Target-controlled infusion: A comparative, prospective, observational study of the conventional TCI pump and the novel smartphone-based application iTIVA.

Background and Aims: Empirically adjusted, standard drug doses fail to address interindividual pharmacokinetic and pharmacodynamics variability. Target-controlled infusion (TCI) delivers drugs in calibrated boluses to achieve and maintain a selected target plateau drug level (plasma or effect site). Interactive total intravenous anesthesia (iTIVA™) smartphone software simulates TCI and employs 31 established pharmacokinetic models for 11 different intravenous agents and is coupled with standard volumetric infusion pumps for administering TCI. Material and Methods: This prospective, observational, study investigates the degree of agreement between iTIVA and a conventional TCI pump (CTP) for the volume of propofol infused using the Schnider pharmacokinetic model in adult patients of either sex undergoing oncosurgery lasting 1-3 h under total intravenous anesthesia. Bland-Altman analysis of 124 data pairs from 30 patients provided bias, precision, and limits of agreement between the volumes infused by CTP and iTIVA (V-CTP and V-iTIVA) during specific identical time periods. Spearman's rho and Kendall's tau rank correlation coefficients provided the degree of association between V-CTP and V-iTIVA. Results: Spearman's rho and Kendall's tau were 0.996 and 0.964, respectively. Bias or the mean of differences was -0.02, while the limits of agreement were 0.58 and -0.63, respectively (Bland-Altman plot). The maximum allowed difference of 2 ml was much larger than the 95% confidence intervals for the limits of agreement. The Mountain plot was short tailed (-1.28 to 1.55) and centred over zero (0.01). Conclusion: The volume of propofol infused using TCI pump was similar to that calculated by iTIVA in identical time periods, confirming the clinical applicability of iTIVA.

Assessment of stress response due to C-Mac D-blade guided videolaryngoscopic endotracheal intubation and docking of da Vinci surgical robot using perfusion index in patients undergoing transoral robotic oncosurgery.

Clinical utility of perfusion index (PI) has entered a new realm as a non-invasive, quantitative index of stress response to endotracheal intubation. Transoral robotic surgery (TORS) involves F-K retractor aided docking of the surgical robot producing haemodynamic and stress responses akin to laryngoscopy. We compared the stress response to videolaryngoscopy with that due to docking of da Vinci surgical robot using PI, heart rate and mean arterial pressure evaluated at specific time points post-laryngoscopy and post-docking. Twenty-six adult patients, scheduled for TORS under general endotracheal anaesthesia were included in this prospective, observational, single-centric cohort study. Statistical analysis included paired samples t-test, dotted box-whisker plots, trendlines and correlograms for comparative analysis of two stressors, laryngoscopy and docking. Baseline PI was 4.14. PI values increased post-midazolam (4.23), 1 min (5.69) and 3 min (6.25) post anaesthetic-induction, plummeted at laryngoscopy (3.24), remained low at 1 min (3.68), 3 min (4.69) thereafter, and were highest at 10 min (6.17) post-laryngoscopy and predocking (6.84). Docking witnessed a fall in PI (4.1), which remained low at 1 min (4.02), 3 min (4.31) and 10 min (4.79) post-docking. PI was significantly higher at laryngoscopy compared with PI at docking (p = 0.0044). At 1 min and 3 min post-laryngoscopy and post-docking, respectively, the differences in PI were statistically insignificant. PI at 10 min post-laryngoscopy was significantly lower than PI at 10 min post-docking (p < 0.0001). As non-invasively quantified by PI, videolaryngoscopic stress response is more intense but shorter-lived versus that due to docking. PI displays a negative correlation with haemodynamic variables. PI at laryngoscopy is a good predictor of PI at docking, enabling pre-emptive measures (fentanyl bolus; deepening of volatile anaesthesia from MAC-maintenance to MAC-intubation) anticipating the docking-induced stress response.Trial registration http://ctri.nic.in ; Identifier: CTRI/2019/11/022091.

Pulse Intensity Effects of Burst and Tonic Spinal Cord Stimulation on Neural Responses to Brushing in Patients With Neuropathic Pain.

