Sensitisation to the acrylate co-polymers glyceryl acrylate/acrylic acid co-polymer, sodium polyacrylate and acrylates/C10-30 alkyl acrylate cross-polymer (Carbopol®) is rare.

BACKGROUND: Acrylate polymers and cross-polymers (ACPs) are frequently used cosmetic ingredients. The British Society for Cutaneous Allergy (BSCA) and the UK Cosmetic, Toiletry and Perfumery Association (CTPA) collaborated to investigate the allergenic potential of three commonly-used ACPs. OBJECTIVES: The objective of this study is to determine the prevalence of allergic contact dermatitis (ACD) to three ACPs: glyceryl acrylate/acrylic acid co-polymer, sodium polyacrylate, and acrylates/C10-30 alkyl acrylate cross-polymer (Carbopol®). MATERIALS AND METHODS: The BSCA prospectively audited data collected from 20 centres in the UK and Ireland between 1st September 2021 and 1st September 2022. Patients with suspected ACD to (meth)acrylates, with facial dermatitis, or consecutive patients, were patch tested to glyceryl acrylate/acrylic acid co-polymer 10% aqueous (aq.) sodium polyacrylate 2% aq., and to acrylates/C10-30 alkyl acrylate cross-polymer 2% aq. (Carbopol®). The frequencies of positive, irritant, and doubtful reactions were recorded. RESULTS: In total, 1302 patients were patch tested. To glyceryl acrylate/acrylic acid co-polymer, there was one doubtful reaction in a patient allergic to multiple (meth)acrylates, and one irritant. To sodium polyacrylate, there were four irritant reactions, one doubtful, and one positive reaction; in all cases, relevance was unknown and there was no demonstrable (meth)acrylate allergy. There were no reactions to Carbopol®. CONCLUSIONS: Sensitisation to these concentrations of the three tested ACPs is rare. Elicitation of dermatitis in (meth)acrylate-sensitised patients by exposure to these three ACPs appears unlikely.

Intubation strategy in COVID-19 era: An observational study.

Background and Aims: Aerosol protection equipment aim at protecting the anaesthesiologist, from aerosol-borne infections, namely, severe acute respiratory syndrome corona virus-2. Methods: We improvised the first-generation intubation box (IB) by increasing its dimensions, including heat and moisture exchanger with filter, suction catheter, and attaching arm sleeves to make a modified intubation box (MIB). The impact of IB, MIB and transparent sheets (TS) on the patient outcomes during airway management was evaluated. Results: A significant difference in median (interquartile range in minutes) was observed in time to intubate between IB (4 [4-5]); TS (0.5 [0.3-0.5]) and MIB (0.3 [0.3-1.5]): P = 0.004); and airway devices; McCoy (0.5 [0.3-2]), CMac (0.5 [0.3-1.5]): P = 0.004. First-pass success was 100% with the TS, whereas more than three attempts were required with IB 66.7% and 5.2% with MIB. Video laryngoscope was associated with less airway-related adverse events (ARAEs). The need for mask ventilation (and hence possible aerosolisation) was maximum with IB. All the ARAEs resolved uneventfully. No breach of personal protective equipment was observed; none of the health-care professionals involved in patient care developed any symptoms suggestive of COVID-19. Conclusion: Video laryngoscope is favourable for managing airway in COVID-19 times. In view of the ongoing pandemic and added protection that it offers, it is worthwhile to include the MIB in the armamentarium for managing the airway of patients with COVID-19.

Postauricular Tubed Flap in the Reconstruction of Auricular Margin Defects: Revisited.

Background Reconstruction of the auricular margin defects is challenging due to the ear's intricate architecture. Tubed flap raised from the postauricular area is a simple and reliable option for reconstructing marginal defects. Methods Eight patients with various auricular margin defects were reconstructed, using a postauricular tubed flap in a staged manner. Parameters like flap survival, reliability, complications, and cosmesis were assessed. Results Out of eight patients, one patient had marginal necrosis, which was managed with debridement and lengthening of the flap. All the flaps settled well with a good aesthetic outcome. Conclusion Postauricular tubed flap is a reliable and efficient method for reconstructing auricular margin defects.

Evaluation of Serum Levels of Procalcitonin and C-Reactive Protein as Prognostic Indicators in Burns.

