Long-term NAD+ supplementation prevents the progression of age-related hearing loss in mice.

Age-related hearing loss (ARHL) is the most common sensory disability associated with human aging. Yet, there are no approved measures for preventing or treating this debilitating condition. With its slow progression, continuous and safe approaches are critical for ARHL treatment. Nicotinamide Riboside (NR), a NAD+ precursor, is well tolerated even for long-term use and is already shown effective in various disease models including Alzheimer's and Parkinson's disease. It has also been beneficial against noise-induced hearing loss and in hearing loss associated with premature aging. However, its beneficial impact on ARHL is not known. Using two different wild-type mouse strains, we show that long-term NR administration prevents the progression of ARHL. Through transcriptomic and biochemical analysis, we find that NR administration restores age-associated reduction in cochlear NAD+ levels, upregulates biological pathways associated with synaptic transmission and PPAR signaling, and reduces the number of orphan ribbon synapses between afferent auditory neurons and inner hair cells. We also find that NR targets a novel pathway of lipid droplets in the cochlea by inducing the expression of CIDEC and PLIN1 proteins that are downstream of PPAR signaling and are key for lipid droplet growth. Taken together, our results demonstrate the therapeutic potential of NR treatment for ARHL and provide novel insights into its mechanism of action.

Predictors of survival and time to progression following operative management of intramedullary spinal cord astrocytomas.

PURPOSE: Surgical resection is considered standard of care for primary intramedullary astrocytomas, but the infiltrative nature of these lesions often precludes complete resection without causing new post-operative neurologic deficits. Radiotherapy and chemotherapy serve as potential adjuvants, but high-quality data evaluating their efficacy are limited. Here we analyze the experience at a single comprehensive cancer center to identify independent predictors of postoperative overall and progression-free survival. METHODS: Data was collected on patient demographics, tumor characteristics, pre-operative presentation, resection extent, long-term survival, and tumor progression/recurrence. Kaplan-Meier curves modeled overall and progression-free survival. Univariable and multivariable accelerated failure time regressions were used to compute time ratios (TR) to determine predictors of survival. RESULTS: 94 patients were included, of which 58 (62%) were alive at last follow-up. On multivariable analysis, older age (TR = 0.98; p = 0.03), higher tumor grade (TR = 0.12; p < 0.01), preoperative back pain (TR = 0.45; p < 0.01), biopsy [vs GTR] (TR = 0.18; p = 0.02), and chemotherapy (TR = 0.34; p = 0.02) were significantly associated with poorer survival. Higher tumor grade (TR = 0.34; p = 0.02) and preoperative bowel dysfunction (TR = 0.31; p = 0.02) were significant predictors of shorter time to detection of tumor growth. CONCLUSION: Tumor grade and chemotherapy were associated with poorer survival and progression-free survival. Chemotherapy regimens were highly heterogeneous, and randomized trials are needed to determine if any optimal regimens exist. Additionally, GTR was associated with improved survival, and patients should be counseled about the benefits and risks of resection extent.

A novel online calculator to predict nonroutine discharge, length of stay, readmission, and reoperation in patients undergoing surgery for intramedullary spinal cord tumors.

