The dopant (n- and p-type)-, band gap-, size- and stress-dependent field electron emission of silicon nanowires.

This study investigates the electron field emission (EFE) of vertical silicon nanowires (Si NWs) fabricated on n-type Si (100) and p-type Si (100) substrates using catalyst-induced etching (CIE). The impact of dopant types (n- and p-types), optical energy gap, crystallite size and stress on EFE parameters has been explored in detail. The surface morphology of grown SiNWs has been characterized by field emission scanning electron microscopy (FESEM), showing vertical, well aligned SiNWs. Optical absorption and Raman spectroscopy confirmed the presence of the quantum confinement (QC) effect. The EFE performance of the grown nanowire arrays has been examined through recorded J-E measurements under the Fowler-Nordheim framework. The Si NWs grown on p-type Si showed a minimum turn-on field and also a higher field enhancement factor. The band-bending diagram also suggests a lower barrier height of p-type Si NWs compared to n-type Si NWs, which plays a key role in enhancing the EFE performance. These investigations suggest that dopant types (n- and p-types), band gap, crystallite size and stress influence the EFE parameters and Si NWs grown on p-type Si (100) substrates are much more favorable for the investigation of EFE properties.

Detection of clinically relevant carbapenemase encoding genes in carbapenem-resistant Enterobacter cloacae complex and Klebsiella pneumoniae isolated from farmed freshwater fish.

AIMS: The present study was aimed to detect clinically relevant carbapenemase encoding genes in carbapenem-resistant Enterobacter cloacae complex (CR-ECC), Klebsiella pneumoniae (CR-KP), and Serratia plymuthica (CR-SP) isolated from farmed freshwater fish. METHODS AND RESULTS: Out of 243 spatially diverse freshwater fish samples analysed, 5.3% were contaminated with CR-ECC, 1.6% with CR-KP, and 0.4% with CR-SP. The CR-ECC was further identified as E. asburiae (38.5%), E. mori (23.1%), E. cloacae (15.4%), E. hormaechei (15.4%), and E. kobei (7.7%) by 16S rRNA gene sequencing. The CR-ECC were resistant to carbapenems and cefoxitin, whereas CR-KP and CR-SP were multi-drug resistant (MDR). The CR-ECC harboured the carbapenemase gene blaIMI alone or in combination with blaTEM, blaEBC, blaCIT, blaACC, and tet(E). Whereas, CR-KP harboured carbapenemase gene, blaNDM-5 along with blaOXA-48, blaSHV, blaOXA-1, blaCTX-M-15, tet(A), sul1, and qnrB. No carbapenemase-encoding genes were detected in CR-SP. The MLST analysis showed that CR-KP belonged to ST231 and ST1561 lineages, while CR-ECC did not show exact match with any reported STs. The plasmid replicons predominantly detected were IncF and IncI1. Broth mating assays of CR-KP and CR-ECC with recipient Escherichia coli J53 indicated that blaNDM-5 was transferable but not blaIMI. CONCLUSION: This study highlights the low-level contamination of carbapenem-resistant Enterobacterales (CRE) harbouring clinically relevant carbapenemase-encoding genes in farmed freshwater fish from India. The CR-ECC of fish origin did not show the potential to spread carbapenem resistance.

Antibacterial activity of palmarosa oil significantly varies between Aeromonas veronii and Aeromonas caviae and exhibits selective action on tetracycline and sulfonamide resistant A. caviae.