Background Burn is a leading cause of fatality in a developing country. C-reactive protein levels (CRP) and procalcitonin (PCT) can be prognostic indicators for the burn patients' mortality. Aim To assess serial levels of serum PCT and serum CRP as prognostic indicators in burns. Patient and Methods In patients admitted with burns, alternate-day serum PCT and CRP were measured from the time of admission until the time of discharge or until survival. The change in trends of CRP and PCT serum levels were studied, and it was then correlated with mortality among these burn patients. Results The first-day value of serum PCT > 1772 pg/mL and serum CRP > 71 mg/mL or any value of serum PCT > 2163 pg/mL and of serum CRP > 90 mg/L indicate a poor prognosis in burns. Conclusions The day-1 values of PCT and CRP were significantly higher in nonsurvivors than survivors in burns. The increasing trends of serum PCT and CRP levels are independent predictors of mortality in burns requiring prompt intervention. Rising PCT and CRP level denote poor prognosis in burns with an increased likelihood of death by 4.5 and 23.6 times, respectively.

Predictors of difficult airway in the obese are closely related to safe apnea time!

BACKGROUND AND AIMS: We aimed to redefine the preoperative factors that may challenge the airway and safe apnea time (SAT) in the obese. MATERIAL AND METHODS: We analyzed 834 patients with body mass index (BMI) >35 kg/m2 for their difficult airway score (DASc). DASc is a consolidation of measures of difficult airway like mask ventilation, difficult intubation, change of device, and number of personnel required. DASc varied from "0" no difficulty to "12" serious difficulty and DASc ≥6 was considered difficult. Preoperative parameters - neck circumference (NC), BMI, STOPBANG score, Mallampati score, obstructive sleep apnea grade, and waist circumference- were assessed. RESULTS: Receiver operating characteristic curve was used to identify risk factors for obese patients at DASc ≥6. The Youden index (for the best threshold, with highest sensitivity and specificity) was BMI 45 kg/m2 and NC 44.5 cm. Their absence had an 81% negative predictive value to include a difficult airway, while their presence had a positive predictive value of 55%. This further has sensitivity of 66% and specificity of 73%. The mean SAT (256 ± 6 s) was inversely related to DASc (P < 0.001). CONCLUSION: This study demonstrates that BMI and NC have a strong association with difficult airway in obese patients and are inversely related to SAT. Amongst these NC is the single most important predictor of difficult airway in obese and should be used as a screening tool.

The supraglottic airway device as first line of management in anticipated difficult mask ventilation in the morbidly obese.

BACKGROUND AND AIMS: Supraglottic airway devices (SGAs) are used to rescue difficult and failed mask ventilation (DMV). We aimed to use the SGA as first-line device, prior to obtaining a definitive airway and to find any predictors of difficulty for the same, in the morbidly obese patients. MATERIAL AND METHODS: Obese surgical patients [body mass index (BMI) >35 kg/m2] were investigated. Difficulties with bag mask ventilation (MV) was graded using the following scale: MV-1, one anesthesiologist unassisted could achieve MV and maintain SpO2>90%; MV-2, one additional anesthesiologist was needed to facilitate MV to achieve SpO2> 90%; MV-3, two additional anesthesiologists were needed for this purpose; and MV-3P, when a supraglottic device was required to ventilate and maintain SpO2 more than 90%. Parameters studied were age, gender, neck circumference (NC), BMI, STOPBANG score, and safe apnea time (SAT). RESULTS: Logistic regression was performed for predictors of MV-3P; receiver operating characteristic curve was used to locate the best cut-off. Analysis of 834 morbidly obese patients revealed an incidence of MV 1/2/3/3-P as 16%/38%/27%/19%, respectively. DMV was associated with BMI ≥50 kg/m2, NC ≥49.5 cm, and STOPBANG ≥6; P < 0.001. The mean SAT for a population with mean BMI 48 ± 8 kg/m2 was 256 ± 66 s. The SAT showed inverse relation to BMI and NC. As per our results, the NC was the single most important predictor of MV-3P, with sensitivity 0.62 and specificity 0.85 at best cut-off 49.5 cm; P < 0.001. CONCLUSION: NC ≥49.5 cm is strongly associated with low SAT and need for SGA to achieve MV. SGA may provide safety for initial management following induction of anesthesia in this patient population.

Transversus abdominis plane block for pain relief in patients undergoing in endoscopic repair of abdominal wall hernia: A comparative, randomised double-blind prospective study.