OBJECTIVES: Tonic spinal cord stimulation (SCS) is accompanied by paresthesia in affected body regions. Comparatively, the absence of paresthesia with burst SCS suggests different involvement of the dorsal column system conveying afferent impulses from low-threshold mechanoreceptors. This study evaluated cortical activation changes during gentle brushing of a pain-free leg during four SCS pulse intensities to assess the effect of intensity on recruitment of dorsal column system fibers during burst and tonic SCS. MATERIALS AND METHODS: Twenty patients using SCS (11 burst, nine tonic) for neuropathic leg pain participated. Brushing was administered to a pain-free area of the leg during four SCS intensities: therapeutic (100%), medium (66%), low (33%), and no stimulation. Whole-brain electroencephalography was continuously recorded. Changes in spectral power during brushing were evaluated using the event-related desynchronization (ERD) method in theta (4-7 Hz), alpha (8-13 Hz), and beta (16-24 Hz) frequency bands. RESULTS: Brushing was accompanied by a suppression of cortical oscillations in the range 4-24 Hz. Stronger intensities of burst and tonic SCS led to less suppression of 4-7 Hz and 8-13 Hz bands in parietal electrodes, and in central electrodes in the 16-24 Hz band, with the strongest, statistically significant suppression at medium intensity. Tonic SCS showed a stronger reduction in 4-7 Hz oscillations over right sensorimotor electrodes, and over right frontal and left sensorimotor electrodes in the 8-13 Hz band, compared to burst SCS. CONCLUSIONS: Results suggest that burst and tonic SCS are mediated by both different and shared mechanisms. Attenuated brushing-related ERD with tonic SCS suggests a gating of cortical activation by afferent impulses in the dorsal column, whereas burst may engage different pathways. Diminished brushing-related ERD at medium and therapeutic intensities of burst and tonic SCS points towards a nonlinear effect of SCS on somatosensory processing.

Common anti-COVID-19 drugs and their anticipated interaction with anesthetic agents.

The corona virus disease 2019 (COVID-19) pandemic has till date (26/7/20) affected 1crore 62 lac 73 thousand 638 people globally with almost 6.5 lakh mortalities. COVID-19 has invaded the operation theatre and intensive care unit (ICU) in a short span of 6 months. It appears inevitable that all of us, as anesthesiologists, have to treat COVID-positive patients, either in the ICU or the operation theatre. Many asymptomatic, presumably noninfected people including frontline health care workers are also consuming potential anticorona viral drugs (such as hydroxychloroquine) prophylactically and may present for surgery. Detailed knowledge of which anesthetic and perioperative care drugs can interact with anti-COVID drugs would be very valuable for pre, intra-, and postoperative management of such patients and COVID-19 positive patients requiring intubation, mechanical ventilation, and ICU-sedation. Powered with this knowledge, anesthesiologists and intensivists can minimize the adverse effects of drug interactions. An extensive literature search using different search engines including Cochrane, Embase, Google Scholar, Scopus, and PubMed for all indexed review articles, original articles, case reports, and referenced webpages was performed to extract the most current and relevant literature on drug-drug interactions for clinicians.

The COVID-19 hydroxychloroquine prophylaxis perception of Indian anesthesiologists: A survey-based original article.

BACKGROUND AND AIMS: HCQ gained importance following the National Task Force advisory as an anti-SARS-Cov-2 (coronavirus disease-2019 [COVID-19]) drug for frontline healthcare workers (including anesthesiologists). Report of a young anesthesiologist in Assam developing cardiac arrest following HCQ intake for COVID-19 prophylaxis made us even more concerned. A conscious decision has been made by a large majority among us--to have or not to have HCQ. However, less severe complications such as gastrointestinal upset, skin-rash, visual-disturbance, headache, and dizziness even if experienced by HCQ users were likely to go unreported unless shared. The present survey was conducted to assess the prevailing perception among Indian anesthesiologists about HCQ's preventive effect against COVID-19. The information has been pooled together and discussed in this study. MATERIAL AND METHODS: A total of 247 respondents participated in this pan-India survey. The survey questionnaire was prepared using "Google Forms" and conducted via links delivered through WhatsApp and electronic-mail. RESULTS: 55.9% (138/247) of the respondents had consumed HCQ, 38% (94/247) did not, and 6.1% (15/247) were undecided at the time of responding to the survey. In total, 47 respondents who ingested HCQ reported a side-effect, gastritis being the commonest (31). CONCLUSION: The evidence for the effectiveness of HCQ against COVID-19 in India is reportedly as strong and weak as other drugs that have been promoted. The survey highlights the reasons consumption of HCQ and represents the opinion of 247 practicing Indian anesthesiologists. It informs the benefits and side effects of HCQ, which can help others in reaching a balanced decision.