BACKGROUND CONTEXT: Intramedullary spinal cord tumors (IMSCTs) are rare tumors associated with significant morbidity and mortality. Surgical resection is often indicated for symptomatic lesions but may result in new neurological deficits and decrease quality of life. Identifying predictors of these adverse outcomes may help target interventions designed to reduce their occurrence. Nonetheless, most prior studies have employed population-level datasets with limited granularity. PURPOSE: To determine independent predictors of nonroutine discharge, prolonged length of stay (LOS), and 30 day readmission and reoperation, and to deploy these results as a web-based calculator. STUDY DESIGN: Retrospective cohort study PATIENT SAMPLE: A total of 235 patients who underwent resection of IMSCTs at a single comprehensive cancer center. OUTCOME MEASURES: Nonroutine discharge, prolonged LOS, 30 day readmission, and 30 day reoperation METHODS: Patients who underwent surgery from June 2002 to May 2020 at a single tertiary center were included. Data was collected on patient demographics, clinical presentation, tumor histology, surgical procedures, and 30 day readmission and reoperation. Functional status was assessed using the Modified McCormick Scale (MMS) and queried preoperative neurological symptoms included weakness, urinary and bowel dysfunction, numbness, and back and radicular pain. Variables significant on univariable analysis at the α≤0.15 level were entered into a stepwise multivariable logistic regression model. RESULTS: Of 235 included cases, 131 (56%) experienced a nonhome discharge and 68 (29%) experienced a prolonged LOS. Of 178 patients with ≥ 30 days of follow-up, 17 (9.6%) were readmitted within 30 days and 13 (7.4%) underwent reoperation. Wound dehiscence (29%) was the most common reason for readmission. Nonhome discharge was independently predicted by older age (OR=1.03/year; p<.01), thoracic location of the tumor (OR=2.36; p=.01), presenting with bowel dysfunction (OR=4.09; p=.03), and longer incision length (OR=1.44 per level; p=.03). Independent predictors of prolonged LOS included presenting with urinary incontinence (OR=2.65; p=.05) or a higher preoperative white blood cell count (OR=1.08 per 103/µL); p=.01), while GTR predicted shorter LOS (OR=0.40; p=.02). Independent predictive factors for 30 day unplanned readmission included experiencing ≥1 complications during the first hospitalization (OR=6.13; p<.01) and having a poor (A-C) versus good (D-E) baseline neurological status on the ASIA impairment scale (OR=0.23; p=.03). The only independent predictor of unplanned 30 day reoperation was experiencing ≥1 inpatient complications during the index hospitalization (OR=6.92; p<.01). Receiver operating curves for the constructed models produced C-statistics of 0.67-0.77 and the models were deployed as freely available web-based calculators (https://jhuspine5.shinyapps.io/Intramedullary30day). CONCLUSIONS: We found that neurological presentation, patient demographics, and incision length were important predictors of adverse perioperative outcomes in patients with IMSCTs. The calculators can be used by clinicians for risk stratification, preoperative counseling, and targeted interventions.

Perioperative outcomes and survival after surgery for intramedullary spinal cord tumors: a single-institution series of 302 patients.

OBJECTIVE: Intramedullary spinal cord tumors (IMSCTs) are rare neoplasms whose treatment is often technically challenging. Given the low volume seen at most centers, perioperative outcomes have been reported infrequently. Here, the authors present the largest single-institution series of IMSCTs, focusing on the clinical presentation, histological makeup, perioperative outcomes, and long-term survival of surgically treated patients. METHODS: A cohort of patients operated on for primary IMSCTs at a comprehensive cancer center between June 2002 and May 2020 was retrospectively identified. Data on patient demographics, tumor histology, neuraxial location, baseline neurological status, functional deficits, and operative characteristics were collected. Perioperative outcomes of interest included length of stay, postoperative complications, readmission, reoperation, and discharge disposition. Data were compared across tumor histologies using the Kruskal-Wallis H test, chi-square test, and Fisher exact test. Pairwise comparisons were conducted using Tukey's honest significant difference test, chi-square test, and Fisher exact test. Long-term survival was assessed across tumor categories and histological subtype using the log-rank test. RESULTS: Three hundred two patients were included in the study (mean age 34.9 ± 19 years, 77% white, 57% male). The most common tumors were ependymomas (47%), astrocytomas (31%), and hemangioblastomas (11%). Ependymomas and hemangioblastomas disproportionately localized to the cervical cord (54% and 59%, respectively), whereas astrocytomas were distributed almost equally between the cervical cord (36%) and thoracic cord (38%). Clinical presentation, extent of functional dependence, and postoperative 30-day outcomes were largely independent of underlying tumor pathology, although tumors of the thoracic cord had worse American Spinal Injury Association (ASIA) grades than cervical tumors. Rates of gross-total resection were lower for astrocytomas than for ependymomas (54% vs 84%, p < 0.01) and hemangioblastomas (54% vs 100%, p < 0.01). Additionally, 30-day readmission rates were significantly higher for astrocytomas than ependymomas (14% vs 6%, p = 0.02). Overall survival was significantly affected by the underlying pathology, with astrocytomas having poorer associated prognoses (40% at 15 years) than ependymomas (81%) and hemangioblastomas (66%; p < 0.01) and patients with high-grade ependymomas and astrocytomas having poorer long-term survival than those with low-grade lesions (p < 0.01). CONCLUSIONS: The neuraxial location of IMSCTs, extent of resection, and postoperative survival differed significantly across tumor pathologies. However, perioperative outcomes did not vary significantly across tumor cohorts, suggesting that operative details, rather than pathology, may have a stronger influence on the short-term clinical course, whereas pathology appears to have a stronger impact on long-term survival.

