A comparative study of key quality performance indicators in anesthesia and surgery in operation theatre at a tertiary care hospital in Rishikesh.

Background and Aims: A Key Performance Indicator (KPI) is a critical metric measuring organizational success or specific activities, reflecting the periodic achievement of operational goals aligned with strategic objectives. Material and Methods: A retrospective cross-sectional study of key quality performance indicators, (CQI-NABH) concerning anesthesia and surgical services was conducted at a tertiary care hospital after taking institutional ethical clearance (AIIMS/IEC/21/150). It was as per COP 13, COP 14, and COP 15 standards of NABH 4th edition published in 2015. The study was conducted at the department of anesthesiology at a tertiary care hospital, and data were retrospectively analyzed from 01 October 2019, till November 2020. All patients undergoing elective or emergency surgical procedures under monitored anesthesia care and regional or general anesthesia during the study period were considered.The primary objective was to analyze Continuous Quality Improvement (CQI) in perioperative services, with secondary goals including gap identification, suggesting corrective actions, and examining quality indicators during the COVID-19 pandemic in 2020. Results: Out of 8574 patients operated during the study, 6705 were in the four months before the pandemic, and 1869 were operated during the COVID-19 scenario. In the pre-COVID era, many of the cases were performed on an elective basis (71.23%), and emergencies constituted 16.9% of the total number of cases. In the COVID era, most of the cases were emergencies (45.4%) and semi-emergencies (40.25%), and elective cases were only 14.05% of the total cases performed. The percentage of modification of anaesthesia plans ranged from 0-3.34%. Adverse anaesthesia events were observed in 0-2.1%, primarily related to cardiovascular, respiratory, and airway issues. No anaesthesia-related mortality was reported. Prophylactic antibiotic administration within one hour of surgery ranged from 88-100%. Conclusions: Monitoring and evaluating healthcare performance, specifically through KPIs, is vital for optimizing care and resource utilization. These indicators provide an overview of hospital service efficiency, aiding in key areas such as patient treatment, satisfaction, healthcare quality improvement, cost reduction, and optimal resource utilization. Addressing identified issues ensures effective and sustainable quality improvement in anaesthesia services, emphasizing ongoing monitoring as a foundation for hospital quality assurance.

Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial.

BACKGROUND: Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking. METHODS: In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months. RESULTS: An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported. CONCLUSIONS: An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. TRIAL REGISTRATION NUMBER: NCT04854616.

Incidence, risk factors, and outcomes of acute kidney injury in patients undergoing emergency laparotomy - A prospective observational exploratory study.

Background and Aims: Acute kidney injury (AKI) can occur in post-laparotomy patients, with a variable incidence. This study aimed to determine the incidence of AKI in patients undergoing emergency laparotomy under general anaesthesia, the effect of preoperative variables on the development of AKI, and the association of post-operative AKI with patient outcomes. Methods: This prospective exploratory study in patients undergoing emergency laparotomy was followed up for 7 days to determine the incidence of post-operative AKI. We determined the patients developing different severity of AKI based on kidney disease improving global outcome staging. Fisher's exact test or Chi-squared test was used to study the association of demographic variables, and various periopertaive variables on the development of postoperative AKI. The association of AKI with the duration of hospital stay was estimated using the Wilcoxon-Mann-Whitney U Test, and Fisher's exact test was used to study the association between AKI and mortality. Results: No patient had AKI in the pre-operative period. On day 3, 18 patients; on day 5, 28 patients; and on day 7, 24 patients developed AKI. Overall, a maximum of 33 patients (out of 100) developed AKI at any time. Our study found that the American Society of Anesthesiologists (ASA) IV and sepsis were independent risk factors for post-operative AKI. Our results also show a moderate-to-high independent association between AKI and duration of hospital stay and mortality (within 30 days). Conclusion: Incidence of post-operative AKI following emergency laparotomy was 33%. Higher preoperative ASA physical status and sepsis were significantly associated with postoperative AKI development.