AIMS: To investigate the antibacterial activity of three (palmarosa, basil and rosemary) essential oils (EOs) on Aeromonas veronii and Aeromonas caviae, and determine minimum inhibitory concentration (MIC) of potent EO against tetracycline and sulfonamide resistant strains. METHODS AND RESULTS: Palmarosa oil (PMO) showed significantly (p < 0.05) higher inhibition zones against both A. veronii and A. caviae (n = 30) than basil and rosemary in the disk diffusion assay. The MIC (% v/v) of PMO ranged from 0.008% to 1.00%. The mean MIC was significantly higher for A. caviae (0.48 ± 0.24%) than A. veronii (0.21 ± 0.15%). Further, the MIC of PMO was compared in six groups: Group 1: Tetracycline Resistant A. veronii (TRV); Group 2: Tetracycline Resistant A. caviae (TRC); Group 3: Sulfonamide Resistant A. veronii (SRV); Group 4: Sulfonamide Resistant A. caviae (SRC); Group 5: Susceptible A. veronii (SV) and Group 6: Susceptible A. caviae (SC). No significant differences were observed between overall resistant (TRV+ SRV) and susceptible A. veronii (SV). However, in A. caviae, the resistant group had a lower MIC than the susceptible group. Moreover, the MIC was significantly lower for TRC (0.31 ± 0.11%) as compared to SRC (0.46 ± 0.10%). The time of kill of PMO for both the species of Aeromonas was 20-30 min. CONCLUSION: Palmarosa oil exhibited significantly higher activity on A. veronii than A. caviae. The resistant strains of A. caviae were inhibited at a lower concentration than susceptible strains. SIGNIFICANCE AND IMPACT OF THE STUDY: Palmarosa oil could be explored as an alternative antimicrobial agent for mitigating antimicrobial resistance and managing Aeromonas infection in fish and their risks to public health.

Effect of spatio-temporal variables, host fish species and on-farm biosecurity measures on the prevalence of potentially pathogenic Aeromonas species in freshwater fish farms.

AIMS: To determine the prevalence of Aeromonas species in freshwater fish farms, factors affecting their prevalence and virulence factors associated with each species. METHODS AND RESULTS: In a cross-sectional study from 128 farms in four districts of Uttar Pradesh, India, 11 species of Aeromonas were identified by gyrB sequencing including the first report of Aeromonas crassostreae from fish. Four species of Aeromonas were more prevalent (MP) in fish farms, A. veronii bv. sobria (50.0%) was the highest, followed by A. caviae (18.8%), A. veronii bv. veronii (11.7%) and A. dhakensis (7.0%). The less prevalent (LP) species were A. hydrophila, A. media, A. jandaei, A. allosaccharophila, A. salmonicida, A. crassostreae and A. taiwanensis. Spatial variation in the prevalence of Aeromonas species was observed. Dominance of biovar sobria ranged from 33.3 to 68.6%, notably lesser in farms with on-farm biosecurity measures. The prevalence of biovar veronii was significantly associated with pangas fish, rainy season and farms with on-farm biosecurity measures. The prevalence of LP species was significantly higher in mrigal fish and winter season. Multiple virulence factors (>6) were detected in 70.2% of the Aeromonas species. Significant association of ß-hemolysin, DNase, slime production, act, ahh1, aexT and lip was observed with different species of Aeromonas. Moreover, 75.8% of Aeromonas species possessed one or more enterotoxins genes (act/alt/ast). CONCLUSION: Significant association of spatio-temporal variables, host fish species and on-farm biosecurity measures were observed on the prevalence of some of the Aeromonas species in freshwater fish farms. Most of the Aeromonas species harboured virulence factors indicating their potential for pathogenicity. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first study that determined the prevalence and identified the factors that affect the prevalence of Aeromonas species in freshwater fish farms. This information will be useful in managing Aeromonas infection in fish and their risks to public health.

Besdata Video Laryngeal Mask (BD-VLM)- a New Vision-Incorporated 3rd Generation Video Laryngeal Mask Airway : Dear editor.

Since the recent editorial 2, we were approached to evaluate another video laryngeal mask airway - the Besdata Video Laryngeal Mask (BD-VLM) TM, which has a different design concept, specifications and characteristics (Figure 1) compared to the other two.

Features of new vision-incorporated third-generation video laryngeal mask airways.