Laryngoscope decontamination techniques: A survey.

BACKGROUND AND AIMS: India is a vast country with variable, nonuniform healthcare practices. A laryngoscope is an important tool during general anesthesia and resuscitation. The study aimed to determine the current practices of laryngoscope decontamination in India. MATERIAL AND METHODS: An online survey was conducted amongst 100 anesthesiologists to determine the common methods of laryngoscope decontamination adopted in their settings. The survey was done over 6 months after validating the questionnaire. RESULTS: A total of 73 responses were received out of 100. The result of the survey revealed that there is no uniform technique of laryngoscope decontamination. There is marked variability in techniques followed not only among different institutions, but also within the same institution. CONCLUSION: There are no fixed protocols adopted for laryngoscope decontamination. Thus, there is a need to develop definitive guidelines on this subject, which can be implemented in India.

Topical anesthesia.

Topical anesthetics are being widely used in numerous medical and surgical sub-specialties such as anesthesia, ophthalmology, otorhinolaryngology, dentistry, urology, and aesthetic surgery. They cause superficial loss of pain sensation after direct application. Their delivery and effectiveness can be enhanced by using free bases; by increasing the drug concentration, lowering the melting point; by using physical and chemical permeation enhancers and lipid delivery vesicles. Various topical anesthetic agents available for use are eutectic mixture of local anesthetics, ELA-max, lidocaine, epinephrine, tetracaine, bupivanor, 4% tetracaine, benzocaine, proparacaine, Betacaine-LA, topicaine, lidoderm, S-caine patch™ and local anesthetic peel. While using them, careful attention must be paid to their pharmacology, area and duration of application, age and weight of the patients and possible side-effects.

Current concepts of optimal cerebral perfusion pressure in traumatic brain injury.

Traumatic brain injury (TBI) consists of varied pathophysiological consequences and alteration of intracranial dynamics, reduction of the cerebral blood flow and oxygenation. In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation. Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg. Cerebral blood flow and metabolism are heterogeneous after TBI and with regional temporal differences in the requirement for CPP. Brain monitoring techniques such as jugular venous oximetry, monitoring of brain tissue oxygen tension (PbrO2), and cerebral microdialysis provide complementary and specific information that permits the selection of the optimal CPP. This review highlights the rationale for use CPP directed therapies and neuromonitoring to identify optimal CPP of head injured patients. The article also reviews the evidence provided by various clinical trials regarding optimal CPP and their application in the management of head injured patients.

Communication skills of anesthesiologists: An Indian perspective.

BACKGROUND: Communication failure is a risk factor for mishaps and complaints, which can be reduced by effective communication between operating room team members and patients. AIM: To conduct a survey among anesthesiologists regarding communications skills and related issues like stress in case of communication failure, need for training, music in operation theater, and language barrier at their work place. MATERIALS AND METHODS: We conducted a survey among anesthesiologists coming for a neuroanesthesia conference in India (n = 110) in February 2011 by questionnaire sent by e-mail to them. RESULTS: The response rate was 61.8% (68/110). Majority (95.5%) of the respondents agreed that good verbal communication leads to better patient outcome, better handling of crisis and is important between surgeons and anesthesiologists (98.5%). A total of 86% of the anesthesiologists felt that failure of communication caused stress to them. The idea of communication by e-mail or phone text messages instead of verbal communications was discouraged by 65.2%. A total of 82% of respondents felt that training of communication skills should be mandatory for all medical personnel and 77.6% were interested in participating in such course. Language barrier at work place was seen as hurdle by 62.7% of the respondents. A total of 80% of respondents felt that playing music in operating theater is appropriate. CONCLUSION: Results of the survey highlight the need for effective communication in the operating room between team members and need for formal training to improve it.