INTRODUCTION: Transversus abdominis plane (TAP) block is now a well-established technique in post-operative analgesia for lower abdominal surgeries. We evaluated the effect of ultrasound-guided TAP block on recovery parameters in patients undergoing endoscopic repair of abdominal wall hernia. METHODS: Thirty adults were randomised to receive either ropivacaine with dexmedetomidine (TR) or saline (TP) in TAP block, before emergence from anaesthesia. The patients were assessed for pain relief, sedation, time to ambulate (TA), discharge readiness (DR), postoperative opioid requirement and any adverse events. RESULTS:: The median visual analogue scale pain score of the study group (TR) and the control group (TP) showed a significant difference at all time points. TA was 5.3 ± 0.5 (TR) versus 7.4 ± 0.8 (TP), P< 0.001 and DR was 7.5 ± 0.9 (TR) versus 8.9 ± 0.6 (TP), P< 0.001 in hours. No adverse events were observed in any group. CONCLUSION: This study demonstrates that TAP block is a feasible option for pain relief following endoscopic repair of abdominal wall hernias. It produces markedly improved pain scores and promotes early ambulation leading to greater patient satisfaction and earlier discharge.

S-WD-EEMD: A hybrid framework for imbalanced sEMG signal analysis in diagnosis of human knee abnormality.

The diagnosis of human knee abnormalities using the surface electromyography (sEMG) signal obtained from lower limb muscles with machine learning is a major problem due to the noisy nature of the sEMG signal and the imbalance in data corresponding to healthy and knee abnormal subjects. To address this challenge, a combination of wavelet decomposition (WD) with ensemble empirical mode decomposition (EEMD) and the Synthetic Minority Oversampling Technique (S-WD-EEMD) is proposed. In this study, a hybrid WD-EEMD is considered for the minimization of noises produced in the sEMG signal during the collection, while the Synthetic Minority Oversampling Technique (SMOTE) is considered to balance the data by increasing the minority class samples during the training of machine learning techniques. The findings indicate that the hybrid WD-EEMD with SMOTE oversampling technique enhances the efficacy of the examined classifiers when employed on the imbalanced sEMG data. The F-Score of the Extra Tree Classifier, when utilizing WD-EEMD signal processing with SMOTE oversampling, is 98.4%, whereas, without the SMOTE oversampling technique, it is 95.1%.

Loss of TDP-43 induces synaptic dysfunction that is rescued by UNC13A splice-switching ASOs.

TDP-43 loss of function induces multiple splicing changes, including a cryptic exon in the amyotrophic lateral sclerosis and fronto-temporal lobar degeneration risk gene UNC13A, leading to nonsense-mediated decay of UNC13A transcripts and loss of protein. UNC13A is an active zone protein with an integral role in coordinating pre-synaptic function. Here, we show TDP-43 depletion induces a severe reduction in synaptic transmission, leading to an asynchronous pattern of network activity. We demonstrate that these deficits are largely driven by a single cryptic exon in UNC13A. Antisense oligonucleotides targeting the UNC13A cryptic exon robustly rescue UNC13A protein levels and restore normal synaptic function, providing a potential new therapeutic approach for ALS and other TDP-43-related disorders.

A comparative study to evaluate the effect of intranasal dexmedetomidine versus oral alprazolam as a premedication agent in morbidly obese patients undergoing bariatric surgery.

BACKGROUND: Morbidly obese patients with obstructive sleep apnea are extremely sensitive to sedative premedication. Intranasal dexmedetomidine is painless and quick acting. Intranasal dexmedetomidine can be used for premedication as it produces adequate sedation and also obtund hemodynamic response to laryngoscopy and tracheal intubation. MATERIALS AND METHODS: Forty morbidly obese patients with BMI > 35 were chosen and divided into two groups. Group DEX received intranasal dexmedetomidine 1 mcg/kg (ideal body weight) while other group (AZ) received oral alprazolam 0.5 mg. Sedation scale, heart rate and the mean arterial pressure was assessed in both the groups at 0 hour, 45 minutes, during laryngoscopy and tracheal intubation. RESULTS: The demographic profile, baseline heart rate, means arterial pressure, oxygen saturation and sedation scale was comparable between the two groups. The sedation scores, after 45 min, were statistically significant between the two groups i.e., 2.40 ± 1.09 in the AZ group as compared to 3.20 ± 1.79 in DEX group P value 0.034. The heart rate, mean arterial pressure and oxygen saturation were statistically similar between the two groups, after 45 min. The heart rate was significantly lower in the DEX group as compared to the AZ group. There was no statistical difference in the mean arterial pressure between the two groups either during laryngoscopy or tracheal intubation. CONCLUSION: Intranasal dexmedetomidine is a better premedication agent in morbidly obese patients than oral alprazolam.