Numerous studies have shown that blindly inserted supraglottic airway devices (SADs) are sub-optimally placed in 50 to 80% of all cases. Placement under direct vision has been recommended. We describe the very first two new SADs of the third generation that incorporate a videoscope with flexible tip. Both devices are made up of two interlocking components-the SAD and a videoscope. The 3rd generation, direct vision SADs allow vision-guided insertion, corrective manoeuvres, if needed, and correct placement in the hypopharynx and possess additional features which permit insertion of a gastric tube and endotracheal intubation should the need arise. This article describes the two new devices' physical characteristics, features, rationale for use, advantages and limitations in comparison to existing devices. Each of the two new devices-the Video Laryngeal Mask (VLMTM, UE Medical®) and the SafeLM® Video Laryngeal Mask System (SafeLMTM VLMS, Magill Medical Technology®) consist of two parts: (a) a disposable 2nd generation SAD with a silicone cuff and an anatomically curved tube; and (b) a reusable patient-isolated videoscope and monitoring screen, with the flexible scope located into a specially-designed, blind-end channel terminating in the bowl of the SAD, preventing the videoscope from contacting patient body fluids in the SAD bowl. Third generation placement-under-direct-vision supraglottic airway devices possess several theoretical safety and ease of use advantages which now need to be validated in clinical use.

Current Attitudes and Beliefs in Interdisciplinary Return to Play Management for Pediatric Concussion: A Survey.

CONTEXT: The pediatric population is more susceptible to sustaining concussion and experiencing more severe and prolonged symptoms as compared with adults. Current evidence indicates conflicting beliefs within the interdisciplinary team in terms of best practices for managing pediatric concussion. OBJECTIVES: (1) To describe current practices on interdisciplinary coordination among physical therapists (PTs) and athletic trainers (ATs) during management and return to play (RTP) of children and adolescents with concussion and (2) to describe their confidence in implementing RTP protocols, their comprehension of concussion legislation, and scope of practice of their profession regarding returning pediatric athletes to sport postconcussion. DESIGN AND METHODS: A 34-item anonymous survey containing questions regarding demographics, confidence with concussion management, knowledge of sports-related concussion state legislation, beliefs of interdisciplinary concussion management team, and referral/communication patterns was electronically distributed through alumni networks. PARTICIPANTS: 141 respondents (80 ATs and 61 PTs). RESULTS: Only 12.5% of ATs believed that PTs had any role in the initial concussion management, whereas 65% of PTs regarded the role of ATs in initial management as important. In terms of legislation, 44% of PTs and 12.5% of ATs were unsure of state laws pertaining to concussion management or health care professions responsible for RTP. There was consensus among PTs and ATs (61%) in the lack of interdisciplinary coordination of care and lack of awareness among physician groups regarding RTP protocols. Within their respective disciplines, a greater proportion of PTs (63%) agreed that the process of care lacked standardization as compared with ATs (21%). CONCLUSION: Lack of interdisciplinary communication and collaboration during management of pediatric concussion may cause premature RTP that may lead to catastrophic effects on the developing pediatric brain. Barriers regarding education, time management, knowledge of state laws, and understanding other professions' scope of practice need to be further addressed to ensure safe RTP.

Incidence of Enteric Fever in a Pediatric Cohort in North India: Comparison with Estimates from 20 Years Earlier.

BACKGROUND: An earlier cohort in 1995-1996 showed a very high burden of typhoid in Delhi. Our aim was to estimate the current overall and age-specific incidence of culture-confirmed enteric fever among children aged 6 months to 15 years in Delhi. METHODS: We enrolled a cohort of 6000 children aged 6 months to <14 years in South Delhi and followed them up weekly for 24 months or until 15 completed years of child age, whichever was earlier. Blood culture to confirm enteric fever was done in children with ≥3 consecutive days of fever. RESULTS: We recorded a total of 14 650 episodes of fever in the 11 510 person-years (PY) of follow-up. A total of 81 fever episodes were positive for enteric fever. The incidence (95% confidence interval) of all enteric fever was 703.7 (560.5-874.7) per 100 000 PY. The incidences of typhoid and paratyphoid fevers were 608.1 (95% confidence interval, 481.1-768.7) and 111.7 (59.5-191.1) per 100 000 PY, respectively, highest among children aged 10-15 years. CONCLUSIONS: Despite a 35% reduction in incidence compared with the 1995-1996 cohort, our study suggested a substantial burden of enteric fever in the population. Continued efforts to improve water, sanitation, and hygiene parameters along with implementation of novel vaccination strategies and disease surveillance can help achieve the goal of disease elimination.

Stress-The hidden pandemic for school children and adolescents in India during COVID-19 era.