Impact of race on nonroutine discharge, length of stay, and postoperative complications after surgery for spinal metastases.

OBJECTIVE: Previous studies have suggested the possibility of racial disparities in surgical outcomes for patients undergoing spine surgery, although this has not been thoroughly investigated in those with spinal metastases. Given the increasing prevalence of spinal metastases requiring intervention, knowledge about potential discrepancies in outcomes would benefit overall patient care. The objective in the present study was to investigate whether race was an independent predictor of postoperative complications, nonroutine discharge, and prolonged length of stay (LOS) after surgery for spinal metastasis. METHODS: The authors retrospectively examined patients at a single comprehensive cancer center who had undergone surgery for spinal metastasis between April 2013 and April 2020. Demographic information, primary pathology, preoperative clinical characteristics, and operative outcomes were collected. Factors achieving p values < 0.15 on univariate regression were entered into a stepwise multivariable logistic regression to generate predictive models. Nonroutine discharge was defined as a nonhome discharge destination and prolonged LOS was defined as LOS greater than the 75th percentile for the entire cohort. RESULTS: Three hundred twenty-eight patients who had undergone 348 operations were included: 240 (69.0%) White and 108 (31.0%) Black. On univariable analysis, cohorts significantly differed in age (p = 0.02), marital status (p < 0.001), insurance status (p = 0.03), income quartile (p = 0.02), primary tumor type (p = 0.04), and preoperative Karnofsky Performance Scale (KPS) score (p < 0.001). On multivariable analysis, race was an independent predictor for nonroutine discharge: Black patients had significantly higher odds of nonroutine discharge than White patients (adjusted odds ratio [AOR] 2.24, 95% confidence interval [CI] 1.28-3.92, p = 0.005). Older age (AOR 1.06 per year, 95% CI 1.03-1.09, p < 0.001), preoperative KPS score ≤ 70 (AOR 3.30, 95% CI 1.93-5.65, p < 0.001), preoperative Frankel grade A-C (AOR 3.48, 95% CI 1.17-10.3, p = 0.02), insurance status (p = 0.005), being unmarried (AOR 0.58, 95% CI 0.35-0.97, p = 0.04), number of levels (AOR 1.17 per level, 95% CI 1.05-1.31, p = 0.004), and thoracic involvement (AOR 1.71, 95% CI 1.02-2.88, p = 0.04) were also predictive of nonroutine discharge. However, race was not independently predictive of postoperative complications or prolonged LOS. Higher Charlson Comorbidity Index (AOR 1.22 per point, 95% CI 1.04-1.43, p = 0.01), low preoperative KPS score (AOR 1.84, 95% CI 1.16-2.92, p = 0.01), and number of levels (AOR 1.15 per level, 95% CI 1.05-1.27, p = 0.004) were predictive of complications, while insurance status (p = 0.05), income quartile (p = 0.01), low preoperative KPS score (AOR 1.64, 95% CI 1.03-2.72, p = 0.05), and number of levels (AOR 1.16 per level, 95% CI 1.05-1.30, p = 0.004) were predictive of prolonged LOS. CONCLUSIONS: Race, insurance status, age, baseline functional status, and marital status were all independently associated with nonroutine discharge. This suggests that a combination of socioeconomic factors and functional status, rather than medical comorbidities, may best predict postdischarge disposition in patients treated for spinal metastases. Further investigation in a prospective cohort is merited.

Utility of expanded anterior column resection versus decompression-alone for local control in the management of carcinomatous vertebral column metastases undergoing adjuvant stereotactic radiotherapy.

