Impact of C-reactive Protein on Anticoagulation Monitoring in Extracorporeal Membrane Oxygenation.

OBJECTIVE: To evaluate the impact of inflammation on anticoagulation monitoring for patients supported with extracorporeal membrane oxygenation (ECMO). DESIGN: Prospective single-center cohort study. SETTING: University-affiliated tertiary care academic medical center. PARTICIPANTS: Adult venovenous and venoarterial ECMO patients anticoagulated with heparin/ MEASUREMENTS AND MAIN RESULTS: C-Reactive protein (CRP) was used as a surrogate for overall inflammation. The relationship between CRP and the partial thromboplastin time (PTT, seconds) was evaluated using a CRP-insensitive PTT assay (PTT-CRP) in addition to measurement using a routine PTT assay. Data from 30 patients anticoagulated with heparin over 371 ECMO days was included. CRP levels (mg/dL) were significantly elevated (median, 17.2; interquartile range [IQR], 9.2-26.1) and 93% of patients had a CRP of ≥5. The median PTT (median 58.9; IQR, 46.9-73.3) was prolonged by 11.3 seconds compared with simultaneously measured PTT-CRP (median, 47.6; IQR, 40.1-55.5; p < 0.001). The difference between PTT and PTT-CRP generally increased with CRP elevation from 2.7 for a CRP of <5.0 to 13.0 for a CRP between 5 and 10, 17.7 for a CRP between 10 and 15, and 15.1 for a CRP of >15 (p < 0.001). In a subgroup of patients, heparin was transitioned to argatroban, and a similar effect was observed (median PTT, 62.1 seconds [IQR, 53.0-78.5 seconds] vs median PTT-CRP, 47.6 seconds [IQR, 41.3-57.7 seconds]; p < 0.001). CONCLUSIONS: Elevations in CRP are common during ECMO and can falsely prolong PTT measured by commonly used assays. The discrepancy due to CRP-interference is important clinically given narrow PTT targets and may contribute to hematological complications.

Role of Antioxidant Vitamins in Oral Submucous Fibrosis: A Narrative Review.

Oral submucous fibrosis (OSMF) has a high rate of malignant transformation and is an insidious chronic inflammatory disease. Though this disorder seems to be multifactorial in origin, betel quid chewing appears to be the main etiologic factor. Various treatment strategies have been attempted but none proven to cure the disorder because of its multimodal pathogenesis. Reactive oxygen species (ROS) appear to have a role in cancer formation. As OSMF is an oral premalignant disorder and found to be associated with carcinogens like areca nut and tobacco, it is believed to have some relationship with ROS. Tissue damage due to ROS along with other mechanisms may result in the complex pathophysiology of OSMF. The antioxidant system in the body helps to prevent damage caused by highly reactive ROS and helps in the repair of tissues. To study the levels of oxidative stress and antioxidant vitamins in OSMF condition, the present review was done. We carried out a thorough literature search to identify original reports and studies determining the status of oxidative stress and antioxidant vitamins in OSMF condition using several databases including Google Scholar, PubMed, and Scopus. Our review observed that the oxidative stress increased in the condition of OSMF as shown by an increase in malonaldehyde (MDA) and a decrease in antioxidant vitamins like vitamin A, vitamin C, and vitamin E. Also, after the intake of antioxidant vitamins, there was symptomatic improvement in OSMF patients. With the help of identifying oxidative stress and antioxidant status, we can assess the clinical stage of OSMF and can develop a comprehensive treatment plan.

The Year in Thoracic Anesthesia: Selected Highlights from 2022.

This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.

Exploring the Role of Anatomical Imaging Techniques in Preoperative Planning for Orthopaedic Surgeries.