The effects of coronavirus are not just physical but also psychological in all age groups and more so common among children. Some children may have had experience of quarantine restrictions during this COVID-19 pandemic. Due to increased digital connections 'emotional contagion' where the distress and fear experienced by one spread to another person may also be common in children. The present study aims to determine whether COVID-19 pandemic and the lockdown has caused stress and affected mental health of children and youth. The current study assessed stress in children and youth between 9 and 18 years age based on Short Self-Rating Questionnaire (SSRQ) during the COVID-19 pandemic. The study design was an observational study,  a descriptive cross-sectional study using online survey. Total 369 schools children participated in the survey. Score Scale and analysis was done to categorize the stress levels as Low, Moderate and Severe. Data analysis based on the total score levels (Delhi+Mathura zone, n=369) showed 30.08% (n=111) students with Low stress level, 62.87% (n=232) within Moderate stress level and 7.08% (n=26) with severe stress level. Students T Test revealed that there was a significant difference (p≤0.04) of the stress level male vs. female in total (Delhi + Mathura zone combined). However, the stress level was not significantly different between Delhi and Mathura zone alone. It is utmost to give primary importance to address the stress issues in children and adoloscents in the current scenario. Inclusion of Intervention strategies that are empirically supported and culturally appropriate as per the need of the communities for children and families may be helpful. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12144-022-02827-3.

Association of Obstructive Sleep Apnea With Difficult Intubation: Prospective Multicenter Observational Cohort Study.

BACKGROUND: Obstructive sleep apnea (OSA) has been found to be associated with difficult airway, although there is a paucity of prospective studies investigating thresholds of OSA severity with difficult airway outcomes. The aim of this study was to examine the association between OSA and difficult intubation or difficult mask ventilation. We also explored the utility of the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-Bang) score for difficult airway prediction. METHODS: The Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) trial was an international prospective cohort study of surgical patients 45 years or older with one or more cardiac risk factor presenting for noncardiac surgery, with planned secondary analyses of difficult airway outcomes. Multivariable logistic regression analyses tested associations between OSA severity and predictors of difficult airway with difficult intubation or difficult mask ventilation. Overall, 869 patients without prior diagnosis of OSA were screened for OSA risk with the STOP-Bang tool, underwent preoperative sleep study, and had routine perioperative care, including general anesthesia with tracheal intubation. The primary outcome analyzed was difficult intubation, and the secondary outcome was difficult mask ventilation. RESULTS: Based on the sleep studies, 287 (33%), 324 (37%), 169 (20%), and 89 (10%) of the 869 patients had no, mild, moderate, and severe OSA, respectively. One hundred and seventy-two (20%) had a STOP-Bang score of 0-2 (low risk), 483 (55%) had a STOP-Bang score of 3-4 (intermediate risk), and 214 (25%) had a STOP-Bang score 5-8 (high risk). The incidence of difficult intubation was 6.7% (58 of 869), and difficult mask ventilation was 3.7% (32 of 869). Multivariable logistic regression demonstrated that moderate OSA (odds ratio [OR] = 3.26 [95% confidence interval {CI}, 1.37-8.38], adjusted P = .010) and severe OSA (OR = 4.05 [95% CI, 1.51-11.36], adjusted P = .006) but not mild OSA were independently associated with difficult intubation compared to patients without OSA. Relative to scores of 0-2, STOP-Bang scores of 3-4 and 5-8 were associated with increased odds of difficult intubation (OR = 3.01 [95% CI, 1.13-10.40, adjusted P = .046] and 4.38 [95% CI, 1.46-16.36, adjusted P = .014]), respectively. OSA was not associated with difficult mask ventilation, and only increasing neck circumference was found to be associated (adjusted P = .002). CONCLUSIONS: Moderate and severe OSA were associated with difficult intubation, and increasing neck circumference was associated with difficult mask ventilation. A higher STOP-Bang score of 3 or more may be associated with difficult intubation versus STOP-Bang score of 0-2. Anesthesiologists should be vigilant for difficult intubation when managing patients suspected or diagnosed with OSA.

Time to consider supraglottic airway device oropharyngeal leak pressure measurement more objectively.