Intra-operative Tranexamic Acid Administration Significantly Decreases Incidence of Postoperative Bleeding Without Increasing Venous Thromboembolism Risk After Laparoscopic Sleeve Gastrectomy: a Retrospective Cohort Study of Over 400 Patients.

BACKGROUND: There is evidence that tranexamic acid (TXA) reduces surgical bleeding and is widely used in trauma, obstetrics and other specialties. This practice is less well-established in laparoscopic sleeve gastrectomy (LSG) due to concerns surrounding venous thromboembolism (VTE); equally postoperative bleeding is a serious complication often requiring re-operation. METHODS: This retrospective cohort study compared 30-day outcomes following primary LSG in patients receiving intra-operative TXA (March 2020-July 2022) to those who did not (March 2011-March 2020). The primary outcome was postoperative bleeding (Hb < 9 g/dL) requiring transfusion or re-operation. Secondary outcomes were incidence of VTE, serious postoperative complications (Clavien-Dindo > grade 3) and death. Patients underwent standardised-protocol LSG without staple line re-enforcement under a single surgeon within the independent sector (private practice). TXA 1 g intravenous was administered immediately after a methylene blue leak test, prior to extubation. RESULTS: TXA group had 226 patients and non-TXA group had 192 patients. Mean age was 40.5 ± 10.3 and 39.1 ± 9.8 years, respectively. In the TXA group, no postoperative bleeds [versus 3 (1.6%) in non-TXA group, p = 0.0279] occurred. One staple line leak (0.4%) occurred in the TXA group compared to zero in the non-TXA group (p = ns). There was no VTE or death. CONCLUSIONS: This is the largest cohort study of intra-operative TXA in primary LSG to date, which demonstrates significant decrease in postoperative bleeding without increasing VTE risk. The authors recommend administration of TXA immediately following leak test, or removal of bougie to maximise efficacy. Data of TXA in LSG is awaited from the randomised controlled PATAS trial.

Complications of Epicardial Pacing Wire Removal Following Adult Cardiac Surgery: A Systematic Review.

Pacing wires are commonly used during cardiac surgery to monitor heart rhythm and, if necessary, provide temporary pacing. These wires are usually removed a few days after surgery, but the procedure has been associated with complications. The purpose of this study was to summarize the literature on complications related to pacing wire removal after cardiac surgery. A systematic review was conducted using the PubMed, Embase, and Cochrane Library databases. Articles from January 1, 1998, to December 31, 2022, were considered. The literature was then registered with PROSPERO (registration number: CRD42023418165). PROSPERO is the first database to record systematic reviews in health, and it promotes best practices around the world through broad consultation to eliminate redundancy and waste of time and money. Following that, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to screen the data. PRISMA consists of a four-stage flow diagram and a "checklist" of 27 elements necessary for the rigorous and transparent dissemination of the systematic review's techniques and conclusions. These methods were used to ensure the integrity of the systematic review. The systematic review included six studies with a total of 18,453 patients. The most common pacing wire removal complications were retention of the wire (0.56%), arrhythmia (0.67%), delayed discharge due to delayed wire removal (0.41%), and cardiac tamponade (0.1%). The overall complication rate was 1.74%. A subgroup analysis revealed that earlier removal (within 48-72 hours of surgery) was associated with a higher incidence of bleeding, whereas later removal (after 72 hours) was associated with a higher incidence of delayed discharge. Pacing wire removal following cardiac surgery is associated with many complications, including retention of wire, arrhythmia, delayed discharge, tamponade, and death. These complications are more likely to occur with earlier or later removal of the pacing wires. Although the complication rate was lower, clinicians should be aware of these risks and take appropriate precautions when scheduling pacing wire removal. More research is needed to determine the necessity of pacing wires in cardiac surgery.

A computational model of current control mechanism for long-term potentiation (LTP) in human episodic memory based on gene-gene interaction.

