

Comparison between perfusion index, pleth variability index, and pulse pressure variability for prediction of hypotension during major abdominal surgery under general anaesthesia: A prospective observational study.

Background and Aims: Short-term hypotension after general anaesthesia can negatively impact surgical outcomes. This study compared the predictive potential of the pleth variability index (PVI), pulse pressure variability (PPV), and perfusion index (PI) for anaesthesia-induced hypotension. This study's primary objective was to evaluate the predictive potential of PI, PVI, and PPV for hypotension. Methods: This observational study included 140 adult patients undergoing major abdominal surgery under general anaesthesia. Mean arterial pressure, heart rate, PVI, PPV, and PI were collected at 1-min intervals up to 20 min post anaesthesia induction. Hypotension was assessed at 5-min and 15-min intervals. Receiver operating characteristic (ROC) curves were plotted to determine the diagnostic performance and best cut-off for continuous variables in predicting a dichotomous outcome. Statistical significance was kept at P < 0.05. Results: Hypotension prevalence within 5 and 15 min of anaesthesia induction was 36.4% and 45%, respectively. A PI cut-off of <3.5 had an area under the ROC curve (AUROC) of 0.647 (P = 0.004) for a 5-min hypotension prediction. The PVI's AUROC was 0.717 (P = 0.001) at cut-off >11.5, while PPV's AUROC was 0.742 (P = 0.001) at cut-off >12.5. At 15 min, PVI's AUROC was 0.615 (95% confidence interval 0.521-0.708, P = 0.020), with 54.9% positive predictive value and 65.2% negative predictive value. Conclusion: PVI, PPV, and PI predicted hypotension within 5 min after general anaesthesia induction. PVI had comparatively higher accuracy, sensitivity, specificity, and positive predictive value than PI and PPV when predicting hypotension at 15 min.

Effect of Enhanced Recovery after Surgery (ERAS) protocol on maternal outcomes following emergency caesarean delivery: A randomized controlled trial.

Background: With ever increasing rates of emergency caesarean deliveries (CD),incorporating the ERAS protocol might provide a perfect window of opportunity to increase maternal comfort during the postsurgical period, but also improve outcomes and facilitate optimal return of physiological function. Objective: To determine whether an ERAS pathway at emergency caesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction. Material & methods: Patients undergoing emergent caesarean delivery at ≥ 34 weeks of gestation were randomized to ERAS or conventional care. The primary outcome was to compare postoperative length of hospital stay. Secondary outcome variables included first oral intake, passage of flatus/defecation, first ambulation, first urination after catheter removal and postoperative pain scores in both groups. Results: We randomized 142 women (71 each in ERAS versus Conventional arm) undergoing emergency cesarean delivery. Incorporation of ERAS protocol resulted in shorter length of hospital stay (73.92 ± 8.96 in conventional arm vs 53.87 ± 15.02 in ERAS arm; p value <.0001). Significant difference was seen in visual analogue scoring during initial ambulation and rest on day 0 and day 1 between ERAS and conventional arms with mean scores being lower in ERAS arm compared to Conventional arm (p value <.05). In terms of quality of life, ERAS arm had better quality of life compared to conventional arm. Conclusion: Incorporation of ERAS protocol in emergency caesarean definitely improves patient outcome in terms of early resumption of activities with better quality of life.

The role and expression of pro/antiangiogenic factors and microRNAs in gestational hypertension and pre-eclampsia.

