Redefining venereology practice in Tamil Nadu, South India - Nakshatra Health - A networking model.

Background: Accessing care for sexual health has always been a challenge in our Indian context. The primary reason is a lack of awareness of modes of transmission of sexually transmitted diseases (STD), appropriate testing, and treatment options. The second is taboo associated with the morality of the individual. The third is the accessibility and availability of Quality STD care by allopathic specialists in comparison to the demand. This has paved way for lots of myths and misconceptions among the general public regarding STDs and HIV disease. Compounding it is the mushrooming of nonqualified practitioners and healers who claim to cure all STDs and HIV has led to poor treatment outcomes. Several methods of partnership with qualified allopathic practitioners have been tried for the provision of quality STD care by various donor-funded, HIV and STD prevention programs in the country. The key reasons for the nonsustainability of these clinics were the lack of technical capability to handle the sexual health and STD clinical cases and the huge cost involved in the advertisement and maintenance of the clinics. Methodology: Seven clinicians from different geographical locations in Tamil Nadu, who were exclusively qualified in Venereology, conceived the idea of provision of comprehensive clinical care cum counseling and testing services through a networking model from December 01, 2020. The model comprised the following: (1) Dedicated YouTube channel (Nakshatra Health) to provide scientific information on STD and HIV, modes of transmission, clinical symptoms, lab testing, interpretation of results, clinical treatment options, and counseling on prevention, (2) Dedicated telephone helpline was established with WhatsApp to answer the queries of clients by the network venereologists, (3) Dedicated website (www.nakshatra.health) was developed to provide information on STD and HIV and options to clarify doubts and fix appointments online, (4) Clinical consultations were done in a hybrid mode with an option for direct clinic and online consultation. Prescriptions were provided using dedicated software instantly, (5) Networking was done with NABL-accredited labs and collection centers for performing STD and HIV tests with e-test request forms, (6) Networking was done with pharma companies to provide pre- and postexposure prophylaxis (PEP) services to clients through e-prescriptions. Cross referrals were made across the network members to facilitate easy access to clinical services by clients from different parts of Tamil Nadu. The entire concept was branded as "Nakshatra health" with a tagline - "Your sparkling solution for safe sexual health care." Quality STD care and ethical practice were the underlying motos of this concept. Results: During the 20 months (December 2020 to July 2022), 6442 phone calls and 9328 WhatsApp messages were received. 82.3% of the calls and messages were queries from clients related to their sexual exposures, and 16.4% were general information seekers. During this period, the Nakshatra Health YouTube channel had 1590 subscribers and nearly 2.4 lakh views of all its 24 videos. Among the viewers, 92.4% were male. 52.29% of viewers were between the ages of 25 and 34 years, 28.25% were between the ages of 18 and 24 years, and 17.25% viewers were between the ages of 35 and 44 years. 86% of the viewers were from India and 13% were Tamil-speaking viewers from Middle East, Southeast Asian countries and 1% were from European, African, and American countries. The most commonly watched videos were related to HIV symptoms and lab tests for STD and HIV. 16% of the viewers repeatedly watched the various videos in the series. The network laboratories provided testing services for 1082 clients with 2423 various STD/HIV tests. Totally 3328 clients availed of online consultation and 924 clients accessed clinic-based services across the network members. Among these cases, 18 cases of Syphilis (primary and secondary) and 12 cases of acute gonococcal urethritis, and 10 cases of genital warts were diagnosed and treated. 12 cases of phimosis and 4 cases of anal warts were surgically treated in collaboration with a surgeon. Through this initiative, PEP and PreP services were provided to 228 and 8 individuals. Conclusion: Designing a comprehensive sexual health service package is crucial to ensure the availability and ease of access to services to the general public. Provision of correct scientific information, networking and cross-referral of cases with like-minded dermatovenereologists/clinicians interested in venereology sexually transmitted infections, easily accessible clinical, laboratory, and treatment services including PreP and PEP medications, and ethical practice are the key factors for scaling this concept.