INTRODUCTION: The incorporation of a three-dimensional (3D) framework enables the surgeon to strategically plan their surgical intervention through the utilisation of the printed model. This encompasses the process of ascertaining the surgical approach, choosing the suitable reduction technique, finding the required implant dimensions, defining the ideal placement and alignment of the implant, and conducting a simulated practise of the procedure using a 3D printed duplicate of the anatomical structures. Therefore, we designed this study to evaluate the role of two imaging modalities (computed tomography (CT) and magnetic resonance imaging (MRI)) for pre-surgical planning for orthopaedic surgeries. METHODOLOGY: The present investigation entailed a prospective analysis of total knee arthroplasties (TKAs) that were performed using patient-specific instrumentation (PSI) from 2019 to 2022. After performing the bone resection operation utilising a customised cutting jig specific to each patient, the exact thickness of the resected bone was evaluated using a vernier calliper. In the MRI group, the researchers directly compared the cutting thickness during surgery with the consistency planned before the operation. In contrast, the CT group added the presumed cartilage thickness (2 mm) to the actual thickness of the bone that was removed from the lateral condyles. RESULTS:  The planned incision thickness in the distal femoral was 8.5 ± 0.8 in the CT group and 8.9 ± 0.5 in the MRI group, while the actual incision thickness was reported as 9.8 ± 0.54 in CT and 8.3 ± 1.1; however, no significant mean difference was found between both groups. The planned incision thickness was 2.6 ± 1.1 in the CT group and 2.43 ± 1.66 in the MRI group, while the actual thickness was observed as 2.5 ± 0.6 and 2.88 ± 1.12 without significant difference (p = 0.86). CONCLUSION: While magnetic resonance imaging (MRI) allows for the visualisation of cartilage, it has been observed that the MRI-based patient-specific instrumentation (PSI) system does not exhibit superior accuracy in projecting bone incision thickness compared to the computed tomography (CT)-based PSI system.

Cells of the renin lineage promote kidney regeneration post-release of ureteral obstruction in neonatal mice.

AIM: Ureteral obstruction leads to significant changes in kidney renin expression. It is unclear whether those changes are responsible for the progression of kidney damage, repair, or regeneration. In the current study, we aimed to elucidate the contribution of renin-producing cells (RPCs) and the cells of the renin lineage (CoRL) towards kidney damage and regeneration using a model of partial and reversible unilateral ureteral obstruction (pUUO) in neonatal mice. METHODS: Renin cells are progenitors for other renal cell types collectively called CoRL. We labeled the CoRL with green fluorescent protein (GFP) using genetic approaches. We performed lineage tracing to analyze the changes in the distribution of CoRL during and after the release of obstruction. We also ablated the RPCs and CoRL by cell-specific expression of Diphtheria Toxin Sub-unit A (DTA). Finally, we evaluated the kidney damage and regeneration during and after the release of obstruction in the absence of CoRL. RESULTS: In the obstructed kidneys, there was a 163% increase in the renin-positive area and a remarkable increase in the distribution of GFP+ CoRL. Relief of obstruction abrogated these changes. In addition, DTA-expressing animals did not respond to pUUO with increased RPCs and CoRL. Moreover, reduction in CoRL significantly compromised the kidney's ability to recover from the damage after the release of obstruction. CONCLUSIONS: CoRL play a role in the regeneration of the kidneys post-relief of obstruction.

Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia.

Background: There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle. Aim: This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India. Method: A retrospective case file study was conducted across several centers in India. Results: Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions. Conclusions: Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Evaluation of the quality of life of patients with maxillofacial defects after prosthodontic rehabilitation: A cross-sectional study.

Context: Oral cancer surgery leads to hard- and soft-tissue loss which can affect the quality of life of the individuals. Maxillofacial prosthodontics focuses on optimizing the disrupted oral function of individuals whose rehabilitation will serve as a psychosocial therapy. Aim: The aim of this study was to assess the oral health-related quality of life (OHRQoL) after the maxillofacial prosthetic rehabilitation following cancer resection surgery. Settings and Design: The sample comprised 15 oral cancer patients who agreed to maxillofacial prosthesis (MFP) after surgery. Materials and Methods: Oral function and OHRQoL were evaluated pre- and postmaxillofacial prosthetic rehabilitation. The masticatory function, swallowing function, and articulatory function were evaluated. The OHRQoL was evaluated by OHIPJ-14 questionnaire. Descriptive methods such as frequency, percentage, mean, and standard deviation were calculated. Statistical Analysis: Descriptive statistics was used to analyze the results. Results: A statistically significant difference was observed between prescores and postscores of dysphagia score (P = 0.05) and OHIP-J14 score (P = 0.00). No statistically significant differences were evident in perceived chewing ability (P = 0.29) and intelligibility score (P = 0.43). A statistically significant difference was evident in the prescore and postscore of OHIP-J14 subscales: functional limitations (P < 0.05), physical pain (P < 0.05), psychological discomfort (P < 0.05), physical disability (P < 0.05), psychological disability (P < 0.05), and handicap (P < 0.05), before and after maxillofacial prosthetic treatment except for social disability (P > 0.05). Conclusion: OHRQoL significantly improved with maxillofacial prosthetic rehabilitation.