OBJECTIVE: Pre-eclampsia and gestational hypertension are two common hypertensive disorders of pregnancy with pre-eclampsia accounting for high foetal and maternal morbidity and mortality rate. These disorders have an unknown aetiology and their hypertensive and end-organ pathophysiology may present too late in pregnancy. This makes the identification of early detection and differentiation markers vital. MicroRNAs have strongly been associated with pregnancy and their imbalance has been associated with the angiogenic dysregulation seen in pre-eclampsia. This study assesses the expression of pro- and antiangiogenic factors and their corresponding microRNAs in the maternal circulation of patients with pre-eclampsia and gestational hypertension. STUDY DESIGN: We analyzed angiogenic factors expression (sEng, TGF-ß, VEGF) normalized against housekeeping gene ß-actin and microRNAs (miRs: 210, 29B, 126) normalized against miR U6, potentially associated with pre-eclampsia and gestational hypertension using the targeted qPCR technique. These analytes were examined from early-onset (<34 weeks) (EOPE) (n = 12), late-onset (>34 weeks) (LOPE) (n = 12) pre-eclampsia, gestational hypertension (GH) (n = 12) and two gestationally matched normotensive groups (NG1 and 2) (n = 12) each in South African women of African ancestry. Group comparisons of experimental vs. control groups were assessed using t-test analysis for significance and represented as fold change expression. RESULTS: The relative expression in group comparisons showed significant (p < 0.05) fold change of VEGF, TGF-ß, sEng and miR126 in the EOPE vs. NG1. The GH vs. NG1 exhibited significant changes in VEGF, TGF-ß, miR126, miR210 and miR29B. The LOPE vs. NG2 showed significant relative expression in all the angiogenic factors (VEGF, TGF-ß and sEng). The GH vs. NG2 showed significant expression in VEGF and miR29B. The LOPE vs. EOPE showed significant fold changes in VEGF and miR210. Finally, only the GH vs. EOPE showed significant differences in miR210 and miR29B (p < 0.05). CONCLUSION: This study provides better insights into angiogenic factors and microRNAs specificity to the subtypes of gestational hypertensive disorders in pregnancy. Relative expression analysis of angiogenic factors and microRNAs showed possible novel characteristics of gestational hypertension, and potential common molecular and pathological profiles with pre-eclampsia. Furthermore, we postulate that sEng and miR29B could be early detection markers for pre-eclampsia and gestational hypertension, respectively.

Elucidating the structural and functional prophecy of the Rv2326c gene, an ABC transporter of Mycobacterium tuberculosis H37Rv through computational approach.

Tuberculosis is a fatal disease caused by Mycobacterium tuberculosis. M. tuberculosis becoming drug-resistant day by day, necessitating to know the mechanism behind the drug resistance and how to overcome this deadly malady. Drug resistance and reduced drug bioavailability are caused by a class of transporter proteins called the ATP-binding cassette (ABC) transporters, which pump a range of medicines out of cells at the price of ATP hydrolysis. By using computational approaches, we tried to elaborate the probable function of the Rv2326c gene of M. tuberculosis, perhaps involved in drug resistance mechanism. The presence of the signature motif of ABC transporters (LSGGELQRLALAAAL and LSGGQMRRVVLAGLL) and ATP binding motif (GXXXXGKT and GXXXXGKS) in the protein sequence signifying its importance in the ATP binding and transportation of molecules. Further, this manuscript elaborated about tertiary structure and validation, functional category, localization, phosphorylation site prediction, mutational analysis of conserved motifs. Ligand docking study shows the highest affinity with ATP than GTP justified its function as an ATP binding protein. The Rv2326c protein is present in the inner membrane and working as an ATP binding protein and might be playing a dynamic role in transportation. In this study, we found that Rv2326c protein might be working as an ABC transporter by which the drugs and other molecules are imported or exported into the bacterium. As a result, the current study provides a means to better understand its normal functioning and basic biology, which can help in the development of novel therapeutic targeting approaches for Rv2326c protein.

Spatiotemporal variability and health risk assessment of PM2.5 and NO2 over the Indo-Gangetic Plain: A three years long study (2019-21).