The establishment of long-term potentiation (LTP) is a prime process for the formation of episodic memory. During the establishment of LTP, activations of various components are required in the signaling cascade of the LTP pathway. Past efforts to determine the activation of components relied extensively on the cellular or molecular level. In this paper, we have proposed a computational model based on gene-level cascading and interaction in LTP signaling for the establishment and control of current signals for achieving the desired level of activation in the formation of episodic memory. This paper also introduces a model for a generalized signaling pathway in episodic memory. A back-propagation feedback mechanism is used for updating the interaction levels in the signaling cascade starting from the last stage and ending at the start stage of the signaling cascade. Simulation of the proposed model has been performed for the LTP signaling pathway in the context of human episodic memory. We found through simulation that the qualifying genes correction factors of all stages are updated to their maximum limit. The article explains the signaling pathway for episodic memory and proves its effectiveness through simulation results.

Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta-analyses.

BACKGROUND: Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e-cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies. OBJECTIVES: To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e-cigarettes, when used to help people stop smoking tobacco. SEARCH METHODS: We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e-cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co-interventions (e.g. behavioural support) were eligible if the co-intervention was provided equally to study arms. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta-analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta-regression. We evaluated certainty using GRADE. MAIN RESULTS: Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e-cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high-certainty evidence that nicotine e-cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast-acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high-certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast-acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate-certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non-nicotine/placebo e-cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low-certainty evidence), equating to one additional quitter (95% CrI -2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low-certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non-nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low-certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e-cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e-cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2). AUTHORS' CONCLUSIONS: The most effective interventions were nicotine e-cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high-certainty evidence for the effectiveness of nicotine patch, fast-acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non-nicotine e-cigarettes and tapering of nicotine dose (both low certainty). There was moderate-certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head-to-head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation.

Changes in lung cancer staging and emergency presentations during the first year of the COVID-19 pandemic.

Aim: This study retrospectively analyses the impact of the 1st year of the COVID-19 pandemic on route of presentation and staging in lung cancer compared to the 2 years before and after implementation of the Leicester Optimal Lung Cancer Pathway (LOLCP) in Leicester, United Kingdom. Method: Electronic databases and hospital records were used to identify all patients diagnosed with lung cancer in 2018 (pre-LOLCP), 2019 (post-LOLCP), and March 2020-2021 (post-COVID-19 lockdown). Information regarding patient characteristics, performance status, stage, and route of diagnosis was documented and analysed. Emergency presentation was defined as diagnosis of new lung cancer being made after unscheduled attendance to urgent or emergency care facility. Results: Following implementation of the LOLCP pathway, there was a significant decrease in emergency presentations from 26.8 to 19.6% (p = 0.002) with a stage shift from 33.9% early stage disease to 40.3%. These improved outcomes were annulled during the COVID-19 pandemic, with emergency presentations increasing to 38.9% (p < 0.001) and a reduction in early-stage lung cancer diagnoses to 31.5%. There was a 61% decline in 2 week wait referrals but no significant decline in the LOLCP direct-to-CT referrals. Conclusion: We have demonstrated a significant increase in late-stage lung cancer diagnoses and emergency presentations during the first year of the COVID-19 pandemic. The causes for these changes are likely to be multifactorial. The long-term effect on lung cancer mortality remains to be seen and is an important focus of future study.

Primary lung adenocarcinoma in transplanted lung in post bilateral lung transplantation.

