A novel remote assessment pathway to streamline the management of two-week-wait suspected head and neck cancer referrals: a prospective analysis of 660 patients.

OBJECTIVE: This study analyses outcomes for 660 patients managed via a novel telescopic pathway for suspected head and neck cancer referrals. METHOD: Data were collected prospectively between January 2021 and December 2022, capturing all two-week-wait referrals triaged as low risk and managed via a nurse-led clinic for nasendoscopic examination and consultant-led remote assessment. RESULTS: In total, 660 patients were included. There were six head and neck cancers diagnosed, giving a conversion rate of 0.9 per cent. Mean (standard deviation) time to informing the patient whether they did or did not have cancer (28-day faster diagnosis standard) was 28.6 days (20.2), with no significant difference observed in patients imaged prior to review (p = 0.63). No missed cancers were detected in the follow-up period. CONCLUSION: Low-risk head and neck cancer referrals can be safely managed in a nurse-led clinic for recorded examination with asynchronous consultant-led management. Further work is required to ensure adherence to the new faster diagnosis standard.

Recent Advances in Fuel-Driven Molecular Switches and Machines.

The molecular switches and machines arena has entered a new phase in which molecular machines operate under out-of-equilibrium conditions using appropriate fuel. Unlike the equilibrium version, the dissipative off-equilibrium machines necessitate only one stimulus input to complete each cycle and decrease chemical waste. Such a modus operandi would set significant steps towards mimicking the natural machines and may offer a platform for advancing new applications by providing temporal control. This review summarises the recent progress and blueprint of autonomous fuel-driven off-equilibrium molecular switches and machines.

Copper alumina @ poly (aniline-co-indole) nanocomposites: synthesis, characterization, electrical properties and gas sensing applications.

Poly(aniline-co-indole)/copper alumina (PANI-co-PIN/Cu-Al2O3) with excellent AC conductivity, dielectric properties, and ammonia gas detecting capabilities were synthesised via in situ chemical oxidative polymerization. The presence of Cu-O bonding vibrations and shift of some characteristic peaks in the Fourier transform infrared spectroscopy (FT-IR) revealed the successful encapsulation of Cu-Al2O3 nanoparticles in the copolymer. The XRD studies showed the crystalline peaks of Cu-Al2O3 in the PANI-co-PIN nanocomposites. The high-resolution transmission electron microscopy (HR-TEM) images confirmed the reinforcement of the inorganic moiety in the copolymer. The results from thermogravimetric analysis (TGA) showed that the inclusion of Cu-Al2O3 in the copolymer matrix greatly increases the thermal stability of PANI-co-PIN. The alternate current (AC) conductivity and dielectric properties of nanocomposites were higher than pure PANI-co-PIN. The improved electrical properties of nanocomposites were due to strong contact between the copolymer and metal oxide surfaces. The gas sensing properties of synthesized copolymer nanocomposites showed excellent sensitivity and response towards ammonia gas at room temperature. The PANI-co-PIN/5 wt% Cu-Al2O3 nanocomposite has the best gas sensing characteristics. The higher AC conductivity, dielectric properties and gas sensing characteristics of PANI-co-PIN/Cu-Al2O3 might be used to develop electrochemical sensing devices.

Introduction of a novel telescopic pathway to streamline 2-week-wait suspected head and neck cancer referrals and improve efficiency: A prospective service evaluation.