Oropharyngeal leak pressure (OLP) is considered a measure of successful placement, adequate performance and is a useful comparator between supraglottic airway devices (SADs). OLP measurement is based on the premise that the SAD is sited properly in the hypopharynx after blind placements, but the evidence suggests otherwise. Several limitations and controversies surround OLP. This editorial addresses the uses and pitfalls of OLP, the rationale for and methods of ascertaining OLP, the pros and cons of OLP measurement and newer modalities to improve its accuracy.

Measuring endotracheal tube intracuff pressure: no room for complacency.

Tracheal intubation constitutes a routine part in the care of critically ill and anaesthetised patients. Prolonged use of endotracheal with inflated cuff is one of the major multifactorial causes of complications. Both under-inflation and over-inflation of cuff are associated with complications. Despite known problems, regular measurement of cuff pressure is not routine, and it is performed on an ad hoc basis.

Choosing the best supraglottic airway for ophthalmic general anaesthesia: a manikin study.

General anaesthesia is sometimes favoured over regional anaesthesia in ophthalmic surgery. The use of supraglottic airway (SGA) or laryngeal mask airway (LMA) as the primary airway device is increasing due to numerous advantages over tracheal intubation. Compared with 1st generation SGAs, 2nd generation SGAs have an added benefit of isolating the airway from the alimentary tract. However, the vertical profile of SGAs may encroach into the surgical field and hence interfere with surgery. We investigated the vertical projections of 1st generation SGAs (LMA Classic, Ambu AuraFlex) and commonly used 2nd generation SGAs in our institution (LMA ProSeal, LMA Supreme, LMA Protector, Ambu AuraGain and I-gel) in a manikin model. Each device was connected to a corrugated catheter mount or angled connector following insertion as per usual clinical practice in our institutions. Vertical projections of all devices were measured from the chin using a centimetre ruler. Securing of airway device to the chin with an adhesive tape was possible for the LMA Classic and Ambu AuraFlex with straight corrugated connector, whereas the stiffer 2nd generations SGAs required the addition of an angled connector or straight corrugated tubing to direct the airway tube caudally, away from the surgical field. The LMA ProSeal had the lowest vertical projection amongst the 2nd generation SGAs and may be the suitable choice for ophthalmic surgery. We also describe a novel technique of utilising a 1st generation SGA with placement of an orogastric tube, although with some reservations. This study has several limitations and transferability of our findings into clinical practice is questionable as the use of a manikin may not fully imitate the real condition of the patient. Our study is the first study comparing vertical projected height of different SGAs in manikin, but future studies should investigate the use of SGA in the clinical setting during ophthalmic surgery.

Comparative study of silicone membrane simulator and animal eye models for sub-Tenon's block.

To compare and assess silicone membrane-based sub-Tenon's block (STB) simulator and animal eye model (goat's eye) for practicing STB in terms of anatomical similarity and feel of texture of eye layers. The study included 34 participants (26 learners and 8 consultants) from tertiary ophthalmic centres. The participants were divided into groups A and B. Group A performed STB on the goat's eyes before using the silicone membrane simulator. Group B performed STB on the simulator and further proceeded to the goat's eye. Participants had to rate the anatomical similarity and feel of the texture for the simulator model on a scale of 0-10 and share their preference between the two models. In group A, the scores given to the simulator model and the feel of texture of layers were 8.05 ± 0.88 and 7.97 ± 1.07, respectively, and the scores given to the animal model and the feel of texture of layers were 8.11 ± 0.97 and 8.21 ± 0.88, respectively. Group B participants scored the simulator model and feel of texture of layers with 8.13 ± 0.95 and 8.25 ± 0.99, respectively. Overall, 89% participants preferred the simulator; the reasons included ease of usage, helpful warning system, absence of biological waste, and facility for repeatable training. The study validated anatomical accuracy, preference, and ability of usage of the STB simulator. For broader usage, further study involving higher number of participants is recommended.

The case for a 3rd generation supraglottic airway device facilitating direct vision placement.