Studying the spatiotemporal variability of pollutants is necessary to identify the pollution hotspots with high health risk and enable the agencies to implement pollution abatement strategies in a targeted manner. Present study reports the spatio-temporal variability and health risk assessment (HRA) of PM2.5 (Particulate matter with aerodynamic diameter <2.5µm) and NO2 over IGP from 2019-2021. The HRA is expressed as passively smoked cigarettes (PSC) for four different health outcomes i.e., low birth weight (LBW), percentage decreased lung function (DLF) in school aged children, lung cancer (LC), and cardiovascular mortality (CM). The findings confirm very high PM2.5 and NO2 mass concentrations and high health risk over middle IGP and Delhi as compared to upper and lower IGP. Within Delhi, north Delhi region is the most polluted and at highest risk as compared to central and south Delhi. The health risk associated with PM2.5 over IGP is highest for DLF, equivalent to 21.63 PSCs daily, followed by CM (11.69), LBW (8.27) and LC (6.94). For NO2, the health risk is highest for DLF (3.09 PSCs) and CM (2.95), followed by LC (1.47) and LBW (1.04). PM2.5 and NO2 concentrations, along with the associated health risks, are highest during the post-monsoon and winter seasons and lowest during the monsoon season.

Anesthetic Management of Pregnant Patient With Undiagnosed Neurofibromatosis for Emergency Cesarean Section.

Neurofibromatosis type I is a genetic autosomal dominant disorder with multisystem involvement and is particularly challenging for the anesthesiologist in emergency surgery. The presence of neurofibromas can cause airway difficulty, make delivery of gases difficult, and blood pressure variations during general anesthesia. Regional anesthesia becomes challenging due to the presence of spinal and intracranial tumors, and in undiagnosed situations, it becomes tricky. This is a case report of anesthesia management in a pregnant patient with undiagnosed neurofibromatosis for an emergency cesarean section.

Design and Molecular Docking Studies of N-Mannich Base Derivatives of Primaquine Bearing Isatin on the Targets involved in the Pathophysiology of Cerebral Malaria.

BACKGROUND: Malaria is considered one of the life-threatening mosquito-borne infectious diseases responsible for approximately more than 4,00,000 deaths every year all over the world. Plasmodium falciparum and Plasmodium vivax are widespread species, but infections caused by the former are of great concern. OBJECTIVE: Among the various forms of infections associated with Plasmodium falciparum, cerebral malaria (CM) is the most severe neurological complication, accounting for almost 13% of all malariarelated mortality. The development of effective therapeutics is urgently needed to overcome the fatality of this dreadful disease. METHODS: The present work attempted to design and virtually screen a chemical library of 75 molecules (N-Mannich base derivatives of primaquine bearing isatin moiety as heterocyclic) by molecular docking studies against anti-malarial target proteins-Cystein Protease Falcipain-2; Dipeptidyl Aminopeptidase- 1; Dipeptidyl Aminopeptidase-3 and Glycogen synthase Kinase-3ß receptors, for evaluating their anti-malarial potential. Among all studied anti-malarial target receptors, the designed molecules showed an overall higher affinity for Dipeptidyl Aminopeptidase-3. Furthermore, the molecules were analyzed for binding affinity and drug-like properties using Lipinski rules, and 30 best hits were shortlisted and analyzed for the pharmacokinetic profile. RESULTS: Two of these hits were found to be more toxic than primaquine, hence were omitted in further analysis. Later, these 28 hits were docked against two target proteins, (a) Plasmodium falciparum erythrocyte membrane protein-1 and (b) Intracellular adhesion molecule-1, to determine their efficiency against cerebral malaria, and the results were recorded. Analysis of docking results led to the identification of the 8 studied molecules as lead molecules which were selected for chemical synthesis, in vivo studies, and further preclinical evaluation. CONCLUSION: The molecule DSR 11 was predicted as the most appropriate lead molecule for anti-CM activity in the present investigation apart from the other seven molecules (DSR4, DSR26, DSR38, DSR40, DSR49, DSR56, and DSR70).

Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study.

