A comparative evaluation of fibreoptic bronchoscopy versus C-MAC® D-BLADE-guided videolaryngoscopy for nasotracheal intubation under general anesthesia in oropharyngeal carcinoma surgery patients.

PURPOSE: Nasotracheal intubation (NTI) is required for surgery in oropharyngeal (OP) carcinoma patients, but it may be challenging because of distorted anatomy, mucosal congestion, and increased risk of bleeding. Flexible bronchoscopy (FB)-guided NTI is preferred in these cases but has limitations. In this randomized controlled study, we sought to compare C-MAC® D-BLADE-guided videolaryngoscopy (VL) (Karl Storz SE & Co. KG, Tuttlingen, Germany) with FB for NTI under general anesthesia in patients with OP carcinomas. METHODS: We randomized a total of 100 patients with OP carcinoma and El-Ganzouri's risk index (EGRI) < 7 to undergo NTI under general anesthesia with FB (n = 50) or C-MAC D-BLADE-guided VL (n = 50). The primary outcome was the total intubation time. We also recorded the time to glottis view, nasal intubation difficulty scale (NIDS) score, best percentage of glottis opening score, and complications. RESULTS: The median [interquartile range (IQR)] total intubation time was shorter with VL than with FB (total intubation time, 38 [26-43] sec vs 60 [52-65] sec; difference, -20 sec [95% confidence interval (CI), -27 to -11]; P < 0.001). Similarly, the median [IQR] time to glottis view was shorter with VL compared to FB (8 [6-9] sec vs 22 [14-25] sec; difference, -13 sec [95% CI, -17 to -10]; P < 0.001). The median NIDS score was higher with VL (difference, 2 [95% CI, 2 to 3]; P < 0.001). The incidences of airway trauma (two cases with FB vs seven with VL; P = 0.30) and postoperative sore throat (ten cases in both groups; P = 0.56) were similar. CONCLUSION: Compared to FB, C-MAC D-BLADE-based VL reduced the total time for nasal intubation oropharyngeal carcinoma patients, potentially representing an acceptable alternative in selected cases. TRIAL REGISTRATION: CTRI.nic.in (2018/11/0162830); first submitted 8 November 2018.

RéSUMé: OBJECTIF: L'intubation nasotrachéale est nécessaire pour la chirurgie chez la patientèle atteinte de carcinome oropharyngé, mais elle peut être difficile en raison d'une anatomie déformée, d'une congestion des muqueuses et d'un risque accru de saignement. Dans ces cas, il est préférable d'utiliser une intubation nasotrachéale guidée par bronchoscopie flexible (BF), mais cette modalité a ses limites. Dans cette étude randomisée contrôlée, nous avons cherché à comparer la vidéolaryngoscopie guidée par lame D-BLADE C-MAC® (VL) (Karl Storz SE & Co. KG, Tuttlingen, Allemagne) à la BF pour réaliser l'intubation nasotrachéale sous anesthésie générale chez les patient·es ayant un carcinome oropharyngé. MéTHODE: Au total, nous avons randomisé 100 personnes atteintes d'un carcinome oropharyngé et présentant un indice de risque d'El-Ganzouri (EGRI) < 7 à bénéficier d'une intubation nasotrachéale sous anesthésie générale par BF (n = 50) ou par VL guidée par lame D-BLADE C-MAC (n = 50). Le critère d'évaluation principal était le temps d'intubation total. Nous avons également enregistré le temps écoulé jusqu'à la visualisation de la glotte, le score sur l'échelle de difficulté de l'intubation nasale (NIDS), le meilleur pourcentage de score d'ouverture de la glotte et les complications. RéSULTATS: La durée totale d'intubation médiane [écart interquartile (ÉIQ)] était plus courte avec la VL qu'avec la BF (durée totale d'intubation, 38 [26­43] sec vs 60 [52 à 65] secondes; différence, −20 sec [intervalle de confiance (IC) à 95 %, −27 à −11]; P < 0,001). De même, le temps médian [ÉIQ] jusqu'à la visualisation de la glotte était plus court avec la VL qu'avec la BF (8 [6­9] sec vs 22 [14 à 25] secondes; différence, −13 sec [IC 95 %, −17 à −10]; P < 0,001). Le score médian sur l'échelle NIDS était plus élevé avec la VL (différence, 2 [IC 95 %, 2 à 3]; P < 0,001). L'incidence des traumatismes des voies aériennes (deux cas avec la BF vs sept avec la VL; P = 0,30) et le mal de gorge postopératoire (dix cas dans les deux groupes; P = 0,56) étaient similaires. CONCLUSION: Par rapport à la BF, la VL guidée par lame D-BLADE C-MAC a réduit le temps total d'intubation nasale pour les personnes atteintes d'un carcinome oropharyngé, ce qui représente potentiellement une alternative acceptable dans certains cas. ENREGISTREMENT DE L'éTUDE: CTRI.nic.in (2018/11/0162830); première soumission le 8 novembre 2018.