Although 1st and 2nd generation supraglottic airway devices (SADs) have many desirable features, they are nevertheless inserted in a similar 'blind' way as their 1st generation predecessors. Clinicians mostly still rely entirely on subjective indirect assessments to estimate correct placement which supposedly ensures a tight seal. Malpositioning and potential airway compromise occurs in more than half of placements. Vision-guided insertion can improve placement. In this article we propose the development of a 3rd generation supraglottic airway device, equipped with cameras and fiberoptic illumination, to visualise insertion of the device, enable immediate manoeuvres to optimise SAD position, verify whether correct 1st and 2nd seals are achieved and check whether size selected is appropriate. We do not provide technical details of such a '3rd generation' device, but rather present a theoretical analysis of its desirable properties, which are essential to overcome the remaining limitations of current 1st and 2nd generation devices. We also recommend that this further milestone improvement, i.e. ability to place the SAD accurately under direct vision, be eligible for the moniker '3rd generation'. Blind insertion of SADs should become the exception and we anticipate, as in other domains such as central venous cannulation and nerve block insertions, vision-guided placement becoming the gold standard.

Optimized Aluminum Reflector for Enhancement of UVC Cathodoluminescence Based-AlGaN Materials with Carbon Nanotube Field Emitters.

The far ultraviolet C (UVC) light sources based on carbon nanotube (CNT) field emitters as excitation sources have become promising light sources for sterilization, disinfection, and water purification. However, the low light extraction efficiency of UVC-CNT light sources still hinders the practical application of these structures. Herein, we report an optimized aluminum (Al) reflector to enhance the light extraction efficiency of UVC-CNT light sources. Optical analysis of UVC-CNT light sources covered by the Al reflectors with various thicknesses ranging from 30 to 150 nm was performed to realize the optimized reflector. The UVC-CNT light sources exhibit the highest light extraction efficiency when the Al reflector layer has an optimized thickness of 100 nm. For comparison, the cathodoluminescence (CL) spectra were recorded for UVC-CNT light sources with and without the optimized Al reflector. The measured light output power and the estimated power efficiency of the UVC-CNT light-source-tube with Al reflector were enhanced by about 27 times over the reference. This enhancement is mainly attributed to the outstanding reflection effect of the Al reflector.

A prospective randomized comparison of airway seal using the novel vision-guided insertion of LMA-Supreme® and LMA-Protector®.

The laryngeal mask airways supreme (LMA-Supreme™) and protector (LMA-Protector™) are generally placed blindly, often resulting in a less than optimal position and vision-guided placement has been recommended. This prospective, randomized controlled study compared the efficacy of airway seal by measuring the oropharyngeal leak pressure in 100 surgical patients who underwent a variety of non-thoracic surgery under general anaesthesia, suitable with a supraglottic airway device. Patients were allocated to either the LMA-Supreme (n = 50) or LMA-Protector (n = 50) group. All insertions were performed under vision of a videolaryngoscope using an 'insert-detect-correct-as-you-go' technique with standardized corrective measures. Our primary endpoint, mean oropharyngeal leak pressure, was significantly higher in the LMA-Protector (31.7 ± 2.9 cm H2O) compared to the LMA-Supreme (27.7 ± 3.5 cm H2O) group (mean difference 4.0 cm H2O, 95% confidence interval (CI) 2.7-5.3 cm H2O, p < 0.001) after achieving a near-optimal fibreoptic position in the LMA-Protector (94%) and LMA-Supreme (96%) groups. No statistically significant differences were shown for secondary outcomes of alignment, number of insertion attempts and malpositions, and final anatomical position as scored by fibreoptic evaluation. Corrective manoeuvres were required in virtually all patients to obtain a correct anatomically positioned LMA. Position outcomes of the two devices were similar except for the proportion of procedures with folds in the proximal cuff (90% LMA-Supreme vs. 2% LMA-Protector, p < 0.001), the need for intracuff pressure adjustments (80% LMA-Supreme vs. 48% LMA-Protector, p = 0.001) and size correction (18% LMA-Supreme vs. 4% LMA-Protector, p = 0.025). In conclusion, a higher oropharyngeal leak pressure can be achieved with LMA-Protector compared to LMA-Supreme with optimal anatomical position when insertion is vision-guided.

Choosing anesthesia options for cataract surgery in patients with dementia.