BACKGROUND: Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. METHODS: Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg-1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. RESULTS: Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p = 0.55). CONCLUSION: This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Effect of intraoperative alveolar recruitment maneuver on intraoperative oxygenation and postoperative pulmonary function tests in patients undergoing robotic-assisted hysterectomy: a single-blind randomized study

Abstract Background Robotic-Assisted Hysterectomies (RAH) require Trendelenburg positioning and pneumoperitoneum, which further accentuate alteration in respiratory mechanics induced by general anesthesia. The role of Recruitment Maneuver (RM) as a lung-protective strategy during intraoperative surgical settings has not been much studied. We planned this study to evaluate the effect of RM on perioperative oxygenation and postoperative spirometry using PaO2/FiO2 and FEV1/FVC, respectively in patients undergoing RAH. Methods Sixty-six ASA I‒II female patients scheduled for elective RAH were randomized into group R (recruitment maneuver, n = 33) or group C (control, n = 33). Portable spirometry was done one day before surgery. Patients were induced with general anesthesia, and mechanical ventilation started with volume control mode, with Tidal Volume (TV) of 6-8 mL.kg−1, Respiratory Rate (RR) of 12 min, inspiratory-expiratory ratio (I: E ratio) of 1:2, FiO2 of 0.4, and Positive End-Expiratory Pressure (PEEP) of 5 cmH2O. Patients in group R received recruitment maneuvers of 30 cmH2O every 30 minutes following tracheal intubation. The primary objectives were comparison of oxygenation and ventilation between two groups intraoperatively and portable spirometry postoperatively. Postoperative pulmonary complications, like desaturation, pulmonary edema, pneumonia, were monitored. Results Patients who received RM had significantly higher PaO2 (mmHg) (203.2+-24.3 vs. 167.8+-27.3, p < 0.001) at T2 (30 min after the pneumoperitoneum). However, there was no significant difference in portable spirometry between the groups in the postoperative period (FVC, 1.40 ± 0.5 L vs. 1.32 ± 0.46 L, p= 0.55). Conclusion This study concluded that intraoperative recruitment did not prevent deterioration of postoperative spirometry values; however, it led to improved oxygenation intraoperatively.

Impact of general or regional anaesthesia on recurrence of colorectal cancer after surgery: Systematic review.

Background and Aims: Studies have suggested that anaesthetic agents have modulatory effects on the immune system, leading to cancer recurrence. The association between colorectal cancer (CRC) recurrence and anaesthesia is still unclear. Therefore, this systematic review aimed to determine the association between the recurrence of CRC after surgery and anaesthesia. Methods: A database search of PubMed, Cochrane, Embase, and Scopus was performed for articles on the recurrence of CRC after surgeries under general anaesthesia (GA) and regional anaesthesia (RA), published between January 2002 and January 2023. Qualitative and risk-of-bias assessment of retrospective studies was performed using the Newcastle-Ottawa scale (NOS). Synthesis Without Meta-analysis guidelines were used to report data synthesis. The primary outcome was cancer recurrence, and the secondary outcomes were disease-free survival (DFS) and overall survival. The standardised metric to represent data synthesis was the median hazard ratio (HR). Evidence quality was rated as per GRADE pro-GDT. Results: A total of six retrospective cohorts were identified through the literature search for inclusion. The risk of bias was low in all studies and was rated good quality as per the NOS. The pooled risk ratio for cancer recurrence in the two studies was 1.04, 95% confidence interval 0.98-1.10 (P = 0.20). The median HR for cancer recurrence was 0.895. DFS was not statistically significant with GA or RA, with a median HR of 1.06. Conclusion: No conclusive association was found between regional anaesthesia and colorectal cancer recurrence. However, due to a lack of studies reporting cancer recurrence and less data for comparison and different intervention groups, a conclusive association cannot be made.

Efficacy of splanchnic nerve neurolysis in the management of upper abdominal cancer pain: A systematic review and meta-analysis.