Transition of an acronym from nonalcoholic fatty liver disease to metabolic dysfunction-associated fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is a global public health concern owing to its substantial contribution to chronic liver diseases. The disease is closely linked to metabolic syndrome (MS), suggesting a common biological pathway and shared disease mechanism for both ailments. Previous studies revealed a close relationship of NAFLD with the components of MS including abdominal obesity, dyslipidemia, hypertension, and hyperglycemia. Hence, a group of experts recently renamed NAFLD as metabolic dysfunction-associated fatty liver disease (MAFLD) in order to encompass a more appropriate pathogenesis of the disease. NAFLD was first named to describe a condition similar to alcoholic hepatitis in absence of significant alcohol consumption. However, knowledge pertaining to the etiopathogenesis of the disease has evolved over the past four decades. Recent evidence endorses NAFLD as a terminology of exclusion and suggests that it may often leads to misdiagnosis or inappropriate management of patients, particularly in clinical practice. On the other hand, the new definition is useful in addressing hepatic steatosis with metabolic dysfunction, which ultimately covers most of the patients with such illness. Therefore, it seems to be helpful in improving clinical diagnosis and managing high-risk patients with fatty liver disease. However, it is imperative to validate the new terminology at the population level to ensure a holistic approach to reduce the global burden of this heterogeneous disease condition.

A grid-based map for the Biogeographical Regions of Europe.

BACKGROUND: Biogeographical units are widely adopted in ecological research and nature conservation management, even though biogeographical regionalisation is still under scientific debate. The European Environment Agency provided an official map of the European Biogeographical Regions (EBRs), which contains the official boundaries used in the Habitats and Birds Directives. However, these boundaries bisect cells in the official EU 10 km × 10 km grid used for many purposes, including reporting species and habitat data, meaning that 6881 cells overlap two or more regions. Therefore, superimposing the EBRs vector map over the grid creates ambiguities in associating some cells with European Biogeographical Regions. NEW INFORMATION: To provide an operational tool to unambiguously define the boundaries of the eleven European Biogeographical Regions, we provide a specifically developed raster map of Grid-Based European Biogeographical Regions (GB-EBRs). In this new map, the borders of the EBRs are reshaped to coherently match the standard European 10 km × 10 km grid imposed for reporting tasks by Article 17 of the Habitats Directive and used for many other datasets. We assign each cell to the EBR with the largest area within the cell.

Microsurgical Anatomy of Stapedius Muscle: Anatomy Revisited, Redefined with Potential Impact in Surgeries.

Stapedius muscle even though being the smallest skeletal muscle in human body, it has a major role in otology. As many of the distinguished books in otology missed to explain much about stapedius muscle, and also considering the need for the anatomy based visit to this small muscle we felt it was important to have a exercise like this. In the dissection hall of our institution we dissected 32 cadaveric temporal bones and delineated stapedius muscle as a part of PG teaching programme to have a clear idea of the anatomy of stapedius muscle, its origin, attachment, extension, size (all dimensions). Length of the stapedius muscle varied between 9 and 11 mm. Stapedial tendon measured about 2 mm. The muscle had a classical sickle shape with tendon looking like the handle of the sickle. It has a bulky belly with a maximum breadth of 2-3 mm. It was found to be medial to midportion of vertical limb of facial nerve. All of our temporal bones measured size varied from 9 to 11 mm in length excluding stapedial tendon. Stapedial tendon measured almost 2 mm. Muscle is classical sickle shaped with tendon acting like the handle of the sickle. It has a bulky tummy which forms the maximum breadth of 1-3 mm. Why to have a clear idea about the anatomy of stapedius muscle is that, unless the anatomy is clear there is chance of confusing the muscle with that of facial nerve while doing facial nerve grafting and also while drilling for facial nerve decompression in experienced hands may get confused and decompress the muscle. Stapedius muscle said to be the smallest muscle in the body, but its not as small as its been described. Detailed awareness of the anatomy of stapedius muscle is needed so as to avoid confusion while facial nerve grafting and while drilling.

Beyond the brotherhood: Skoal Bandits' role in the evolution of marketing moist smokeless tobacco pouches.