BACKGROUND AND AIMS: Not all patients with dementia are the same, and Global Deterioration Scale (GDS) helps in staging dementia. Ophthalmologists usually prefer general anesthesia (GA) for cataract surgery in patients with dementia. We evaluated the impact of "Choosing Wisely" initiative on anesthesia options for cataract surgery in patients with dementia undergoing cataract surgery. MATERIAL AND METHODS: A retrospective review of electronic perioperative database was performed over a 4-year period of patients with a specific diagnosis of dementia undergoing cataract surgery, after the introduction of the "Choosing Wisely" based on preoperative GDS assessment. Preferred method by the listing ophthalmologist, changes in anesthesia modality based on GDS, and the occurrence of intraoperative events were analyzed. RESULTS: One hundred and thirty-six patients with dementia underwent cataract surgery over a 4-year period. The mean patient age was 78 years, 73.5% female, and 55% ASA physical status III. GA was administered for GDS stage 6-7, and regional anesthesia (RA) for GDS stages 1-5. Surgery was uneventful under RA in 64% of the patients (87 out of 136), and 2% (3 patients) originally deemed suitable for RA were converted to GA. CONCLUSIONS: The authors found a reduced requirement for GA when "Choosing Wisely' initiative was used based on the GDS stage.

Effect of immunization of rohu Labeo rohita with inactivated germinated zoospores in providing protection against Aphanomyces invadans.

Infection with Aphanomyces invadans is one of the most destructive diseases of freshwater fishes. Indian major carps, the dominant cultured species in the Indian sub-continent are highly susceptible to this disease. Till date, there is no effective treatment for control of this disease and immunization can be one of the strategies to reduce disease-related losses. In the present study, inactivated germinated zoospores of A. invadans were evaluated as antigen in conjunction with and without adjuvant Montanide™ ISA 763 A VG, for assessing their efficacy in rendering protection against A. invadans infection. For the experiment, rohu Labeo rohita, (n = 160, 74 ±â€¯12 g) were divided into 4 groups (C, A, G and GA) with 40 fish in each group. The fish in groups i.e., C, A, G and GA were injected intraperitoneally with PBS, adjuvant emulsified with PBS, inactivated germinated zoospores, and inactivated germinated zoospores emulsified with adjuvant, respectively. After 21 days of immunization, the fish were given a booster dose as above. After 7 days of the booster dose, the fish were challenged with zoospores of A. invadans to determine the relative percent survival (RPS). The results revealed that all the fish in C, A and G group succumbed to infection (0% RPS), although there was delayed mortality in fish from A and G groups in comparison to the C group. However, the fish in GA group showed significantly higher (P < 0.05) protection (66.7% RPS). In addition, following booster immunization (before challenge), the antibody level in the GA group was significantly higher (P < 0.05) than the control group. In western blotting, sera from G and GA groups showed reactivity with peptides of about 54 KDa. Following challenge (on 14th day), the antibody level as well as total antiprotease activity in fish of all the groups was significantly decreased in comparison to pre-challenge, except fish in GA group not exhibiting any gross lesions. In addition, sera of surviving fish of GA group showed significant inhibition of germination of zoospores and germlings growth in comparison to other groups (P < 0.05). Further, histopathological examination of the muscle tissue revealed that, in fish of GA group without any gross lesions, there were well developed granulomas and extensive mononuclear cell infiltration restricted to the site of injection, whereas in other groups, there was extensive myonecrosis with proliferating hyphae. These preliminary findings indicate that inactivated germinated zoospores of A. invadans in combination with adjuvant could stimulate good immune response and confer remarkable protection in rohu.

Intraoperative Valsalva maneuver: a narrative review.

The Valsalva maneuver (VM) involves expiratory effort against a closed mouth and/or glottis in the sitting or supine position with the increased intraoral and intrathoracic pressure raised to 40 mmHg for 15-20 sec after which the pressure is suddenly released and the breathing restored to normal. Complex cardiovascular and other physiologic changes occur during the VM. The VM has been used for diagnostic and therapeutic reasons as well as intraoperatively during specific surgical procedures. Although the VM is usually safe, rare complications have been reported. This review examines the published literature surrounding the VM and explores the physiologic changes that occur during its performance. Attempts have been made to understand its intraoperative uses and complications and how these can be prevented.