Background and Aims: Neurolytic splanchnic nerve block (NSNB) is practised in intractable abdominal pain secondary to intra-abdominal malignancies. This review evaluated the efficacy of NSNB. Methods: PubMed, Embase, Scopus, and Cochrane databases were searched for articles published from January 2001 to October 2023. Two independent reviewers extracted the data from the included studies. The quality of randomised controlled trials (RCTs) was assessed using the revised Cochrane risk-of-bias tool (RoB 2), and the Newcastle-Ottawa scale was used for cohort studies. Results: Fourteen articles (4 RCTs, 3 non-randomised prospective, and 7 retrospectives) were included. Ten articles were quantitatively assessed and demonstrated significant pain relief at 1 week (standardised mean difference (SMD): 3.46 [2.09, 4.83], P < 0.001, I2 = 95%), 2 weeks (SMD: 4.45 [2.61, 6.29], P < 0.001, I2 = 95%), 4 weeks (SMD: 3.35 [2.23, 4.47], P < 0.001, I2 = 97%), 8 weeks (SMD: 3.7 [2.71, 4.7], P < 0.001, I2 = 86%), 12 weeks (SMD: 4.01 [2.66, 5.36], P < 0.001, I2 = 95%), and 24 weeks (SMD: 2.54 [1.71,3.37], P < 0.001, I2 = 84%). Daily narcotic consumption and quality of life (QOL) significantly improved post neurolysis, but survival rates showed controversial results. Significant heterogeneity was reported, and sub-group analysis revealed a moderate level of variability [I2 = 47.3%] pertaining to study design as a source of heterogeneity. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Pro GDT recommendation for the primary objective was 'high' for the analysis of RCTs and 'very low' evidence quality for observational studies. Only transient minor complications were reported. Conclusion: NSNB appears to be an efficacious technique that provides substantial pain relief, reduces opioid consumption, and ameliorates QOL.

Efficacy of cryoneurolysis in the management of chronic non-cancer pain: A systematic review and meta-analysis.

Background and Aims: Cryoneurolysis, a neuroablative technique, is used in the event of failure of conservative treatment in chronic pain conditions. To date, no systematic review has been published to demonstrate its effectiveness in managing chronic non-cancer pain. Therefore, this review was done to ascertain the efficacy of cryoneurolysis and describe its role in chronic non-cancer pain management. Methods: We searched PubMed, Cochrane, Embase, Scopus, and Google Scholar databases for articles published between January 2011 and September 2021. Two independent reviewers extracted the data from the included studies. Assessment of risk of bias of included randomised controlled trials (RCTs) was done using RevMan 5.4.1 software and Newcastle-Ottawa scale was used for non-randomised studies. Results: Ten studies enroling a total of 425 patients were included in the qualitative analysis. Eight studies were assessed quantitatively. RCTs were found only for cervicogenic headache and knee osteoarthritis management. The rest of the included studies were prospective non-controlled and retrospective studies. A significant pain reduction was seen at seven-day [Standardised Mean Difference (SMD) 1.77 (1.07, 2.46)], P < 0.00001, I2 = 79%), one-month (SMD 3.26 [2.60, 3.92], P < 0.00001, I2 = 45%), three-month (SMD 2.58 [1.46, 3.70], P < 0.00001, I2 = 93%), six-month (SMD 2.38 [0.97, 3.79], P = 0.001, I2 = 86%) follow-ups. Improved disability and no serious complications were noted. Conclusion: Cryoneurolysis appeared to be effective in pain alleviation in refractory painful conditions for up to six months. It is safe and well-tolerated with an excellent safety profile but the quality of evidence is limited by substantial heterogeneity between trials. Therefore, more comparative clinical trials on a larger sample size are needed to provide more concrete evidence.

An observational study of pro- and anti-angiogenic factors in hypertensive disorders of pregnancy in women of African ancestry.