Key Clinical Message: Primary lung cancer was reported by a bilateral lung transplant patient without any risk factors. Single lung transplantation should be contemplated instead of double lung transplantation as it has been shown to increase the risk of lung cancers. Abstract: This is a case report of a 37-year-old woman, with no history of smoking, who developed adenocarcinoma in her transplanted lung 17 years post transplantation. The development of lung cancer 17 years after transplantation is considered as a rare finding in this case report. According to the Annual Report on Cardiothoracic Organ Transplantation 2019-2020, the NHS Blood and Transplant Data, approximately 156 lung transplants were performed in the UK during 2019-2020. The third most common primary disease group recipient was cystic fibrosis and bronchiectasis. There are several medical complications described in the recipients' post-lung transplantation, and the increased risk of lung malignancy due to immunosuppression is well-established in comparison to the general population. Most cancers, however, develop in the native lung following a single lung transplant. Several cases of lymphoproliferative malignancies in the transplanted lung have been reported following bilateral lung transplantation. This is a case report of a 37-year-old woman with no history of smoking who developed adenocarcinoma in her transplanted lung 17 years later. This patient underwent lobectomy via thoracotomy and was discharged home in good condition. Only a few cases of patients developing primary lung cancer in the transplanted lung with no recipient risk factor have been reported in the literature to date. The development of lung cancer 17 years after transplantation was a rare finding in this case report.

A prospective exploratory study to assess echocardiographic changes in patients with supratentorial tumors - Effect of craniotomy and tumor decompression.

Background: Functional changes in the myocardium secondary to increased intracranial pressure (ICP) are studied sparingly. Direct echocardiographic changes in patients with supratentorial tumors have not been documented. The primary aim was to assess and compare the transthoracic echocardiography changes in patients with supratentorial tumors presenting with and without raised intracranial pressure for neurosurgery. Methods: Patients were divided into two groups based on preoperative radiological and clinical evidence of midline shift of <6 mm without features of raised ICP (Group 1) or greater than 6mm with features of raised ICP (Group 2). Hemodynamic, echocardiographic, and optic nerve sheath diameter (ONSD) parameters were obtained during the preoperative period and 48 h after the surgery. Results: Ninety patients were assessed, 88 were included for analysis. Two were excluded based on a poor echocardiographic window (1) and change in the operative plan (1). Demographic variables were comparable. About 27% of the patients in Group 2 had ejection fraction <55% and 21.2% had diastolic dysfunction in Group 2 in the preoperative period. There was a decrease in the number of patients with a left ventricular (LV) function <55% from 27% before surgery to 19% in the postoperative period in group 2. About 5.8% patients with moderate LV dysfunction in the preoperative period had normal LV function postoperatively. We found a positive correlation between ONSD parameters and radiological findings of raised intracranial pressure. Conclusion: The study demonstrated that in patients with supratentorial tumors with ICP, cardiac dysfunction might be present in the preoperative period.

A non-entropy-based optimal multilevel threshold selection technique for COVID-19 X-ray images using chance-based birds' intelligence.

Recently, image thresholding methods based on various entropy functions have been found popularity. Nonetheless, entropic-based methods depend on the spatial distribution of the grey level values in an image. Hence, the accuracy of these methods is limited due to the non-uniform distribution of the grey values. Further, the analysis of the COVID-19 X-ray images is evolved as an important area of research. Therefore, it is needed to develop an efficient method for the segmentation of the COVID-19 X-ray images. To address these issues, an efficient non-entropy-based thresholding method is suggested. A novel fitness function in terms of the segmentation score (SS) is introduced, which is used to reduce the segmentation error. A soft computing approach is suggested. An efficient optimizer using the chance-based birds' intelligence is introduced to maximize the fitness values. The new optimizer is validated utilizing the benchmark test functions. The statistical parameters reveal that the suggested optimizer is efficient. It shows a quite significant improvement over its counterparts-optimization based on seagull/cuckoo birds. Precisely, the paper includes three novel contributions-(i) fitness function, (ii) chance-based birds' intelligence for optimization, (iii) multiclass segmentation. The COVID-19 X-ray images are taken from the Kaggle Radiography database, to the experiment. Its results are compared with three different state-of-the-art entropy-based techniques-Tsallis, Kapur's, and Masi. For providing a statistical analysis, Friedman's mean rank test is conducted and our method Ranked one. Its superiority is claimed in terms of Peak Signal to Noise Ratio (PSNR), Feature Similarity Index (FSIM) and Structure Similarity Index (SSIM). On the whole, an improvement of about 11% in PSNR values is achieved using the proposed method. This method would be helpful for medical image analysis.