OBJECTIVES: This study summarizes the introduction of a novel telescopic pathway, which streamlines 2-week-wait suspected head and neck cancer referrals to our unit, describes the logistics of the pathway, and analyzes referral numbers and outcomes. We also discuss wider issues surrounding remote assessment in head and neck cancer. METHODS: Data were collected prospectively between January and May 2021, capturing all 2-week-wait referrals to our unit following the introduction of a telescopic pathway which utilized a nurse-led clinic for nasendoscopic examination of selected patients and consultant-led remote assessment using store and forward technology. Information on referral numbers, waiting times and outcomes was recorded. RESULTS: Three hundred and forty (185 high risk, 155 low risk) patients entered the telescopic pathway with the remaining 74 patients seen on the conventional standard of care pathway. Cancer conversion rates were 17%, <1%, and 5.4% for the high-risk telescopic, low-risk telescopic and standard of care pathways respectively. No patients discharged from the telescopic pathway were re-referred within 3 months. Review capacity for endoscopic examination was higher per consultant on the telescopic pathway versus the standard of care (p = .01). CONCLUSION: A combination of risk stratification and asynchronous telescopic assessment shows promise for the management of suspected head and neck cancer referrals. Potential benefits include consultant-led care for all patients and enhanced documentation. Digital communication with patients may also assist with adherence to the new NHS 28-day diagnostic standard for cancer referrals. Ongoing data collection is required to assess how the pathway functions over a longer period. LEVEL OF EVIDENCE: 2c.

Postoperative outcomes in patients undergoing elective general surgery after recovery from Covid-19 at a tertiary care centre: A one-year case series.

Background Planned elective surgery had to be postponed for a large number of patients who tested positive for Covid-19 in the preoperative period. We aimed to assess the postoperative outcomes of patients who were operated on for elective indications, following recovery from Covid-19 infection. Methods We did a retrospective study of patients who underwent elective general surgery between 1 April 2020 and 31 March 2021, following recovery from Covid-19. The 30-day postoperative morbidity and mortality were analysed. The data relevant for the study were retrieved from the hospital's electronic medical records. Results Of the 109 patients included, 54.1% were women and the median (range) age was 49 (16-76) years; 53.2% of operations were performed for benign indications and the rest were for malignancies. Eighty-five (78%) patients underwent surgery following recovery from an asymptomatic Covid-19 infection and 23 (21.1%) patients following recovery from mild Covid-19 infection; 73.3% of the operations were performed following a planned delay of 2- 5 weeks from the diagnosis of Covid-19. The 30-day major postoperative morbidity (Clavien-Dindo grade ≥3) was 6.4%, the postoperative pulmonary morbidity was 0.9%, and there was no 30-day mortality. Conclusions Elective general surgical procedures can be done safely in patients who have recovered from asymptomatic and mild Covid-19 infection, following a minimum wait period of 2 weeks.

Chloroform Fraction of Methanolic Extract of Seeds of Annona muricata Induce S Phase Arrest and ROS Dependent Caspase Activated Mitochondria-Mediated Apoptosis in Triple-Negative Breast Cancer.