Hypertensive disorders in pregnancy (HDPs) are the leading cause of maternal and perinatal deaths worldwide. Despite the widely reported multisystemic pathophysiology of pre-eclampsia and other HDPs, it is unknown whether these disorders represent a continuum or separate entities making clinical diagnosis a challenge. This study aimed to investigate angiogenic, metabolic and immunoregulatory specific profiles of hypertensive and gestationally matched normotensive pregnancies. A total of 200 pregnancies from a regional hospital in South Africa, via convenience sampling, were quantitatively analysed for circulating sFlt-1; PlGF; VEGF; sENG; PAPP-A; PP13; ADAMTS 12; TGF-ß1 in maternal serum samples using ELISA technique. Serum protein markers TGF-ß1, sENG and PAPP-A were significantly increased (p < .05) in early-onset pre-eclampsia vs. NG1 groups. sFlt-1 was significantly higher in late-onset pre-eclampsia vs NG2 groups. The GH group showed a significant increase in TGF-ß1 and PAPP-A vs. NG1 counterpart. ADAMTS12 and sENG were significantly lower in gestational hypertension vs. early-onset pre-eclampsia. No significant differences were seen in PlGF, VEGF and PP13 levels across the groups. These changes show the HDP spectrum has distinct characteristics on the angiogenic profile. Based on these results, further validation of diagnostic and prognostic biomarkers of pre-eclampsia and gestational hypertension is warranted.Impact statementWhat is already known on this subject? Hypertensive pregnancy disorders are a public health problem with adverse effects on both mother and neonate. The elusive pathogenesis of this syndrome combined with the late prevalence of symptoms leaves clinicians with a myriad of theories and indefinite treatments. The investigation into conventional anti-/angiogenic factors has been extensively studied in pre-eclampsia patients only. The overlapping clinical presentation of pre-eclampsia and gestational hypertension further complicates the diagnosis of disorders.What do the results of this study add? The investigation of novel angiogenic, metabolic and inflammatory markers will firstly contribute to generating a database for researchers both nationally and internationally. This combinatory triad of markers will assist in elucidating and differentiating between early- and late-onset preeclampsia versus gestational hypertension. The results of our cohort study suggest possible early diagnostic markers for pre-eclampsia and gestational hypertension.What are the implications of these findings for clinical practice and/or further research? Research in this area will contribute to an improvement in early disease management which will ultimately lead to a reduction in health care costs and mortality rate locally and globally. It will also enforce diagnostic and prognostic markers for hypertensive pregnancy diseases and warrant further investigation into the proteins primarily involved in the trophoblastic invasion. This will then clarify whether these two closely related hypertensive disorders represent a continuum or two separate entities.

Estimation of Expenditure and Challenges Related to Rehabilitation After Knee Arthroplasty: A Hospital-Based Cross-Sectional Study.

BACKGROUND: Expenditure for rehabilitation following knee arthroplasty for osteoarthritis- and rehabilitation-related challenges following discharge to home after surgery is not available in the Indian context. OBJECTIVES: To estimate cost of rehabilitation and document challenges in following rehabilitation advices, from a patient perspective. METHODS: We conducted a hospital-based cross-sectional study of patients visiting the orthopedic department at a tertiary care public-funded hospital in New Delhi and included those who recently (less than 4 months) underwent primary knee arthroplasty for osteoarthritis. A trained physiotherapist not involved in clinical care collected information on expenditures incurred after discharge from hospital, patient's ability to recall the advices given by the physician and challenges they experienced using a semi-structured questionnaire. We report median costs by category of direct and indirect cost and used linear regression to explore determinants of cost. RESULTS: We interviewed 82 consecutive patients (mean age 60.8 years and 68% females) with median time since surgery of 28 days. More than half (52%) sought some support for physiotherapy. The median cost of rehabilitation was INR 18,395 (Interquartile-range 11,325-27,775). Direct medical cost contributed to 74% of total cost (32% fee for services, 21% medications and lab investigations, 21% assistive devices). Twenty percent higher costs were incurred among those undergoing bilateral knee surgery after adjusting for age, sex, income, and type of physiotherapy support sought. Challenges were related to recall of advices, not understanding the recovery process and pain management. CONCLUSION: About half patients undergoing knee arthroplasty seek support for rehabilitation after discharge to home contributing to a major portion of expenses incurred during rehabilitation. Cost-effective support mechanism for home-based rehabilitation is required for improving patient rehabilitation experiences. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00405-6.