Pharmacological interventions for reducing catheter-related bladder discomfort in patients undergoing elective surgeries under general anaesthesia: A systematic review and meta-analysis.

Background and Aims: Catheter-related bladder discomfort (CRBD) is identified as a major concern after surgery as it can lead to increased morbidity and prolonged hospital stay. A suitable agent to prevent and treat postoperative CRBD is not yet established, and the literature is scarce in this regard. So, we aimed to find the efficacy of various drugs in preventing CRBD after elective surgery. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the study, and electronic databases like PubMed Central, Cochrane database and Embase were searched. The methodological quality of selected studies was assessed by the Cochrane Collaboration risk of bias tool. Review Manager 5.4.1 was used for statistical analysis. Results: The meta-analysis revealed that antimuscarinic agents were able to lower the incidence of CRBD significantly at 0 hour, 1 hour, 2 hours and 6 hours (P < 0.01) after the surgery. Tramadol was effective at 1 hour, 2 hours and 6 hours postoperatively (P < 0.01), whereas ketamine was effective at 2 and 6 hours (P < 0.01) postoperatively. Antiepileptic drugs (pregabalin and gabapentin) were able to lower the incidence of CRBD at 0 hour (P < 0.01), 1 hour (P < 0.05), 2 hours (P < 0.05) and 6 hours (P < 0.01) postoperatively while dexmedetomidine at 0 hour (P < 0.01) and 2 hours (P < 0.01) after the surgery. Injections paracetamol, amikacin and diphenhydramine were also shown to reduce the incidence of CRBD in separate randomised controlled trials. Conclusion: The current meta-analysis showed that antimuscarinic agents, tramadol, pregabalin, gabapentin, paracetamol and dexmedetomidine are effective in significantly reducing the incidence of postoperative CRBD.

Cessation of smoking trial in the emergency department (CoSTED): protocol for a multicentre randomised controlled trial.

INTRODUCTION: Attendees of emergency departments (EDs) have a higher than expected prevalence of smoking. ED attendance may be a good opportunity to prompt positive behaviour change, even for smokers not currently motivated to quit. This study aims to determine whether an opportunist smoking cessation intervention delivered in the ED can help daily smokers attending the ED quit smoking and is cost-effective. METHODS AND ANALYSIS: A two-arm pragmatic, multicentred, parallel-group, individually randomised, controlled superiority trial with an internal pilot, economic evaluation and mixed methods process evaluation. The trial will compare ED-based brief smoking cessation advice, including provision of an e-cigarette and referral to local stop smoking services (intervention) with the provision of contact details for local stop smoking services (control). Target sample size is 972, recruiting across 6 National Health Service EDs in England and Scotland. Outcomes will be collected at 1, 3 and 6 months. The primary outcome at 6 months is carbon monoxide verified continuous smoking abstinence. ETHICS AND DISSEMINATION: The trial was approved by the South Central-Oxford B Research Committee (21/SC/0288). Dissemination will include the publication of outcomes, and the process and economic evaluations in peer-reviewed journals. The findings will also be appropriately disseminated to relevant practice, policy and patient representative groups. TRIAL REGISTRATION NUMBER: NCT04854616; protocol V.4.2.

Identification of celiac disease associated IgA nephropathy by IgA anti-tissue transglutaminase2 antibody deposits in archived formalin-fixed tissues.