BACKGROUND: Triple Negative Breast Cancers (TNBCs) have high morbidity and shorter survival rate in the population. These types of cancers have high aggressiveness, lymphatic invasion, and absence of receptors. The treatment options for these types of cancers are also scarce. Several studies have been conducted to investigate the effectiveness of seeds of Annona muricata for its anti-cancer activities in various cancer cell lines, such as lung A549, breast MCF7, colon HT-29, oral KB, and human hepatoma cell lines. But works related to its anti-cancer effect and mechanism of action in TNBCs have not been elucidated. OBJECTIVE: The present study was undertaken to evaluate the in vitro, in vivo, and in silico anti-cancer potential of chloroform fraction of methanolic extract of seeds of Annona muricata (CMAM) against TNBC along with elucidation of its mechanistic pathway. METHODS: In vitro cytotoxicity- and antiproliferative- studies in three triple-negative breast cancer cell lines were conducted using the MTT and SRB assays, respectively. The mechanism through which CMAM exerts its pharmacological effect was elucidated in vitro employing cell morphological assessment studies using Acridine Orange/Ethidium Bromide (AO/EB), intracellular reactive oxygen species assay, DNA fragmentation assay, agarose gel electrophoresis, terminal deoxynucleotidyl Transferase dUTP Nick End Labeling (TUNEL) assay, cell cycle analysis, annexin binding assay, and caspase-activated mitochondria-mediated apoptotic assays using western blot. In vivo evaluation in 4T1 induced murine mammary tumor model was also conducted. Phytoconstituents in CMAM were analyzed using liquid chromatography mass spectroscopy. In silico binding studies with various annonaceous acetogenins against BCL-2 and cyclin E were performed. RESULTS: Cytotoxicity studies in MDA-MD-231, 4TI, and BT-549 revealed the IC50 value of CMAM to be 2.5±0.14, 4.8±0.3, and 4.5±0.16µg/mL, respectively. Anti-proliferative studies in 4T1, MDA-MB-231, and BT- 549 revealed the GI50 values to be 0.128+0.03, 18.03+0.20, 0.95+0.04µg/mL, respectively. CMAM exhibited its cytotoxicity through the lysis of cell membrane, ROS dependent caspase-activated mitochondria-mediated apoptosis, and arresting the S phase of the cell cycle. In vivo evaluation also supported the tumoricidal property of CMAM, as evidenced by a reduction in tumor volume and serum biomarkers. Histopathologically, there was a marked reduction in cellularity, nuclear chromatin condensation, and a few normal cells in the group treated with CMAM at a dose of 31mg/Kg. Phytoconstituent evaluation has revealed the presence of annonaceous acetogenins in CMAM. Among the various annonaceous acetogenins, muricatacin alone showed lipophilicity and binding affinity towards BCL-2 and cyclin E1. CONCLUSION: The current study shows the effectiveness of CMAM against TNBC both in vitro and in vivo. This anticancerous effect of CMAM could be by virtue of its ROS dependent caspase-activated mitochondriamediated apoptosis and the S-phase arrest of the cell cycle in the TNBCs. Our results indicate that the presence of annonaceous acetogenins, especially muricatacin, could be contributing to this anticancerous effect of CMAM. Thus, muricatacin could be a potential candidate for the targeted therapy of TNBCs.

Transoral Robotic Surgery for Residual and Recurrent Oropharyngeal Cancers.

Transoral robotic surgery (TORS) is a well-established treatment option for treatment-naïve oropharyngeal cancer. For residual, recurrent, and new primary oropharyngeal tumors emerging in previously irradiated fields, the global experience of management with TORS is limited. This article discusses current concepts on this topic, offers a deeper insight into the transoral anatomy for these cases, and covers the specific complexities of resections in the various subsites of the oropharynx. It provides practical tips on reconstruction, recovery, and rehabilitation as well as offering a synthesis of the current evidence and exploring future trends.

Telescopic otology referrals: Evaluation of feasibility and acceptability.

OBJECTIVE: A remote telemedical otology referral and advice service was introduced to interested general practices. General practitioners (GPs) were given a new device, "endoscope-i" that combines an optimized smartphone high definition video app with an otoendoscope. They were specifically trained to examine and capture images of patients' eardrums, which were sent electronically with a summary of clinical information and an in-app hearing testing (if required), for specialist advice to two ear, nose, and throat (ENT) consultants. We describe the findings from an evaluation of the first 6 months of this service to establish the feasibility and acceptability of an otology telemedical referral and advice service. METHODS: The new service was advertised to GP practices in Northern Staffordshire. All interested GPs were provided with training and equipment to deliver the remote referral service. Data were collected from GPs at baseline, informal feedback in response to referral outcomes and end of service feedback. Referral data were collected routinely during the service delivery. RESULTS: Fifteen GP leads from 15 practices received training and equipment. One quickly lost the equipment. Of the remaining 14 practices, eight sent a total of 53 remote referrals using this technology over 6 months. The most common reason for referral was an uncertainty of what could be seen in or around the eardrum. The primary barrier for implementation was lack of wireless internet connections within practices. GPs reported that they used this technology to share examination findings with patients. CONCLUSIONS: GPs were positive about the technology, from initial engagement with training and after advice were given. Some GPs expanded the role of the technology to a consultation aid. Referral volume was manageable. Commissioners should consider tariffs structures for such services; empirical cost-effectiveness and workload-impact evaluation would inform this.