Choosing the correct-sized adult double-lumen tube: Quest for the holy grail.

Appropriate size selection of double-lumen tubes (DLTs) for one-lung ventilation (OLV) in adults is still a humongous task. Several important factors are to be considered like patient height, gender, tracheal diameter, left main bronchial diameter, and cricoid cartilage transverse diameter. In addition to radiological assessment of the airway diameters, the manufacturing details of the particular DLT being used also play a significant role in size selection. Optimal positioning of the appropriately sized DLT is indispensable to avoid complications like airway trauma, cuff rupture, hypoxemia, and tube displacement. It is imperative to know whether the one-size-fits-all dictum holds for DLT size selection as claimed by certain studies. Further randomized studies are required for crystallizing standard protocols ascertaining the correct DLT size. This systematic review article highlights the various parameters employed for DLT size selection and explores the newer DLTs used for adult OLV.

Supraclavicular block evaluation in oncoorthopedic patients under general anesthesia using perfusion index: A prospective cohort study.

Background: Supraclavicular brachial plexus blocks (SCBPB) are routinely placed prior to anaesthetic induction for post-operative pain relief after prolonged orthopaedic oncosurgery, since patients are required to remain awake for sensorimotor evaluation of block. If the window period after surgery but before anesthesia-reversal is employed for administering SCBPB, it bestows the quadruple advantage of being painless, not augmenting surgical bleed, longer post-operative analgesia and reduced opioid-related side effects. The problem spot is assessing SCBPB-efficacy under general anesthesia. Methods: This prospective, single-centric, observational cohort study included 30 patients undergoing upper limb orthopaedic oncosurgery under general anesthesia. Perfusion index (PI) was assessed using two separate units of Radical-7™ finger pulse co-oximetry devices simultaneously in both the upper limbs and PI ratios calculated. Skin temperature was noted. Results: After successful block, PI values in blocked limb suddenly increased after 5 min, progressively increasing for next 10 min, whereas PI failed to increase further above that attained post anaesthetic-induction in unblocked limb. PI values in the blocked limb were 4.32, 4.49, 4.95, 7.25, 7.71, 7.90, 7.94, 7.89, and 7.93 at 0, 2, 3, 5, 10, and 15 min post block-institution at reversal and 2 min, 5 min post-reversal, respectively. PI ratios at 2, 3, 5, 10, and 15 min post block-administration in the blocked limb, taking PI at local anaesthetic injection as denominator were 1.04, 1.15, 1.67, 1.78, and 1.83, respectively. Correlation between PI and skin temperature in the blocked limb gave a repeated measures correlation coefficient of 0.79. Conclusion: Monitoring trends in PI and PI-ratio in the blocked limb is a quantitative, non-invasive, inexpensive, simple, effective technique to monitor SCBPB-onset in anaesthetised patients.

Restorative neurostimulation for chronic mechanical low back pain - Three year results from the United Kingdom post market clinical follow-up registry.

Introduction: Mechanical chronic low back pain is often associated with impaired neuromuscular control of the lumbar multifidus muscles, the most important stabilizers of the lumbar spine. Restorative neurostimulation is a modality for the treatment for this specific subset of patients aimed to facilitate restoration of neuromuscular control by bilateral stimulation of the L2 medial branches. Evidence from both prospective and randomised clinical trials to date has demonstrated substantial improvements in clinical outcomes such as pain, disability and health-related quality of life. Methods: This study is an open label prospective follow-up for the treatment of chronic mechanical low back pain of nociceptive origin with restorative neurostimulation. Patients completed assessments for pain, disability and health-related quality of life. Outcomes were collected at 45, 90 and 180 days, and 1, 2 and 3 years after the activation visit. Results: Forty-two patients were implanted with the device and 33 (79%) were available at the 3-year appointment. Patients in this cohort presented with severe chronic low back pain (NRS = 7.0 ± 0.2) and severe disability (ODI 46.6 ± 12.0). The health-related quality of life was also severely impacted at baseline (EQ-5D 0.426 ± 0.061). Changes in pain, disability and quality of life at three-year follow-up demonstrated a statistically significant improvement between baseline and 1, 2 and 3 years. After 3 years of therapy, average NRS scores had reduced to 2.7± 0.3 and mean ODI score to 26.0 ± 3.1 while EQ-5D-5L index improved to 0.707 ± 0.036. Conclusions: The ongoing follow-up of this post market cohort continues to demonstrate that restorative neurostimulation provides a statistically significant, clinically meaningful and durable response across pain, disability and quality-of life scores for patients suffering chronic mechanical low back pain that has been refractory to conventional management. Trial Registration: ClinicalTrials.gov Identifier: NCT01985230.