Establishing Trimester-Specific Haemoglobin A1c Reference Intervals in Pregnant Women: A retrospective study of healthy South Asian women with normal pregnancy outcomes.

Objectives: This study aimed to define trimester-specific haemoglobin A1c (HbA1c) reference intervals in healthy, pregnant South Asian women. Methods: This retrospective study was conducted at St. Stephen's Hospital, Delhi, India, between January 2011 and December 2016. Healthy pregnant women were compared to a control group of healthy non-pregnant women. Pregnant participants had term deliveries of babies with appropriate gestational weights. The HbA1c levels were calculated in terms of non-parametric 2.5 and 97.5 percentiles for women in first (T1), second (T2) and third (T3) trimester groups. Statistical tests were used to obtain the normal HbA1c reference values and were considered significant when P <0.05. Results: This study included a total of 1,357 healthy pregnant women and a control group of 67 healthy, non-pregnant women. Pregnant women had a median HbA1c of 4.8% (4-5.5%) or 32 mmol/mol (20-39 mmol/mol); non-pregnant women had a median HbA1c of 5.1% (4-5.7%) or 29 mmol/mol (20-37 mmol/mol; P <0.001). The HbA1c levels for the T1, T2 and T3 groups were 4.9% (4.1-5.5%) or 30 mmol/mol (21-37 mmol/mol), 4.8% (4.5-5.3%) or 29 mmol/mol (20-34 mmol/mol) and 4.8% (3.9-5.6%) or 29 mmol/mol (19-38 mmol/mol), respectively. The HbA1c values were significant when comparing T1 versus T2 (P <0.001), T1 versus T3 (P = 0.002) and T1 versus the non-pregnant group (P = 0.001). However, T2 versus T3 was not significant (P = 0.111). Conclusion: Compared to non-pregnant women, HbA1c levels were lower in pregnant women, despite women in the T2 and T3 groups having a higher body mass index than the women in the T1 and non-pregnant groups. Further research is recommended to understand the factors responsible and validate these findings.

Use of Pearson and Spearman correlation testing in Indian anesthesia journals: An audit.

Background and Aims: Correct usage and interpretation of biostatistical tests is imperative. Aim of the present article was to evaluate the use of "correlation test" for biostatistical analysis in two leading Indian journals of anesthesia and sensitize the readers regarding its correct usage. Material and Methods: A prospective analysis was done for all original articles using the correlation test (Pearson or Spearman) that were published in "Indian Journal of Anaesthesia" (IJA) or "Journal of Anaesthesiology and Clinical Pharmacology" (JOACP) in the years 2019 and 2020. Results: Amongst all included original studies, correlation test were used in 6% (JOACP) and 6.5% (IJA) respectively (averaged for the years 2019 and 2020). Correlation test was usedinappropriately) for evaluating an aim of prediction/agreement/comparison, rather than association, in 25% and 10% instances each (JOACP and IJA). In both JOACP and IJA, there were high rates of using and interpreting results without citing 95% confidence intervals (CIs) of correlation coefficient (88% and 90%, respectively), P value for significance of the association (50% and 90%, respectively), or coefficient of discrimination (88% and 70%, respectively). In majority of the instances, test to ascertain presence of mandatory prerequisites such as normal distribution of data could not be found (62% and 90%, respectively). Conclusion: The complete potential of correlation test in exploring research questions is probably underappreciated. Further, even when used, its application and interpretation are prone to errors. We hope that the present analysis and narrative is a well-timed appropriate step in bridging the gaps in existing knowledge regarding use of correlation test in national anesthesia literature.

Overview of statistical methods usage in Indian anaesthesia publications.