DenseNet-II: an improved deep convolutional neural network for melanoma cancer detection.

Research in the field of medicine and relevant studies evince that melanoma is one of the deadliest cancers. It defines precisely that the condition develops due to uncontrolled growth of melanocytic cells. The current trends in any disease detection revolve around the usage of two main categories of models; these are general machine learning models and deep learning models. Further, the experimental analysis of melanoma has an additional requirement of visual records like dermatological scans or normal camera lens images. This further accentuates the need for a more accurate model for melanoma detection. In this work, we aim to achieve the same, primarily by the extensive usage of neural networks. Our objective is to propose a deep learning CNN framework-based model to improve the accuracy of melanoma detection by customizing the number of layers in the network architecture, activation functions applied, and the dimension of the input array. Models like Resnet, DenseNet, Inception, and VGG have proved to yield appreciable accuracy in melanoma detection. However, in most cases, the dataset was classified into malignant or benign classes only. The dataset used in our research provides seven lesions; these are melanocytic nevi, melanoma, benign keratosis, basal cell carcinoma, actinic keratoses, vascular lesions, and dermatofibroma. Thus, through the HAM10000 dataset and various deep learning models, we diversified the precision factors as well as input qualities. The obtained results are highly propitious and establish its credibility.

Linear morhpea, nevus comedonicus, and lichen striatus in a 5-year-old girl.

Linear morphea, lichen striatus, and nevus comedonicus are rare conditions. We describe a five-year-old girl in whom all three of these dermatoses are present.

Exploring new frontiers: Organ transplant anaesthesia or bariatric anaesthesia.

Unlike previous years, Anaesthesiology today is a major speciality encompassing many areas of modern medicine. Advent of various surgical sub-specialities resulted into the emergence of anaesthesia sub-specialities, as every group of surgery has specific need. Choosing the best-suited speciality is a complex matter. For that, one needs to have an idea about each one of them. A postgraduate anaesthesiology student does not have adequate exposure to choose the speciality. This article will give an overview of two important sub-specialities i.e., Organ Transplant Anaesthesia and Bariatric Anaesthesia.

Pressure vs. volume control ventilation: effects on gastric insufflation with size-1 LMA.

BACKGROUND: In this randomized prospective study, peak airway pressure (PAP) and gastric insufflation were compared between volume control ventilation (VCV) and pressure control ventilation (PCV) using size-1 laryngeal mask airway (LMA) in babies weighing 2.5-5 kg. METHODS: Forty ASA I and II children, weighing 2.5-5 kg, undergoing elective infraumbilical surgeries (duration < 60 min) were randomized to two groups of 20 each to receive either PCV or VCV. Patients at risk of aspiration, difficult airway and upper respiratory tract infection, and poor lung compliance were excluded. Anesthesia technique included sevoflurane/O(2)/N(2)O without neuromuscular blockade. PAP in PCV and tidal volume in VCV modes were changed to achieve adequate ventilation (P(E)CO(2) of 5-5.4 kPa). PAP was maintained below 20 cm H(2)O. Chi-squared test, Mann-Whitney U-test and Wilcoxon W-test were applied; P < 0.05 was considered significant. RESULTS: Mean PAP (cm H(2)O) was 12.2 ± 1.09 in PCV and 13.60 ± 0.94 in VCV groups (P = 0.000). The confidence interval of mean difference of PAP varied from 0.79 to 2.10. Significant increases in abdominal circumference were observed in both groups: PCV: 0.94 ± 1.04 cm and VCV: 2.2 ± 1.3 cm; (P = 0.000). The SpO(2) and hemodynamic variables did not differ between the groups. One patient in VCV group (with PAP = 14 cm H(2)O) could not be ventilated to the target P(E)CO(2), and the LMA had to be replaced with tracheal tube. CONCLUSION: In conclusion, PCV should be the preferred mode to provide positive pressure ventilatio (PPV), when using the size-1 cLMA in babies weighing 2.5-5 kg, in view of less gastric insufflation associated with it for surgeries of brief duration. More studies are required to validate the clinical significance of these two modes of ventilation in longer procedures, in this subpopulation.

The Effect of Bariatric Surgery on Patients with Chronic Kidney Disease.