Development of an interdisciplinary specialist facial pain management programme.

Aims: This article aims to describe the development of a specialist chronic facial pain (CFP) management programme within an already well-established pain management service, including the content from a multidisciplinary perspective, and present preliminary descriptive 6-month outcomes from patients who have attended the programme. Methods: Authors used their clinical experience of working with people who have a diagnosis of CFP. They researched available literature, liaised with CFP support organisations and visited an existing UK-based CFP programme. Programme content was designed based on findings. The roles of pain interdisciplinary team members involved in delivering the programme are described, as well as a brief description of the structure of the programme and programme sessions provided by each discipline. Results: Clinical outcomes from programme participants were collected at assessment, end of treatment and 6 months post-treatment, which measured relevant outcomes for a pain management programme (PMP). Outcomes from 36 participants at both end of programme and 6 months following completion of programme demonstrate promising improvements. Qualitative data from patient satisfaction questionnaires completed at the end of programme suggest that providing a CFP-specific programme was beneficial for participants, with the main critique being that the programme sessions should be longer than 45 minutes. Conclusion: Attending a CFP-specific programme demonstrated positive 6-month changes in relevant outcome measures for people with CFP. With a small sample size, there is a need for further research into the effectiveness. It would also be beneficial to compare outcomes from the usual PMP treatment with people who have CFP, with outcomes from a CFP-specific programme.

Real world experience with minimally invasive wireless percutaneous neuromodulation in a tertiary care centre.

Background: Wireless percutaneous nerve stimulation (PNS) for chronic pain is rapidly evolving in the ever expanding neuromodulation paradigm. Safety and lower risks with a potential of long-term analgesia cannot be over emphasised especially with the ongoing opioid pandemic. PNS with an implanted pulse generator (IPG) has also been shown to provide good benefit, without often unpleasant widespread paraesthesia from conventional spinal cord stimulators. Aim and Methods: We retrospectively extracted data on all wireless PNS implants in our highly specialised pain neuromodulation centre since initiation of wireless PNS service in August 2019. Patient demographics, pain history, analgesic intake and details on implant follow-up data within 1 year post-implant including pain relief, EuroQol-5 Dimension (EQ-5D) and Patients' Global Impression of Change (PGIC) scores were extracted. The cases are presented in a narrative format. Result: A total of five patients were implanted with wireless (Stimwave®) PNS from August 2019 to February 2020. Neuropathic pain was the most common presenting diagnosis. All patients showed >50% pain relief at 3 months. EQ-5D and PGIC did not show any improvement in the subjects. Two of the patients managed to decrease their analgesics after implantation. Similar sustained benefits could not be demonstrated after 1 year. Discussion: PNS can provide analgesia in appropriately selected cases. Naivety of the technique and procedure might cause some degree of uncertainty. External pulse generator with wireless transmission avoids IPG and tunnelling related side effects, but requires individualised special wearable technology to power the lead. Minimally invasive nature of the technique might be attractive and preferable for patients with complex medical issues, nickel allergy and poor general health who may otherwise be unsuitable for Spinal Cord Stimulation (SCS) with conventional hardware. Robust prospective controlled studies and RCTs in future might provide further insights on utility in other neuropathic pain diagnosis, long-term outcomes and acceptability compared to conventional SCS.