Background and Aims: Despite the importance of statistics being well established for medical research, it remains a neglected area of understanding and learning. The present survey aimed to examine the use of various statistical methods in a two-year sample (2019-2020) of representative Indian anaesthesia journals and compare it with an international top-ranked journal. Methods: The literature survey included analysis of 748 original articles from 'Indian Journal of Anaesthesia' (179), 'Journal of Anaesthesiology Clinical Pharmacology' (125) and 'Anesthesia & Analgesia' (444) published over the period. Original research articles were identified from the table of contents of each issue. Articles were assessed for statistical methods, categorised as being descriptive, elementary, multivariable, advanced multivariate or diagnostic/classification. Results: Compared to Anesthesia & Analgesia, the Indian journals (considered together) had a significantly greater use of mean (standard deviation) (91.2% versus 70%) and percentages (79.5% versus 67.6%) (P = 0.000 each); and lesser for Wilcoxon (5.4% versus 14.6%) and Pearson/Spearman (5.1% versus 13.5%) correlation tests (P = 0.000 each), multivariable tests including various regression methods (P < 0.001), classification/diagnostic tests [Receiver operating characteristic (ROC) curve analysis, P = 0.022; sensitivity/specificity, P = 0.000; precision, P = 0.006; and relative risk/risk ratio, P = 0.010] and a virtual absence of complex multivariate tests. Conclusion: The findings show limited use of advanced complex statistical methods in Indian anaesthesia journals, usually being restricted to descriptive or elementary. There was a strong bias towards using randomised controlled designs. The findings suggest an urgent and focussed need on training in research methodology, including statistical methods, during postgraduation and continued medical training.

COVID 19-related burnout among healthcare workers in India and ECG based predictive machine learning model: Insights from the BRUCEE- Li study.

OBJECTIVES: COVID-19 pandemic has led to unprecedented increase in rates of stress and burn out among healthcare workers (HCWs). Heart rate variability (HRV) has been shown to be reflective of stress and burnout. The present study evaluated the prevalence of burnout and attempted to develop a HRV based predictive machine learning (ML) model to detect burnout among HCWs during COVID-19 pandemic. METHODS: Mini-Z 1.0 survey was collected from 1615 HCWs, of whom 664, 512 and 439 were frontline, second-line and non-COVID HCWs respectively. Burnout was defined as score ≥3 on Mini-Z-burnout-item. A 12-lead digitized ECG recording was performed and ECG features of HRV were obtained using feature extraction. A ML model comprising demographic and HRV features was developed to detect burnout. RESULTS: Burnout rates were higher among second-line workers 20.5% than frontline 14.9% and non-COVID 13.2% workers. In multivariable analyses, features associated with higher likelihood of burnout were feeling stressed (OR = 6.02), feeling dissatisfied with current job (OR = 5.15), working in a chaotic, hectic environment (OR = 2.09) and feeling that COVID has significantly impacted the mental wellbeing (OR = 6.02). HCWs with burnout had a significantly lower HRV parameters like root mean square of successive RR intervals differences (RMSSD) [p < 0.0001] and standard deviation of the time interval between successive RR intervals (SDNN) [p < 0.001]) as compared to normal subjects. Extra tree classifier was the best performing ML model (sensitivity: 84%) CONCLUSION: In this study of HCWs from India, burnout prevalence was lower than reports from developed nations, and was higher among second-line versus frontline workers. Incorporation of HRV based ML model predicted burnout among HCWs with a good accuracy.

Design and rationale of an intelligent algorithm to detect BuRnoUt in HeaLthcare workers in COVID era using ECG and artificiaL intelligence: The BRUCEE-LI study.

BACKGROUND: There is no large contemporary data from India to see the prevalence of burnout in HCWs in covid era. Burnout and mental stress is associated with electrocardiographic changes detectable by artificial intelligence (AI). OBJECTIVE: The present study aims to estimate the prevalence of burnout in HCWs in COVID-19 era using Mini Z-scale and to develop predictive AI model to detect burnout in HCWs in COVID-19 era. METHODS: This is an observational and cross-sectional study to evaluate the presence of burnout in HCWs in academic tertiary care centres of North India in the COVID-19 era. At least 900 participants will be enrolled in this study from four leading premier government-funded/public-private centres of North India. Each study centre will be asked to recruit HCWs by approaching them through various listed ways for participation in the study. Interested participants after initial screening and meeting the eligibility criteria, will be asked to fill the questionnaire (having demographic and work related with Mini Z questionnaire) to assess burnout. The healthcare workers will include physicians at all levels of training, nursing staff and paramedical staff who are involved directly or indirectly in COVID-19 care. The analysis of the raw electrocardiogram (ECG) data and development of algorithm using convolutional neural networks (CNN) will be done by experts. CONCLUSIONS: In Summary, we propose that ECG data generated from the people with burnout can be utilized to develop AI-enabled model to predict the presence of stress and burnout in HCWs in COVID-19 era.

Tumor-host interface in oral squamous cell carcinoma: Impact on nodal metastasis and prognosis.