BACKGROUND CONTEXT: With improvements in adjuvant radiotherapy and minimally invasive surgical techniques, separation surgery has become the default surgical intervention for spine metastases at many centers. However, it is unclear if there is clinical benefit from anterior column resection in addition to simple epidural debulking prior to stereotactic body radiotherapy (SBRT). PURPOSE: To examine the effect of anterior column debulking versus epidural disease resection alone in the local control of metastases to the bony spine. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Ninety-seven patients who underwent open surgery followed by SBRT for spinal metastases at a single comprehensive cancer center. OUTCOME MEASURES: Local tumor recurrence following surgery and SBRT. METHODS: Data were collected regarding radiation dose, cancer histology, extent of anterior column resection, and recurrence. Tumor involvement was categorized using the International Spine Radiosurgery Consortium guidelines. Univariable analyses were conducted to determine predictors of local recurrence and time to local recurrence. RESULTS: Among the 97 included patients, mean age was 60.5±11.4 years and 51% of patients were male. The most common primary tumor types were lung (20.6%), breast (17.5%), kidney (13.4%) and prostate (12.4%). Recurrence was seen in 17 patients (17.5%) and local control rates were: 85.5% (1-year), 81.1% (2-year), and 54.9% (5-year). Overall predictors of local recurrence were tumor pathology (p<.01; renal cell carcinoma and colorectal adenocarcinoma associated with poorest PFS) and undergoing anterior column debulking versus epidural decompression-alone (p=.03). Only tumor pathology predicted time to local recurrence (p<.01), though inspection of Kaplan-Meier functions showed superior long-term local control in patients with radiosensitive tumor pathologies, no previous irradiation of the metastasis, and who underwent anterior column resection versus epidural removal alone. Median time to recurrence was 288 days with 100% of lesions showing anterior column recurrence and recurrence in the epidural space. CONCLUSIONS: With the increasing shift towards surgery as a neoadjuvant to radiotherapy for patients with spinal column metastases, the role for surgical debulking has become less clear. In the present study, we find that anterior column debulking as opposed to epidural debulking-alone decreases the odds of local recurrence and improves long-term local control.

Comparison of frailty metrics and the Charlson Comorbidity Index for predicting adverse outcomes in patients undergoing surgery for spine metastases.

OBJECTIVE: Frailty-the state defined by decreased physiological reserve and increased vulnerability to physiological stress-is exceedingly common in oncology patients. Given the palliative nature of spine metastasis surgery, it is imperative that patients be healthy enough to tolerate the physical insult of surgery. In the present study, the authors compared the association of two frailty metrics and the widely used Charlson Comorbidity Index (CCI) with postoperative morbidity in spine metastasis patients. METHODS: A retrospective cohort of patients who underwent operations for spinal metastases at a comprehensive cancer center were identified. Data on patient demographic characteristics, disease state, medical comorbidities, operative details, and postoperative outcomes were collected. Frailty was measured with the modified 5-item frailty index (mFI-5) and metastatic spinal tumor frailty index (MSTFI). Outcomes of interest were length of stay (LOS) greater than the 75th percentile of the cohort, nonroutine discharge, and the occurrence of ≥ 1 postoperative complication. RESULTS: In total, 322 patients were included (mean age 59.5 ± 12 years; 56.9% of patients were male). The mean ± SD LOS was 11.2 ± 9.9 days, 44.5% of patients had nonroutine discharge, and 24.0% experienced ≥ 1 postoperative complication. On multivariable analysis, increased frailty on mFI-5 and MSTFI was independently predictive of all three outcomes: prolonged LOS (OR 1.67 per point, 95% CI 1.06-2.63, p = 0.03; and OR 1.63 per point, 95% CI 1.29-2.05, p < 0.01, respectively), nonroutine discharge (OR 2.65 per point, 95% CI 1.74-4.04, p < 0.01; and OR 1.69 per point, 95% CI 1.36-2.11, p < 0.01), and ≥ 1 complication (OR 1.95 per point, 95% CI 1.23-3.09, p = 0.01; and OR 1.41 per point, 95% CI 1.12-1.77, p < 0.01). CCI was found to be independently predictive of only the occurrence of ≥ 1 postoperative complication (OR 1.45 per point, 95% CI 1.22-1.72, p < 0.01). CONCLUSIONS: Frailty measured with either mFI-5 or MSTFI scores was a more robust independent predictor of adverse postoperative outcomes than the more widely used CCI. Both mFI-5 and MSTFI were significantly associated with prolonged LOS, higher complication rates, and nonroutine discharge. Further investigation in a prospective multicenter cohort is merited.

Hyperbaric oxygen therapy in malignant otitis externa: A systematic review of the literature.

