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Tropical oceans are the main global water vapor and latent heat sources, but their responses to radiative forcing remain unclear. Here, we investigate oceanic moisture dynamics of the western tropical Pacific (WTP) over the past 210,000 years through an approach of planktonic foraminiferal triple oxygen isotope (Δ' 17 O). The Δ' 17 O record is dominated by the precession cycles (~23,000 years), with lower values reflecting higher humidity in concert with higher Northern Hemisphere summer insolation. Our empirical and modeling results, combined with other geological archives, suggest that the enhanced moisture convergence over the WTP largely intensifies changes in the meridional and zonal hydrological cycles, affecting rainfall patterns in East Asia and northern South America. We propose that the insolation-driven WTP moisture dynamics play a pivotal role in regulating tropical hydroclimate.

Characterization of transport pathways and depositional changes in Mercury (Hg) and their connection to climatic and environmental changes on various time scales are crucial for better understanding the anthropogenic impacts on the global Hg cycle in the Anthropocene epoch. In this study, we examined Hg variations recorded in a stalagmite from central China, covering the period from 25.5 to 10.9 thousand years ago. Our data show a marked increase in Hg concentrations during the late Last Glacial Maximum, which coincided with the period of highest dust deposition on the Chinese Loess Plateau. Hg concentrations were lower during Heinrich events 1 and 2 and the Younger Dryas but higher during the Bølling-Allerød and the early Holocene. We suggest that regional dust load, which enhances atmospheric dry deposition of Hg, is the primary factor influencing Hg deposition in central China on glacial-interglacial timescales. On millennial-to-centennial timescales, climate also plays a significant role. Warmer and wetter conditions increase vegetation, litterfall, and soil/rock weathering, which in turn boost mineral dissolution and soil erosion in the vadose zone. These processes collectively result in higher Hg concentrations in the stalagmite., (Copyright © 2024 Science China Press. Published by Elsevier B.V. All rights reserved.)

Mucus plug obstruction is a common complication in prone patients associated with loss of ventilation and hemodynamic instability. This case presents a 62-year-old female with chronic bronchitis who underwent posterior cervical fusion for a type III dens fracture with extension into the pars articularis and pedicles. Glycopyrrolate was administered to assist with fiberoptic intubation. After successful intubation, bronchoscopy revealed copious endotracheal secretions requiring preoperative therapeutic removal. Despite extensive removal of thick endotracheal secretions preoperatively, obstructive mucus plugging developed intraoperatively with complete loss of end-tidal carbon dioxide (ETCO 2 ) while the patient was in Mayfield head pins. With limited airway access, suctioning and prone flexible bronchoscopy were performed, successfully restoring ETCO 2 . This experience underscores the need for heightened awareness and preparedness for mucus plug obstruction in chronic bronchitis patients undergoing prone cervical spine surgeries., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Veligandla et al.)

In recent years, deep learning (DL) has shown great potential in the field of dermatological image analysis. However, existing datasets in this domain have significant limitations, including a small number of image samples, limited disease conditions, insufficient annotations, and non-standardized image acquisitions. To address these shortcomings, we propose a novel framework called DermSynth3D. DermSynth3D blends skin disease patterns onto 3D textured meshes of human subjects using a differentiable renderer and generates 2D images from various camera viewpoints under chosen lighting conditions in diverse background scenes. Our method adheres to top-down rules that constrain the blending and rendering process to create 2D images with skin conditions that mimic in-the-wild acquisitions, ensuring more meaningful results. The framework generates photo-realistic 2D dermatological images and the corresponding dense annotations for semantic segmentation of the skin, skin conditions, body parts, bounding boxes around lesions, depth maps, and other 3D scene parameters, such as camera position and lighting conditions. DermSynth3D allows for the creation of custom datasets for various dermatology tasks. We demonstrate the effectiveness of data generated using DermSynth3D by training DL models on synthetic data and evaluating them on various dermatology tasks using real 2D dermatological images. We make our code publicly available at https://github.com/sfu-mial/DermSynth3D., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ghassan Hamarneh reports financial support was provided by Natural Sciences and Engineering Research Council of Canada. Ghassan Hamarneh reports equipment, drugs, or supplies was provided by Digital Research Alliance of Canada. Ghassan Hamarneh reports financial support was provided by British Columbia Cancer Foundation. Djamila Aouada reports financial support was provided by Luxembourg National Research Fund. Ghassan Hamarneh reports equipment, drugs, or supplies was provided by NVIDIA Corp. Ghassan Hamarneh reports a relationship with Triage Technologies Inc. that includes: equity or stocks. Jeremy Kawahara reports a relationship with Triage Technologies Inc. that includes: equity or stocks. Jeremy Kawahara has patent System to collect and identify skin conditions from images and expert knowledge issued to Triage Technologies Inc. JK switched affiliation after this work, from Simon Fraser University to AIP Labs, (Copyright © 2024. Published by Elsevier B.V.)