Utility of lung ultrasound for extravascular lung water volume estimation during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND AND AIMS: Rising extravascular lung-water index (ELWI) following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC), if not timely intervened, can progress to pulmonary oedema. Transpulmonary thermodilution (TPTDL) is a standard technique to estimate ELWI (T-ELWI score), and track ongoing changes. Lung ultrasound (LUS) is another technique for ELWI (L-ELWI score) estimation. However, reproducibility and reliability of LUS for tracking serial L-ELWI changes during CRS + HIPEC remains to be validated. METHODS: This prospective observational study included 360 L-ELWI and T-ELWI measurements at 12 peri-operative time-points. Cohen's Kappa test was used to assess reproducibility, Inter-rater agreement (between the anaesthetist and radiologist), and agreement between LUS and TPTDL for classifying the severity of pulmonary oedema. Reliability of LUS for 'tracking serial changes' in ELWI over time in individual patients was assessed by determining the repeated measures correlation (z-rrm) between weighted L-ELWI and T-ELWI scores. The ability of both techniques to discriminate pulmonary oedema was compared by analysing the area under ROC curves. RESULTS: Excellent inter-rater agreement for assigned L-ELWI scores was observed (linear weighted κ = 0.95 for both). Both techniques had a good agreement in classifying the severity of pulmonary oedema (linear weighted κ = 0.63, 95% CI 0.51-0.79). T-ELWI and weighted L-ELWI scores correlated strongly (z-rrm = 0.88, 95% CI 0.80-0.92, P < 0.0001). Both techniques had comparable ability to discriminate pulmonary oedema (difference in area under ROC curve = 0.0014, 95%CI -0.0027 to 0.0055, P = 0.5043). CONCLUSION: We found the utility of LUS as a reliable and reproducible technique for ELWI estimation and tracking its changes over time in CRS + HIPEC.

Experiences and Outcomes of Attending a Facial Pain Management Program: A Qualitative Study.

AIMS: To understand the experiences of patients diagnosed with chronic facial pain (CFP) who attended a specialist facial pain management program (PMP); specifically, to explore how they experienced attending the facial PMP itself and how they felt it impacted their management of CFP. METHODS: Qualitative methodology and focus groups were used to gather patients' views and experiences of attending a facial PMP. Two focus groups were conducted for patients who had all completed the facial PMP. Discussions were recorded and transcribed. Data were then analyzed using thematic analysis to establish key themes relating to participants' experiences of the facial PMP. RESULTS: Thematic analysis identified three main themes, with numerous subthemes within them. The theme "psychologic change" had subthemes of self-compassion, acceptance, and reflection. The theme "behavioral change" contained subthemes of re-engagement with valued activity, medication, and communication. The theme "structure and process" contained subthemes of concentration, need for one-on-one time with the clinician, meeting others, and not enough time (clinical and nonclinical). CONCLUSION: Facial PMPs may provide a valuable treatment to support long-term coping and adaptation for patients with CFP. Positive changes to coping include both psychologic and behavioral elements. Further research is necessary to clarify how group-based facial PMPs should be structured and delivered.

Restorative Neurostimulation for Chronic Mechanical Low Back Pain: Results from a Prospective Multi-centre Longitudinal Cohort.

INTRODUCTION: Low back pain impacts most people throughout the course of their lives and contributes significantly to the global burden of disease. In some patients, symptoms resolve with little intervention, while others are amenable to surgical intervention, some cases are intractable to current care paradigms. Restorative neurostimulation is an emerging therapy for chronic mechanical low back pain. METHODS: We conducted a prospective post-market follow-up of 42 patients treated for longstanding chronic mechanical low back pain with restorative neurostimulation. Patients were followed up at 45, 90, and 180 days and 1 and 2 years following activation of the device. Pain, disability, and health-related quality of life were recorded. RESULTS: Among the 37 patients completing 2-year follow-up, numerical rating scale (NRS) pain scores improved from 7.0 ± 0.2 to 3.5 ± 0.3 (p < 0.001), Oswestry Disability Index (ODI) scores improved from 46.2 ± 2.2 to 29.2 ± 3.1 (p < 0.001), and health-related quality of life (measured by the EuroQol 5-Dimension 5-Level questionnaire-EQ-5D-5L) improved from 0.426 ± 0.035 to 0.675 ± 0.030 (p < 0.001). Additionally, 57% of patients experienced a greater than 50% reduction in pain, and 51% of patients benefited by a greater than 15-point reduction in ODI, both substantial improvements. CONCLUSION: This real-world sample of patients shows that restorative neurostimulation can provide substantial and durable benefit to a cohort of patients that have traditionally had few reliable treatment options. Our findings support the continued used of this therapy in well-selected patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01985230.