A cadaveric study quantifying the anatomical landmarks of the facial artery and its parapharyngeal branches for safe transoral surgery.

BACKGROUND: Hemorrhage remains a major potential risk when performing any form of transoral surgery. This is the first study to focus on the location of the facial artery "bulb" (FaB) and its tonsillar branches within the parapharyngeal space (PPS) from the perspective of the transoral surgeon. METHOD: A total of 44 hemi-sections were dissected via the transoral approach with endoscopic assistance: 26 from fresh-frozen specimens and 18 formalin-fixed hemi-sections. The distance from the superior apex of the FaB to the pterygoid hamulus (PH) was recorded, and the arterial branching variations described. RESULTS: The average distance from the PH to the FaB was 4.17 ± 0.4 cm. In 90.9% of cases, the two tonsillar artery branches passed between styloglossus muscle (SGM) and stylopharyngeus muscle (SPM). CONCLUSION: Understanding the FaB location and its branching patterns offers the surgeon confidence dissecting in the PPS transorally.

Ixodid Tick Vectors of Wild Mammals and Reptiles of Southern India.

BACKGROUND: We aimed to focus on the ixodid ticks parasitizing wild mammals and reptiles from Wayanad Wildlife Sanctuary, Western Ghat, southern India. METHODS: The taxonomic identification of ticks collected from wild mammals and reptiles was performed based on the morphology of adults. RESULTS: We revealed eight species of ticks including, Amblyomma integrum, Rhipicephalus (Boophilus) annulatus, Haemaphysalis (Kaiseriana) spinigera, H. (K.) shimoga, H. (K.) bispinosa, H. (Rhipistoma) indica, Rhipicephalus haemaphysaloides and R. sanguineus s.l. collected from nine species of wild mammals while four tick species Ablyomma kraneveldi, A. pattoni, A. gervaisi and A. javanense parasitizing on four species of reptiles. The highest host richness was shown by H. (K.) bispinosa and R. haemaphysaloides parasitizing six and five different host species, respectively. Reports of R. (B.) annulatus on sambar deer, A. javanense and A. kraneveldi on python as well as A. pattoni on Indian rat snake are the new host records from this region. CONCLUSION: Eight species of ticks parasitizing on nine species of wild mammals and four species of parasitizing on four species of reptiles were identified. The highest host richness was shown by H. (K.) bispinosa and R. haemaphysaloides. H. spinigera as the vector of KFD was also identified in this study.

A Novel Approach to Identifying the Spinal Accessory Nerve in Surgical Neck Dissection.

Intraoperative identification of the spinal accessory nerve (SAN) is key in reducing nerve injury. This study aims to explore the surgical anatomy of the SAN and 2 landmarks for its identification-the sternocleidomastoid branch of the occipital artery (SBOA) and superior sternocleidomastoid tendon (SST)-to propose a novel method of identifying the SAN during surgical neck dissections. Twelve cadavers underwent bilateral level II-V neck dissection identifying the SAN, SBOA, and SST. Variation was documented and distance between landmarks and the SAN measured. The most common arrangement had the SST most superficially followed by the SBOA and then the SAN. The SAN was 3.63 ± 4.02 mm from the artery and 2.31 ± 1.72 mm from the tendon. A triangle-bordered by the tendon laterally, artery medially, and digastric muscle superiorly-contained the SAN in 95.8% of cases. This relationship translated into a reliable technique to identify the SAN intraoperatively, which has been used successfully in practice.

The incidence of deep venous thrombosis in high-risk Indian neurosurgical patients: Need for early chemoprophylaxis?