OBJECTIVE: To review the role of adjuvant hyperbaric oxygen therapy (HBOT) in the treatment of malignant otitis externa (MOE). DATA SOURCES: PubMed, Scopus, Web of Science, Science Direct, and Cochrane Library were searched for the following concepts: "hyperbaric oxygen" and "malignant or necrotizing otitis externa." METHODS: Studies were included if they contained (1) patients with reported evidence of MOE, (2) employment of adjuvant HBOT, (3) details on patients' medical condition, and (4) documented survival outcomes. Extracted information included patient demographics, underlying medical conditions, infectious etiology, signs and symptoms, medical and surgical treatments, duration of medical treatment, mean follow up time, HBOT setting, number of HBOT sessions, complications, survival rate, and all-cause mortality. RESULTS: A total of 16 studies comprising 58 patients (mean age 68.0 years) were included. Diabetes was present in 94.7% of cases and Pseudomonas spp (64.3%) was the most common infectious agent. Cranial nerve VII was involved in 55.2% of cases. Overall, the disease cure rate with adjuvant HBOT was 91.4% and all-cause mortality was 8.6%. Among those who had cranial nerve VII involvement, 72.0% had return of function and 93.8% of them survived. CONCLUSION: HBOT may be an effective treatment option for refractory or advanced MOE but its efficacy remains unproven due to lack of strong scientific evidence. However, its therapeutic value should not be underestimated given good results and few adverse events reported in this study.

Drivers of Readmission and Reoperation After Surgery for Vertebral Column Metastases.

OBJECTIVE: To determine those clinical, demographic, and operative factors that predict 30-day unplanned reoperation and readmission within a population of adults who underwent spinal metastasis surgery at a comprehensive cancer center. METHODS: Adults who underwent spinal metastasis surgery at a comprehensive cancer center were analyzed. Data included baseline laboratory values, cancer history, demographics, operative characteristics and medical comorbidities. Medical comorbidities were quantified using the modified Charlson Comorbidity Index (CCI). Values associated with the outcomes of interest were then subjected to multivariable logistic regression to identify independent predictors of readmission and reoperation. RESULTS: A total of 345 cases were identified. Mean age was 59.4 ± 11.7 years, 56% were male, and the racial makeup was 64% white, 29% black, and 7.3% other. Forty-two patients (12.2%) had unplanned readmissions, most commonly for wound infection with dehiscence (14.2%), venous thromboembolism (14.2%), and bowel obstruction/complication (11.9%). Thirteen patients required reoperation (4%), most commonly for wound infection with dehiscence (39%) or local recurrence (23%). Multivariable analysis showed that the modified CCI (odds ratio [OR], 1.25; 95% confidence interval [CI] 1.03-1.52; P = 0.03) was an independent predictor of 30-day readmission. Independent predictors of 30-day unplanned reoperation were: black (vs. white) race (OR, 0.08; 95% CI, 0.01-0.41; P < 0.01), length of stay (OR, 1.05 per day; 95% CI, 1.00-1.09; P = 0.04), and CCI (OR, 1.72 per point; 95% CI, 1.29-2.28; P < 0.01). CONCLUSIONS: Increasing medical comorbidities is independently predictive of both 30-day unplanned readmission and reoperation after spinal metastasis surgery. Unplanned reoperation is also positively predicted by a longer index admission. Neither tumor pathology nor age predicted outcome, suggesting that poor wound-healing factors and increased surgical morbidity may best predict these adverse outcomes.

A Web-Based Calculator for Predicting the Occurrence of Wound Complications, Wound Infection, and Unplanned Reoperation for Wound Complications in Patients Undergoing Surgery for Spinal Metastases.

BACKGROUND: In the present study, we identified the risk factors for wound complications, wound infection, and reoperation for wound complications after spine metastasis surgery and deployed the resultant model as a web-based calculator. METHODS: Patients treated at a single comprehensive cancer center during a 7-year period were included. The demographics, pathology, comorbidities, laboratory values, and operative details were collected. Factors with P < 0.15 on univariable regression were entered into multivariable logistic regression to generate predictive models internally validated using 1000 bootstrapped samples. RESULTS: Of the 330 patients included, 29 (7.6%) had experienced a surgical site infection. The independent predictive factors for wound-related complications were a higher Charlson comorbidity index (CCI; odds ratio [OR], 1.41 per point; P < 0.01), Karnofsky performance scale score ≤70 (OR, 2.14; P = 0.04), lower platelet count (OR, 0.49 per 105/µL; P < 0.01), revision versus index surgery (OR, 3.10; P = 0.02), and increased incision length (OR, 1.21 per level; P = 0.02). Wound infection was associated with a higher CCI (OR, 1.60 per point; P < 0.01), a lower platelet count (OR, 0.35 per 105/µL; P < 0.01), revision surgery (OR, 4.63; P = 0.01), and a longer incision length (OR, 1.25 per level; P = 0.03). Unplanned reoperation for wound complications was predicted by a higher CCI (OR, 1.39 per point; P = 0.003), prior irradiation (OR, 2.52; P = 0.04), a lower platelet count (OR, 0.57 per 105/µL; P = 0.02), and revision surgery (OR, 3.34; P = 0.03), The optimism-corrected areas under the curve were 0.75, 0.81, and 0.72 for the wound complication, infection, and reoperation models, respectively. CONCLUSIONS: Low platelet counts, poorer health status, more invasive surgery, and revision surgery all independently predicted the risk of wound complications, including infection and unplanned reoperation for infection. Validation of the calculators in a prospective study is merited.