PURPOSE: To evaluate tumor-host interface in oral squamous cell carcinoma (OSCC) by the Brandwein-Gensler histological risk score (BG risk score); to assess its association with clinicopathological features and impact on survival outcomes in a contemporary cohort staged as per AJCC 8th edition pTNM classification. METHODS: This retrospective cohort study at a tertiary care centre included 178 cases of OSCC treated by primary surgical resection from 2013 to 2016. Pathological lymph node status, disease-free survival (DFS), overall survival (OS) were assessed. RESULTS: BG risk score assessment categorized 25 (14%) cases as low-risk, 93 (52%) as intermediate-risk, and 60 (34%) as high-risk. BG risk score category progression from low to intermediate to high risk was associated with an incremental risk of worsening pN status, DFS, and OS. BG risk score categories significantly demarcated 2-year DFS (96% in low-risk, 51.6% in intermediate-risk, 15% in high-risk; p < 0.001) and OS (96% in low-risk, 66.7% in intermediate-risk, 31.3% in high-risk; p < 0.001). On stratified analysis, BG risk score could further demarcate prognosis in early (I/II) and late (III/IV) stage subgroups (p < 0.001). Multivariate analysis indicated the prognostic impact of BG risk score categories to be additional to, and of equal magnitude to, impact of pTNM stage. CONCLUSIONS: BG risk score is a powerful prognostic tool in OSCC additional to pTNM staging. It can enable risk stratification and inform decisions regarding post-surgical adjuvant treatment. It is undertaken with routine histopathological evaluation, with no increased expense or turnaround time. A case is made for its inclusion in OSCC reporting guidelines.

Current Status and Future of End-Stage Kidney Disease in Gulf Cooperation Council Countries: Challenges and Opportunities.

There is a paucity of data on epidemiology along with an incomplete registry of end-stage kidney disease (ESKD), nephrologist workforce, and variability among the countries of Gulf Cooperation Council (GCC). The study is an observation, descriptive study which aimed to describe current ESKD burden, nephrologist density, and kidney care infrastructure in GCC. Responses to a questionnaire-based survey obtained from representatives of the Nephrology Societies of GCC countries were analyzed. The categorical variables were compared using Chi-square test. A P = 5% was considered as significant. The mean prevalence of ESKD per million populations (pmp) was 551, highest in Oman (1000/pmp), least in Qatar (347/pmp). Predominant etiology in GCC was diabetes mellitus (DM) and hypertension (HTN) (100%, each), followed by chronic glomerulonephritis (66.7%). A transplant registry was maintained by all GCC countries. Hemodialysis (HD) (67.2%) was the most opted modality of kidney replacement therapy (KRT), followed by kidney transplantation (22%) and peritoneal dialysis (9.6%); 1.0% of patients opted for conservative management. Unplanned initiation of HD was three times more common. The access distribution among incident and prevalent HD patients respectively was (i) nontunneled central catheter (nTCC) (58.7 ± 36.6 vs. 1.5 ± 1.5), (ii) tunneled central catheter (23.5 ± 29.9 vs. 33.6 ± 10.0), and (iii) arteriovenous fistula (17.3± 14.4 vs. 57.8 ± 11.86). Death and transplantation were the reasons for dropout from HD. GCC has adequate kidney care infrastructure. There are 1686 nephrologists [range: Bahrain 9, Kingdom of Saudi Arabia (KSA) 1279]. Qatar, KSA, and Kuwait provide training in kidney biopsy; all countries except Bahrain have formal training programs for nTCC placement. ESKD prevalence is high, DM, HTN; glome-rulonephritis (GN) is the most common causes. The need for KRT is expected to rise in GCC. HD is the predominant KRT modality with a high prevalence of dialysis catheters as vascular access.

Serum and Urinary Hepcidin for Diagnosing Iron-deficiency Anemia in Under-5 Children.

Bone marrow iron estimation remains the gold standard for diagnosing iron-deficiency anemia (IDA); serum ferritin, total iron-binding capacity, and transferrin saturation are routinely used as surrogate markers of IDA. However, these tests are marred by problems like poor specificity and sensitivity. Recently, hepcidin, a protein hormone synthesized in the liver and excreted in urine, has been shown to be related to iron status. We estimated the serum and urinary hepcidin levels in healthy children 6 to 60 months of age with (n=30) and without IDA (n=30). The mean (SD) serum hepcidin levels in children with IDA were significantly lower than those in children without IDA (3.03 [1.06] vs. 4.78 [3.94] ng/mL; P=0.02). The mean (SD) urinary hepcidin levels were also significantly lower in children with IDA than those in children without IDA (2.29 [0.53] vs. 2.79 [0.75] ng/mL; P=0.004). Performance of urinary and serum hepcidin compared with serum ferritin (<12 µg/L) for diagnosing IDA in terms of area under the receiver operating characteristic curve was 0.704 (P=0.007) and 0.59 (P=0.22), respectively. Serum hepcidin is not useful for diagnosing IDA in under-5 children. In contrast, urinary hepcidin holds promise as a noninvasive diagnostic tool for IDA in under-5 children.