INTRODUCTION: Deep venous thrombosis (DVT) is thought to be less common in Asians than in Caucasian population. The incidence of DVT in high-risk groups, especially the neurosurgical (NS) patients, has not been well studied. This leaves no firm basis for the start of early prophylactic anticoagulation within first 5 postoperative days in Indian NS patients. This is a prospective observational study to determine the early occurrence of DVT in the NS patients. PATIENTS AND METHODS: We screened 137 consecutive high-risk NS patients based on inclusion and exclusion criteria. The femoral veins were screened using Doppler ultrasound on day 1, 3, and 5 of admission into the NS Intensive Care Unit (ICU) at tertiary center from South India. RESULTS: Among 2887 admissions to NICU 147 patients met inclusion criteria. One hundred thirty seven were screened for DVT. There was a 4.3% (6/137) incidence of DVT with none of the six patients having signs or symptoms of pulmonary embolism. Among the risk factors studied, there was a significant association with femoral catheterization and a probable association with weakness/paraparesis/paraplegia. The mortality in the study group was 10.8% with none attributable to DVT or pulmonary embolism. CONCLUSION: There is a low incidence of DVT among the high risk neurosurgical population evaluated within the first 5 days of admission to NICU, limiting the need for early chemical thrombo-prophylaxis in these patients. With strict protocols for mechanical prophylaxis with passive leg exercise, early mobilization and serial femoral Doppler screening, heparin anticoagulation can be restricted within the first 5 days of ICU admission in high risk patients.

Single-Stage BAHA and Mastoid Obliteration.

A single-stage fitting of a bone-anchored hearing aid (BAHA) implant and abutment with mastoid obliteration both obviates the need for two separate procedures and utilises the BAHA soft tissue reduction in the mastoid obliteration. Such a procedure has good outcomes in terms of osseointegration and achieving a dry ear. We present a 6-patient case series report highlighting the technique of combined BAHA insertion and mastoid obliteration in six patients. All patients at twelve-month followup have a good degree of sound localisation and hearing thresholds with their BAHA and are free from the social stigma associated with a foul smelling discharging ear.

Molecular characterization of Theileria orientalis causing fatal infection in crossbred adult bovines of South India.

The disease condition attributed to have been caused by Theileria orientalis is generally benign. However, it is also thought that the parasite, at least some strains of it, can cause fatal disease. The present communication deals with the clinical signs, postmortem lesions and diagnosis of a fatal disease due to T. orientalis which caused mortality in crossbred adult bovines of South India. High body temperature, lacrimation, nasal discharge, swollen lymph nodes and haemoglobinuria were the symptoms observed. The postmortem lesions observed were punched out ulcers in abomasum, enlargement of spleen, massive pulmonary oedema, frothy exudates in trachea, epicardial and endocardial haemorrhage and haemorrhagic duodenitis. Peripheral blood smear examination revealed rod shaped Theileria sp. organisms. Polymerase chain reaction that amplify the T. orientalis specific P(32/33) gene, followed by cloning and sequencing, revealed maximum homology with Narathiwat (Thailand) and Jingole -1 (Indonesia) isolates which were positioned as isolate type 7 of T. orientalis.

Nasal injury management: an audit of accident and emergency practice.

Nasal injuries are commonly assessed in the accident and emergency (A&E) departments. Where swelling precludes assessment of deformity, patients are often referred to the ear, nose and throat (ENT) outpatients once the swelling has subsided. However, not all of these pateints require referral. Patients with no deformity, or those in whom there is no deformity after any swelling has subsided, do not need further assessment. The purpose of this audit was to assess the impact of a nasal injury management guideline on nasal injury referrals to the ENT department. An audit was made of nasal injury referrals seen in ENT outpatients, before and after the introduction of a guideline. The proportion of patients seen in ENT outpatients not requiring any ENT treatment after the introduction of the guideline was reduced. We suggest that our guideline can reduce unnecessary ENT outpatient appointments for patients with nasal injuries and may prevent delayed ENT input for those with new onset nasal deformity.