Influence of presence or absence of posts on the failure rates of post endodontic restorations: A systematic review and meta-analysis.

Aim: The study was designed to evaluate the existing evidence on the failure rates of post-endodontic restorations retained with and without post in endodontically treated teeth (ETT). Settings and Design: Preferred Reporting Items for Systematic Reviews and Meta-Analyses- Protocol (PRISMA-P) guidelines were used to formulate the review. Materials and Methods: Randomized controlled trials (RCT's) and prospective clinical studies comparing post endodontic restorations retained with and without post were included. PubMed/Medline, Embase, Cochrane Library and Scopus databases were searched to recognize relevant full-text articles in English language. The quality of the RCT's were evaluated using the Cochrane collaboration tool to assess the risk of bias and reported as having high, low or unclear risk. Random-effects model at a 95% confidence interval was used for the meta-analysis. Statistical Analysis Used: Meta-analyses was performed using the Mantel -Haenszel method31 and risk ratio, with a 95% confidence interval (CI), was estimated for dichotomous data. Random effects model32 was used as the pooling method and 95% confident interval (α = .05 for RR values) in Review Manager (RevMan) [Computer program]. Version 5.4. The Cochrane Collaboration, 2020). Results: Four studies comparing post retained and post free restorations in ETT with a total of 916 restorations were included in the analysis. The total risk ratio was 2.16, (95% CI:1.25 to 3.72). Conclusion: ETT with post retained restorations exhibited significantly lower failure rates compared to restorations without post. Well-designed RCT's are warranted to develop a clinical protocol with respect to post-retained restorations.

Development and Evaluation of the POPBL (Patient-Oriented Problem-Based Learning) Module in Pathology: A Comparative Analysis of Performance and Perception Among Second-Year Pathology Students.

Background and objective Employing the POPBL (Patient-Oriented Problem-Based Learning) method to teach students offers a fresh take on the classroom experience. It helps to enhance the motivation of the students, improves knowledge, self-learning behavior, and clinical reasoning, and also helps to promote long-lasting memory. In our medical college, we adopted a newer technology-oriented method with the use of case history, laboratory findings, a gross specimen of the same case, microscopic live sessions via Deca and Penta head microscopes, television, and microscopic camera. In light of this, in this study, we aimed to develop a patient- and technology-oriented new Problem-Based Learning (PBL) method and compare its effectiveness with the traditional tutorial method. Materials and methods A total of 149 second-year MBBS students were enrolled in the study. Consent was taken from all students. A total of eight systems of systemic pathology from the second-year MBBS curriculum were selected. Of the eight systems, four were covered under POPBL with gross and microscopic features associated with the help of newer-generation audiovisual aids, and the other four systems were covered under the traditional tutorial/lecture method. The evaluation was performed using prevalidated objective types of questions after exposure of about one week. The objective was to evaluate and compare the outcomes and students' performance between these two sets of pathology systems. Results Students gave excellent responses. Performance (87.92% of students had scores >75%) and attendance (94.14%) parameters with respect to POPBL gross and microscopic features associated with the help of newer-generation audiovisual aids like Deca and Penta head microscopes were superior compared to the traditional tutorial/lecture method, where 53.02% of students scored more than 75% and the attendance was 76.12%. The difference in attendance was also statistically significant (p=0.05). Conclusion Using POPBL instead of standard tutorial/lecture methods leads to better outcomes. Students also found POPBL more appealing than standard lectures. It is a student-centered method that provides a significant level of motivation and encourages active participation among students. The efficacy of this new way of teaching and demonstrating will attract more students to this method.

Effectiveness of low-level laser therapy after surgical removal of impacted mandibular third molars: A randomized clinical trial.

Introduction: The low-level laser therapy has been accepted globally as cell bio-modulator, used to reach ideal therapeutic effects, acting in the reduction of the pain response, with anti-inflammatory effects, stimulating local micro-circulation and wounds repair, promoting a rapid recovery, which brings a better quality of life to the patient. In this study, we aim to to determine the effectiveness of low-level laser therapy on reducing the pain and swelling after removal of impacted third molars. Materials and Methods: In this present prospective randomized clinical study, third molar surgeries were performed in thirty patients who were divided into two equal groups (placebo group and study group) a placebo group with routine treatment and a study group with low-level laser therapy which was applied both intraorally and extraorally after the surgical extraction of mandibular third molar. Results: The parameters such as postoperative pain, edema, and trismus were assessed on 1st and 7th day. All these parameters showed statistically significant results in patients with low-level laser therapy. Conclusions: Low-level laser therapy was effective in reducing the postoperative pain, edema, and trismus in the third molar surgeries.