Background: The causal association between IgA nephropathy (IgAN) and celiac disease (CeD) is based on their clinical coexistence. In this prospective study, we screened patients with IgAN for CeD and explored the utility of analysis of IgA anti-TG2 antibody deposits, for establishing a causal association. Methods: Biopsy-proven patients of IgAN were screened for serum IgA anti-tissue transglutaminase antibody (IgA anti-tTG Ab) titer and thereafter were invited to undergo endoscopic duodenal biopsy. Corresponding duodenal and kidney biopsies were subjected to IgA anti-TG2 antibody colocalization study using dual-color immunohistochemistry and immunofluorescence techniques. Additionally, kidney biopsies from 105 patients with IgAN who did not give consent for serology analysis, 30 non-IgA nephropathies, and 10 normal controls were also included. Dual-color-stained slides were interpreted based on stain distribution and intensity scores, and Pearson's index >0.3-1 on confocal imaging was considered significant. Results: Of a cohort of 151 patients with IgAN, 32 consented to undergo sero-screening and 5 of them had high serum anti-tTG Ab titer. Two out of the latter consented to endoscopic duodenal biopsies, in whom modified Marsh grade 3b changes were identified. Strong IgA anti-TG2 antibody deposits were noted in the kidney and duodenal biopsies of these patients. One patient out of non-consenting 105 patients with IgAN and 3 out of 30 patients with other non-IgA nephropathies also showed IgA anti-TG2 deposits. None of the healthy kidney tissues showed IgA anti-TG2 Ab deposits. Conclusions: Co-localized IgA anti-TG2 deposits in the kidney biopsies in patients with IgAN help to establish a pathogenic link with CeD. A small proportion of patients with IgAN have associated CeD.

Comparison between patient state index, bispectral index, and clinical parameters for propofol induction in Indian patients: A prospective study.

Background and Aims: Patient state index (PSI) and bispectral index (BIS) are depth of anesthesia monitors utilized for the dosage of propofol usage for induction. We compare PSI, BIS, and Observer's Assessment of Alertness/Sedation Scale (OAA/S) for propofol dose usage for induction. Material and Methods: Seventy-four ASA I and II patients, aged 18-65 years scheduled for laparoscopic cholecystectomy were included and divided into groups to titrate the drug dosage of propofol needed for induction of anesthesia, monitored by PSI (Group A), BIS (Group B), or clinical OAA/S (Group C). The drug dosage needed for induction was based on a PSI value of 25 ± 2, BIS value of 48 ± 2, and OAA/S value of ≤2 as the endpoint of induction in respective groups. Intraoperative hemodynamic variables and any complications were compared. Results: The mean doses of propofol needed for induction were 2.23 mg/kg (Group A), 2.05 mg/kg (Group B), and 2.11 mg/kg (Group C). A significantly decreased dose was needed to achieve the desired end in Group B compared to Group A (P = 0.01). The hemodynamic variables such as heart rate, systolic blood pressure, and diastolic blood pressure among the three groups were comparable. Conclusion: The clinical method of titrating the dose of propofol for induction and anesthetic depth by the loss of verbal response is comparable to both BIS and PSI monitoring.

A community-based, cross-sectional study of gender egalitarianism: A promising scenario from an urban field practice area attached to a teaching institute from Central India.

Context: Gender-based discrimination is more predominant in India. In spite of various laws, gender inequality is an evil that plagues society even today. This is an important challenge for meeting our Sustainable Development Goals. Methods: This cross-sectional study was carried out in an urban field practice area. Study subjects were married women and their husbands in the age-group of 15-49 years along with their under-five children. Gender egalitarianism was assessed for factors like education, employment and media exposure. Factors which were studied for revealing gender egalitarianism among children included sex ratio, immunization status, nutritional status and health care expenditure. Completed family size and preference for the sex of the child were enquired about to assess the inclination towards male gender of the baby. Anthro software was used for statistical analysis. Results: Gender egalitarianism was found with regards to education. However, significant difference was noted in the employment status of men and women. Overall, sex ratio was in favor of girls. Though gender inequality was evident from the results, it was more in favor of girls. There was no evidence of gender bias for immunization of children. It was observed that more boys were stunted than girls and almost equal proportion of boys and girls were wasted. Conclusions: Factors like high literacy, control over income, access to financial resources made women more empowered and such empowered women were less likely to show son preference. Hence, there was no gender inequality among children in the present study.