Anaesthesia for Awake Fiberoptic Intubation: Ultrasound-Guided Airway Nerve Block versus Ultrasonic Nebulisation with Lignocaine.

BACKGROUND: In anticipated difficult airway, awake fiberoptic guided intubation should be the ideal plan of management. It requires sufficient upper airway anesthesia for patient's comfort and cooperation. We compared the efficacy of ultrasound guided airway nerve blocks and ultrasonic nebulisation with lignocaine for airway anesthesia before performing awake fibreoptic guided intubation. METHODS: This prospective, randomised study included sixty consenting adult patients of both genders (American Society of Anesthesiologists' physical status 1-3) with anticipated difficult airway undergoing surgery. Ultrasound guided airway nerve blocks group received ultrasound-guided bilateral superior laryngeal (1 ml of 2% lignocaine) and transtracheal recurrent laryngeal (2 ml of 2% lignocaine) airway nerve blocks and ultrasonic nebulisation with lignocaine group received ultrasonic nebulisation of 4 ml of lignocaine 4%. The primary outcome was to compare the time required to intubate, whereas the secondary outcomes were to compare cough reflex and gag reflex, hemodynamic changes, number of attempts required, and  comfort score during awake fibreoptic guided intubation in both the groups. RESULTS: The time taken for intubation was significantly lower in the ultrasound guided airway nerve blocks group 69.27±21.85 s than ultrasonic nebulisation with lignocaine group 92.43 ± 42.90 s (p = 0.015). Hemodynamic variables changed during the procedure but the values were comparable in both groups. There were no statistical differences in cough and gag reflexes, number of attempts, and comfort score in both groups. CONCLUSIONS: This study shows that significant lesser time required for performing awake fiberoptic intubation when patient received ultrasound guided airway nerve block in comparison to ultrasonic nebulisation for airway anaesthesia.

Complete mitogenome of Ganges river dolphin, Platanista gangetica gangetica and its phylogenetic relationship with other cetaceans.

The Ganges river dolphin, Platanista gangetica gangetica is one of the endangered cetaceans. Due to increasing anthropogenic activities, it has faced a significant reduction in distribution range since the late 1800s and has even gone extinct from most of the early localities. The investigation of complete mitogenome holds significant relevance for identifying evolutionary relationships and monitoring the endangered species. Herein, we report and characterize for the first time the 16,319 bp complete mitochondrial genome of P. g. gangetica. It comprises 13 protein-coding genes, 22 transfer RNA (tRNA) genes, two ribosomal RNA genes, and one control region (CR). The genome composition was A + T biased (59.6%) and exhibited a positive AT-skew (0.104) and negative GC-skew (- 0.384). All the genes were encoded on the heavy strand, except eight tRNAs and the ND6 gene. In the CR, an 18 bp tandem repeat sequence was observed. Our Bayesian Inference (BI) and Maximum Likelihood (ML) based phylogenetic analysis indicated that studied river dolphins were polyphyletic and the placement of Platanista was to be more basal than other river dolphins (Lipotes, Inia and Pontoporia). The pairwise genetic distance of Platanista with other cetaceans was varied, with an overall close affinity with whales. The model-based BI and ML phylogenetic analysis indicated that Platanista clustering with Ziphiidae with high to moderate supportive values (PP/BP = 98/68). The results of this study provide insights important for the conservation genetics and further evolutionary studies of the freshwater river dolphins.