Severe COVID-19 disease in a 2nd trimester pregnancy: Successful ECMO and mechanical ventilation management.

Extracorporeal membrane oxygenation (ECMO) is an invasive support strategy for cardiac, respiratory, or combined cardiorespiratory failure. ECMO has become increasing utilized in patients with severe respiratory failure due to COVID-19 infection. To our knowledge there is no report of successful ECMO utilization in second trimester of pregnancy leading to a successful outcome. We present a case of severe COVID-19 infection in a patient causing respiratory failure in the second trimester pregnancy. With diligent utilization of ECMO and mechanical ventilation we were able to support the patient's respiratory needs to allow her pregnancy to continue. Ultimately, the patient underwent successful caesarean section in the third trimester. This case highlights excellent lung injury protection and lung recovery can be achieved through optimal utilization of ECMO support together with a careful and closely monitored lung protective ventilation strategy, even while also supporting the patient through the increasing metabolic circumstances of a progressing pregnancy.

Certificate Course in Occupational Safety and Health: A Capacity Building Program for Primary Care Physicians based on Adult Learning Model.

Context: The need for physicians qualified in the field of occupational safety and health (OSH) is growing with the growth of manufacturing and service sectors where maximum number of work-related morbidity and mortality occur. Aims: This article aims to assess the effectiveness and feasibility of the certificate course in occupational safety and health for training and capacity building of primary care physicians in OSH. Methods and Material: Guideline for reporting evidence-based practice educational interventions and teaching (GREET) was used for describing educational interventions. The outcome was assessed by comparing the mean scores. t test with P < 0.005 was considered a level of significance. Results: The result showed significant improvement in the cumulative pre- and post-test scores after each module. The certificate course is suitable for adult learning as there was no intergroup difference in knowledge after the program. Consistent with the findings, the improvement scores indicate that training has made a difference in the knowledge and learning of the trained physicians. Conclusions: This customized training intervention has high potential for scaling up while optimally addressing the scarcity of trained physicians in the OSH in high population density settings like India where a high number of vulnerable workforces work in the informal economy.

Mental health promotion for elderly populations in World Health Organization South-East Asia Region: Needs and resource gaps.

The accelerated population growth of the elderly (individuals aged 60 years or more) across the globe has many indications, including changes in demography, health, the psycho-social milieu, and economic security. This transition has given rise to varied challenges; significant changes have been observed in regard to developing strategies for health care systems across the globe. The World Health Organization (WHO) is also engaging in initiatives and mediating processes. Furthermore, advocacy is being conducted regarding a shift toward the salutogenic model from the pathogenic model. The concept behind this move was to shift from disablement to enablement and from illness to wellness, with the notion of mental health promotion (MHP) being promoted. This article attempts to discuss the MHP of elderly individuals, with special reference to the need to disseminate knowledge and awareness in the community by utilizing the resources of the health sector available in the WHO South-East Asia Region countries. We have tried to present the current knowledge gap by exploring the existing infrastructure, human resources, and financial resources. There is much to do to promote the mental health of the elderly, but inadequate facilities are available. Based on available resources, a roadmap for MHP in elderly individuals is discussed.

Comparative evaluation of flow profile of commercially available vinyl polysiloxane impression materials - An in-vitro study.

Background: Flow characteristics of vinyl polysiloxane (VPS) impression materials are important determinants in the selection of impression materials for the fabrication of accurate indirect restorations. Aims: : The purpose of this study was to determine the flow of three commercially available VPS impression materials at different time intervals using a shark fin device (3M ESPE, Seefeld, Germany). Study Setting and Design: This in-vitro study was carried out at the prosthodontics department of a dental institution. Methods and Material: The height of the shark fin produced by each impression material determined the rate of flow. Statistical Analysis: The data were analysed using one-way analysis of variance (ANOVA) and post-hoc Tukey's test (p-0.05). Results: : Shark fin height of group A VPS impression material was significantly higher at 30 and 120 seconds compared to group B and group C VPS impression materials. Shark fin height produced by group B VPS impression materials at 60 and 90 seconds was significantly higher than the group C VPS impression material but non-significant compared to group A. At 120 seconds, there was no significant difference in the shark fin heights of all the tested materials. Conclusion: All the materials exhibited adequate flow characteristics within clinically acceptable limits.