The effect of bariatric surgery on renal functions of patients with chronic kidney disease (CKD) is not well characterized. This prospective study included 13 adult patients having chronic kidney disease who underwent bariatric surgery. The primary objective was to examine the change in glomerular filtration rate (GFR) at 6 months post-bariatric surgery. Median GFR (measured by creatinine clearance) did not change significantly (55 ml/min vs 59 ml/min, p = 0.345) although there was a significant decrease in the protein excretion rate (1700 mg/day vs 900 mg/day, p = 0.001) at 6 months. An improvement in the KDIGO CKD risk category was seen in 30.7% patients. In CKD patients undergoing bariatric surgery, renal function improves over the first 6 months with a decrease in proteinuria and a stable GFR.

ProSeal laryngeal mask airway in infants and toddlers with upper respiratory tract infections: a randomized control trial of spontaneous vs pressure control ventilation.

BACKGROUND: ProSeal LMA (PLMA), one of the advanced supraglottic devices has been successfully used to provide both spontaneous and controlled ventilation in children with upper respiratory tract infection (URTI). URTI does not imply restriction of disease to upper respiratory tract; it has been shown to produce pulmonary dysfunction. PEEP has been shown to improve oxygenation in such cases. This randomized prospective study was designed to compare postoperative adverse events associated with spontaneous respiration (SR) and pressure control ventilation (PCV) with PEEP in infants and toddlers with URTI when using PLMA as an airway device. METHODS: In the present study, 90 children, 6 months-2 years, scheduled for infra umbilical surgery were randomized to receive either SR or PCV with PEEP of 5cm H2O. Patients with risk of aspiration, bronchial asthma, anticipated difficult airway, snoring, passive smoking, morbid obesity, coexisting pulmonary and cardiac disease, lower respiratory tract infection, fever > 38 degrees C and sneezing, were excluded. At emergence, airway secretions, coughing, breath holding, bronchospasm, upper airway obstruction or laryngospasm (LS) were assessed. RESULTS: The adverse events were significantly higher in spontaneously breathing patients. Score of adverse events was 6.33 +/- 1.6 in PCV and 7.7 +/- 2.2 in SR group (P = 0.001). The mean SpO2 (%) in PACU was 96.5 +/- 2 in PCV and 94.4 +/- 1.37 in SR (P = 000). CONCLUSION: Pressure control ventilation with PEEP using PLMA is associated with lower incidence of adverse events in comparison to spontaneous respiration in infants and toddlers with upper respiratory tract infection undergoing infra umbilical surgeries under general anesthesia.

Enhanced Recovery after Bariatric Surgery in the Severely Obese, Morbidly Obese, Super-Morbidly Obese and Super-Super Morbidly Obese Using Evidence-Based Clinical Pathways: a Comparative Study.

BACKGROUND: We discuss the anesthetic outcome in morbidly obese patients under the enhanced recovery after surgery (ERAS) protocol. Our evidence-based clinical pathways focused on prehabilitation and included interventions like aggressive preoperative optimization of medical comorbidities, familiarizing with perioperative protocols, thromboprophylaxis, opioid free multimodal analgesia, and early ambulation. METHODS: We did a retrospective analysis of prospectively collected data of 823 patients who underwent laparoscopic bariatric surgery. Our goal was to assess the effects of BMI on the recovery and anesthetic outcome parameters, under the categories of severely obese (SeO: BMI <39.9 kg/m2), morbidly obese (MO: BMI 40-49.9 kg/m2), super-morbidly obese (SMO: BMI 50-59.9 kg/m2), and super-super morbidly obese (SSMO: BMI >60 kg/m2). Time to ambulate (TA) was the primary variable. RESULTS: Requirement for non-invasive ventilation (NIV) was the only significant predictor of TA and discharge readiness (DR); the DR was further affected by functional capacity and presence of chest pain. Our analysis indicated that each unit increase in BMI (kg/m2) contributes to increase in ambulation time by 1.24 min (95 % CI: 0.648 to 1.832 min; P < 0.001) and DR by 0.52 h (95 % CI: 0.435 to 0.606 h; P < 0.001). The odds ratio for requirement for NIV (per unit change in BMI) was 1.163 (CI: 1.127/1.197; P < 0.001). CONCLUSIONS: Aggressive preoperative optimization can avert effects of BMI on anesthetic outcome. Practice of prehabilitation and preoperative optimization of comorbidities using evidence-based clinical pathways can complement the principles of ERAS in patients undergoing bariatric surgery to facilitate their discharge readiness.