The goal of this study was to examine the effectiveness of restorative neurostimulation for the treatment of patients with chronic mechanical low back pain. This technique has been studied in a clinical trial setting and been shown to be both safe and effective. This study reports on the real-world experience from five sites in the United Kingdom. Patients with a history of severe low back pain that lasted on average for more than 13 years were implanted with a nerve stimulation device that targets the nerves that control important spinal stabilising muscles. All of the patients were asked to perform two stimulation sessions per day for 30 min each. Over the next 2 years, patients reported substantial reductions in pain and disability and an improvement in health-related quality of life. The safety profile of the therapy was excellent when compared to similar minimally invasive therapies for different spine pathologies. In this difficult-to-treat patient population who have few remaining therapeutic options, restorative neurostimulation is a valuable tool in the clinician's armamentarium.

Intra-operative cerebral blood flow assessment by indocyanine green video-angiography after temporary arterial occlusion in aneurysm surgery and its clinical implications: a prospective study.

OBJECTIVE: Indocyanine green video angiography (ICG-VA) is a routine while performing vascular surgery to assess patency of perforators, completeness of clipping and/or to assess patency of anastomosis. Its usefulness in assessing cerebral blood flow and perfusion is not well studied. This study is aimed to assess the cerebral blood flow and perfusion after temporary clipping and to correlate with the risk of ischemia. METHODS: Prospective analysis of intra-operative ICG-VA performed during temporary arterial occlusion in 38 patients from January 2014 to December 2018 was conducted. Co-relation with post-operative MR diffusion weighted imaging (MR DWI) in terms of vascular territory of interest within 48 hours of surgery was performed. Clinical outcome was assessed using modified Rankin Scale (mRS) score 1-month post-surgery. RESULTS: 43 aneurysms in 38 patients clipped using ICG-VA were included in this study. No side effect of ICG dye was seen in any patients. The number of times temporary clips applied had a direct relationship to the delay in appearance of ICG in the surgical field which became statistically significant after application of 3rd temporary clip. Nine (23.7%) patients developed ischemia following the procedure confirmed by post-operative MR DWI and all the ischemic cases had visible decrease in ICG fluorescence post-temporary clipping. CONCLUSIONS: No previous study had tried to assess the intraoperative cerebral blood flow and perfusion during temporary clipping of parent vessels during aneurysm surgery. The use of ICG-VA can be extended to assess perfusion in desired territory by merely assessing the degree of opacification.

Cancer in corona times.

Humanity is witnessing an unprecedented tsunami of corona virus disease 2019 (COVID-19) patients. Till date, India houses 10,453 confirmed COVID-19 patients with a death toll of 358 nationwide and the number is steadily rising with each passing day. The capital city of Delhi, harbouring 1510 patients, has the dubious distinction of being the second largest hotspot for COVID positive patients in India, second only to the state of Maharashtra. Being immuno-compromised, cancer patients are first more susceptible to catch this virus and secondly may witness a more devastating course. Having cancer is a bigger risk factor for contracting COVID-19 than even old age. "Death due to untreated cancer is a much bigger reality than death due to COVID-19," is one perspective that advocates continuation of cancer therapy in corona times albeit by converting cancer hospitals into virtual corona-free fortresses with several tiers of barriers against corona. The immediate, short and long term implications of the corona pandemic and a nationwide lockdown to curtail it, on cancer patients and their caregivers is discussed at length here tempered with experience from the largest tertiary care oncology setup of Northern India. Rigorous literature review based on Medline, Google scholar, Embase, Cochrane and Scopus database search was utilized.