The Effect of Povidone-Iodine Nasal Spray on Nasopharyngeal SARS-CoV-2 Viral Load: A Randomized Control Trial.

OBJECTIVES/HYPOTHESIS: To determine the effect of povidone-iodine (PVP-I) nasal sprays on nasopharyngeal (NP) viral load as assessed by cycle threshold (Ct) on quantitative polymerase chain reaction (qPCR) of SARS-CoV-2 in outpatients. STUDY DESIGN: Three arm, triple blinded, randomized, placebo-controlled clinical trial. METHODS: Participants were randomized within 5 days of testing positive for COVID-19 to receive nasal sprays containing placebo (0.9% saline), 0.5% PVP-I, or 2.0% PVP-I. NP swabs for qPCR analysis were taken at baseline, 1-hour post-PVP-I spray (two sprays/nostril), and 3 days post-PVP-I spray (20 sprays/nostril). Symptom and adverse event questionnaires were completed at baseline, day 3, and day 5. University of Pennsylvania Smell Identification Tests (UPSIT) were completed at baseline and day 30. RESULTS: Mean Ct values increased over time in all groups, indicating declining viral loads, with no statistically significant difference noted in the rate of change between placebo and PVP-I groups. The 2.0% PVP-I group showed statistically significant improvement in all symptom categories; however, it also reported a high rate of nasal burning. Olfaction via UPSIT showed improvement by at least one category in all groups. There were no hospitalizations or mortalities within 30 days of study enrollment. CONCLUSIONS: Saline and low concentration PVP-I nasal sprays are well tolerated. Similar reductions in SARS-CoV-2 NP viral load were seen over time in all groups. All treatment groups showed improvement in olfaction over 30 days. These data suggest that dilute versions of PVP-I nasal spray are safe for topical use in the nasal cavity, but that PVP-I does not demonstrate virucidal activity in COVID-19 positive outpatients. LEVEL OF EVIDENCE: 2 Laryngoscope, 132:2089-2095, 2022.

Adjuvant Priming Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Obsessive-Compulsive Disorder: In Search of a New Paradigm!

OBJECTIVES: Repetitive transcranial magnetic stimulation (rTMS) is used as a therapeutic option for obsessive-compulsive disorder (OCD) in both clinical and research settings. There has been no consensus with regard to target area and other parameters, although 1-Hz rTMS over the supplementary motor area (SMA) is found to be promising. Priming stimulation, which involves high-frequency followed by low-frequency rTMS, has been shown to enhance neural response to low-frequency rTMS. Hence, this study was conducted to investigate the effect of adjunctive priming rTMS over the SMA in treatment-resistant OCD. METHODS: Thirty patients with OCD who were symptomatic after an adequate selective serotonin reuptake inhibitor trial were randomized into 2 groups: one group receiving active priming stimulation (6-Hz rTMS at 80% resting motor threshold) followed by 1-Hz rTMS (priming rTMS group) and the other receiving sham stimulation followed by 1-Hz rTMS (rTMS-only group). Both groups received 10 sessions of such interventions for 2 weeks. Both the rater and patients were blind to the treatment allocation. Assessments were done using the Yale-Brown Obsessive Compulsive Scale, Hamilton Rating Scale for Depression, Hamilton Rating Scale for Anxiety, and Clinical Global Impression-Improvement scale at baseline, 2 weeks, and 4 weeks. RESULTS: Both groups showed a significant improvement in all domains of psychopathology over time. The priming rTMS group was better than the rTMS-only group in reducing the Yale-Brown Obsessive Compulsive Scale compulsion score (P < 0.023) as well as scores of the Hamilton Rating Scale for Anxiety, Hamilton Rating Scale for Depression, and Clinical Global Impression-Improvement scale. None developed any adverse effects requiring medical attention. CONCLUSIONS: Priming rTMS over the SMA is safe and has favorable effects in OCD. It seems to have a predominant effect on the reduction of compulsions, presumably rectifying the impaired response inhibition in patients with OCD.