Plastic surgery wound closure following resection of spinal metastases.

OBJECTIVE: Surgical site infection and dehiscence are devastating complications of surgery for spinal metastases. Wound closure involving plastic surgeons has been proposed as a strategy to lower post-operative complications. Here we investigated whether plastic surgery closure is associated with lower rates of wound complications, wound infection, and wound reoperation compared to simple closure by spine surgeons. METHODS: Patients surgically treated for metastatic tumors at a single comprehensive cancer center between April 2013-2020 were retrospectively identified. Primary pathology, demographic information, clinical characteristics, pre-operative laboratory values, tumor location, operative characteristics, and post-operative outcomes were collected. Univariable analyses used student t-tests for continuous variables and χ2 tests for categorical variables. Multivariable regressions were performed to control for confounders. RESULTS: We included 317 patients, of which 56 underwent closure by plastic surgeons and 291 by neurosurgeons. Patients in the plastic surgery cohort were more likely to have received prior radiation to the surgical site, more often on long-term corticosteroid therapy, and more likely to have sacrococcygeal tumors. Operations involving plastic surgeons were more likely to be revision surgeries, corpectomies, and to involve a staged approach. Additionally, patients in the plastic surgery cohort had longer incision lengths, longer surgeries, greater intraoperative blood loss (IOBL), were more likely to receive transfusions, and had longer hospitalizations. Local paraspinous advancement flaps were the most common complex wound closure technique. Plastic surgery closure was not significantly associated with a difference in rates of post-operative wound complications, wound infection, or wound-related reoperations compared to simple wound closure. CONCLUSION: We identified that patients undergoing plastic surgery wound closure had worse baseline risk, longer surgeries, greater IOBL, and longer hospitalizations compared to patients receiving simple closure. Despite their increased risk, complex wound closure did not significantly alter the rates of post-operative wound complications, wound infection, or wound-related reoperations. Consideration may be given to plastic surgery closure in patients at high risk of wound complications or with extensive wound defects.

A comparative study on Vamana Karma with Madanaphala and Krutavedhana in Ekakushtha (Psoriasis).

Vamana Karma (therapeutic emesis) is the best therapy for the elimination of vitiated Kapha Dosha. In the present clinical practice Madanaphala (Randia dumetorum) is mainly used for Vamana Karma. Apart from Madanaphala, five other drugs, and in total 355 formulations are described in Charaka Samhita; one of them is Krutavedhana (Luffa acutangula) kalpa (formulations). Krutavedhana is specially indicated in Gadha (compact) Dosha condition like Kushtha (skin diseases), Garavisha (slow poison), and so on, for Vamana Karma. The present study aimed to observe the effect on Vamana Karma and by that its effect on Ekakushtha (Psoriasis). Krutavedhana Beeja Churna (seed powder) was given with Madhu (honey) and Saindhava (rock salt) as Vamana Yoga (emetic formulation), to compare it with Madanaphala Pippali Churna (seed powder). After the Sansarjana Krama (special dietetic schedule), Panchatikta Ghrita (medicated ghee) was given as Shamana Sneha (pacifying oleation). An average dose of Krutavedhana was 5.9 g. Krutavedhana could produce a good number of Vega (bouts), Pittanta Lakshana (bile coming out at the end of Vamana), and Pravara Shuddhi (maximum cleansing) in a majority of patients. Madanaphala is the best among all Vamaka (emetic) drugs, but Krutavedhana showed a similar to higher effect on Vamana Karma in terms of Antiki, Maniki, Vaigiki, and LaingikiShuddhi (cleansing criteria). Vamana Karma by Krutavedhana showed better relief in Matsyashakalopamam (silvery scale), Kandu (itching), and Rukshataa (dryness), while Madanapahala showed better relief in Krishnaruna Varna (erythema). After completion of the Shamana (pacifying) treatment, both the groups showed nearly the same effect on Asvedanam (lack of perspiration), Matsyashakalopamam, Kandu, Rukshataa, Krishnaruna Varna, and Mahaavaastu (bigger lesion).