BACKGROUND: Since 2006, "snus" smokeless tobacco has been sold in the U.S.. However, U.S. Smokeless Tobacco (USST) and Swedish Match developed and marketed pouched moist snuff tobacco (MST) since 1973. METHODS: Analysis of previously secret tobacco documents, advertisements and trade press. RESULTS: USST partnered with Swedish Match, forming United Scandia International to develop pouch products as part of the "Lotus Project." Pouched MST was not commonly used, either in Sweden or the U.S. prior to the Lotus Project's innovation in 1973. The project aimed to transform smokeless tobacco from being perceived as an "unsightly habit of old men" into a relevant, socially acceptable urban activity, targeting 15-35 year-old men. While USST's initial pouched product "Good Luck," never gained mainstream traction, Skoal Bandits captured significant market share after its 1983 introduction. Internal market research found that smokers generally used Skoal Bandits in smokefree environments, yet continued to smoke cigarettes in other contexts. Over time, pouch products increasingly featured increased flavor, size, nicotine strength and user imagery variation. CONCLUSIONS: Marlboro and Camel Snus advertising mirrors historical advertising for Skoal Bandits, designed to recruit new users and smokers subjected to smokefree places. Despite serious efforts, pouched MST marketing has been unable to dispel its association with traditional smokeless tobacco stereotypes as macho and rural. Public education efforts to discourage new users and dual use of MST and cigarettes should emphasize that "new" pouch products are simply repackaging "old" smokeless tobacco.

Redefining face contour with a novel anti-aging cosmetic product: an open-label, prospective clinical study.

BACKGROUND: Skin aging is accelerated by multiple extrinsic factors: ultraviolet radiation, smoking and pollution increase oxidative activity, damaging cellular and extracellular components such as DNA, proteins, and lipids. With age, collagen and hyaluronic acid levels decline, resulting in loss of elasticity and moisture of the skin. Over time this damage leads to characteristic signs that make the skin look older: altered facial contour, sagging skin, wrinkles, and an uneven complexion. This study evaluated the anti-aging effects of a new facial cream formulated with carnosine, Alteromonas ferment extract, crosspolymer hyaluronic acid, and a tripeptide. METHODS: An open-label intra-individual study to assess the anti-aging efficacy of the investigational product in 33 women aged 45 to 65 years. The product was applied twice daily for 56 days. Facial contour and skin deformation, elasticity, hydration, and complexion were measured with specialized equipment at baseline and days 28 and 56. Additionally, subjects completed questionnaires at days 28 and 56 on the perceived efficacy and cosmetic characteristics of the product. RESULTS: After 56 days of use of the investigational product, a redefining effect was observed, with a significant decrease in sagging jawline (7%). Skin was significantly more hydrated (12%), firmer (29%), and more elastic (20%) (P<0.001 for all). On complexion assessment, skin texture (a measure of skin smoothness) and spots (brown and red skin lesions) also improved significantly (12% and 6% decrease, respectively). In the subjective self-evaluation, the majority of subjects reported that the skin was visibly tightened and more elastic, flexible, and moisturized (91%, 88%, 91%, and 90%, respectively). The product was well tolerated with no adverse events reported during the study. CONCLUSION: This new cosmetic product demonstrated anti-aging effects after 56 days of use, most notably a redefined facial contour and improved complexion. It is a safe and effective anti-aging product.

[Special medical problems in end-of-life care : Crisis at the end of life - Which therapy is adequate and when is redefining treatment goals appropriate?] / Spezielle medizinische Probleme am Lebensende : Krisen am Lebensende ­ Welche Behandlung ist angemessen und wann sind Therapiezieländerungen angebracht?

Crisis at the end of life are exceptional challenges for patients, relatives and therapists. With respect to the individual treatment goals and the patients' autonomy, therapeutic action should be commenced in an adequate manner in order to preserve the patients' quality of life as much as possible. Advance care planning for specific critical scenarios may be helpful in order to treat patients according to their wishes and values even if they are not capable to express themselves. Furthermore, a crisis plan can define the scope of action for therapists in emergency situations. Dyspnea, pain and delirium are symptoms that may often lead to emergency calls. In such cases, pharmacological and other treatment options are available. Options for causal therapy should be checked and performed if adequate. Opioids are used to relieve pain and dyspnea. In a state of delirium, highly potent neuroleptics and atypical antipsychotics are used. For the treatment of anxiety or restlessness benzodiazepines can be prescribed. Sedative medication may reduce stress, for instance in the case of acute catastrophic bleeding. Palliative sedation is an ultima ratio concept for refractory symptoms at the end of life. Clinical practice guidelines (such as the German guideline "Palliative care for patients with incurable cancer") may provide an overview of the evidence base on symptom-guided therapy at the end of life.