Background: Sickle cell disease (SCD) is a disorder marked by a single-point mutation in the beta-globin gene. Hydroxyurea is a globally accepted disease-modifying agent that sounds to be effective in managing clinically and probably preventing complications of SCD. The current study aims to document the morbidity pattern and impact of Hydroxyurea therapy in the Outpatient Department of Sickle Cell Institute, Raipur., Materials and Methods: This cross-sectional study was conducted among randomly selected sixty-five patients (adults and children above six years). After obtaining informed consent, relevant data were collected in a predesigned pretested questionnaire. The appropriate statistical exercise was applied for the interpretation of results and inferences., Results: Acute febrile illness 54 (83%) and 53 (81.5%) reported pain crisis observed to have the most common morbidity among the study subjects, followed by 55.4% (36), 33 (50.8%) jaundice and difficulty breathing, respectively. Joint pain was the most commonly observed complaint, particularly at the knee joint (76.9%). Other complaints such as hand-foot syndrome (24.6%), epistaxis (27.7%), and acute chest syndrome (21.5%). Vaso-occlusive crisis (72.4%), difficulty in walking (60.0%) and eyesight (35.4%), leg ulcers (9.2%), and dactylitis (3.1%) were also documented as clinical manifestations among study participants. Less than half (44.46%) had an awareness about SCD. Hydroxyurea therapy was highly significant in improving the patient's clinical picture ( P < 0.01), especially following the frequency of hospitalization and the requirement for blood transfusion., Conclusion: Pain crisis is the most common morbidity among study participants with a low level of knowledge about SCD with febrile illness. Hydroxyurea therapy was found to be quite effective as a disease-modifying therapy, especially for reducing the frequency of blood transfusion and lowering hospitalization rates among SCD patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Family Medicine and Primary Care.)

Background: Undernutrition raises the likelihood of progressing from tuberculosis (TB) infection to active TB illness and causes weight loss. Proper food and nutrition are important in the treatment of tuberculosis patients. Active tuberculosis necessitates a substantial energy expenditure. The Tuberculosis treatment guidelines neglect the nutritional supplementation part of Tuberculosis management. The study aims to determine the factors affecting the nutritional status of pulmonary Tuberculosis patients., Material and Methods: A hospital-based cross-sectional study was conducted from December 2021 to January 2022 among the patients newly diagnosed and above 18 years of age coming to DOTS Centre (DMC) of Pt J.N.M. Medical College, Raipur. Total 120 subjects were selected by consecutive sampling method. Data was analyzed using SPSS version 24, and P value <0.05 was considered statistically significant., Result: Among 120 study subjects, malnourished was 54.16% (BMI <18.50 kg/m 2 ), normal was 35% (BMI 18.50-24.99 kg/m 2 ), overweight was 6.67% (BMI 25-29.99 kg/m 2 ), and obese were 4.17% (BMI 30-34.99 kg/m 2 ). Among 120 study subjects, the maximum number of them (96.3%) had a dietary gap in their diets which was equal in two groups of 1-50% calorie deficit and 51-100% calorie deficit., Conclusion: A high proportion of tuberculosis patients were undernourished, and even a very distal factor for undernutrition became proximal for tuberculosis patients. To control tuberculosis and to end the tuberculosis disease, an improvement in the nutritional status of the patient should be our priority. By knowing the importance of nutrition in TB patients, the primary care physicians can decrease the morbidity and mortality in TB patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Family Medicine and Primary Care.)

Central Asia (CA) is one of the world's most significant arid regions, which is markedly impacted by global warming. A better understanding of the dynamical processes governing its Holocene climate variability is critical for a better understanding of possible future impacts of climate change in the region. To date, most of the existing CA paleoclimate records are from the summer precipitation-dominated eastern CA (ECA), with few records from the winter precipitation-dominated western CA (WCA). Here, we present a precisely dated (~6‰) and highly resolved (<4-y) record of hydroclimatic variations from the WCA covering the period between 7,774 and 656 y BP. Utilizing multiple proxies (δ 18 O, δ 13 C, and Sr/Ca) derived from a stalagmite from the Fergana Valley, Kyrgyzstan, we reveal a long-term drying trend in WCA, which is in contrast with the wetting trend in ECA. We propose that different responses of winter and summer westerly jets to seasonal solar insolation over the past 8,000 y may have resulted in an antiphased precipitation relationship between the WCA and ECA. Our data contain dominant quasiperiodicities of 1,400, 50 to 70, and 20 to 30 y, indicating close connections between the WCA climate and the North Atlantic. We further identified a series of droughts and pluvials on centennial-to-decadal timescales, which may have influenced regional societies and trans-Eurasian culture exchanges during historical and prehistorical times., Competing Interests: Competing interests statement:The authors declare no competing interest.

Abstract: Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes., (Copyright © 2024 Copyright: © 2024 Indian Chest Society.)

Dentine adhesives have demonstrated great success with permanent teeth. Though the results in primary teeth are not well documented, some studies have demonstrated lower values of bond strength in primary teeth than those found in permanent teeth. The aim of this study was to compare and evaluate the effect of grape seed extract (6.5%) (Herbal Bio Solutions, Delhi, India), glutaraldehyde (5%) (Loba Chemie PVT. LTD., Mumbai), hesperidin (0.5%) (Herbal Bio Solutions, Delhi, India), and casein phosphopeptide-amorphous calcium phosphate (tooth mousse) (GC Corporation, Alsip, IL, USA) on the shear bond strength of dentine of primary teeth and to evaluate the resin tags at the resin tooth interface. Seventy-five caries-free human primary molars were collected, and their occlusal surfaces were ground flat. Dentin surfaces were etched using phosphoric acid. Then teeth were randomly assigned in sequential order to five groups according to the dentinal treatment method: Group I (Control group) (no treatment), Group II (5% glutaraldehyde), Group III (6.5% grape seed extract), Group IV (0.5% hesperidin), and Group V (CPP-ACP). Ten teeth from each group were assigned for Shear Bond Strength and five for SEM analysis. ANOVA and a post hoc least significant difference test ( p < 0.05) were used for statistical analysis of the collected data. The grape seed extract group showed significantly increased shear bond strength than the control group ( p < 0.05), and the mean length of resin tags in different dentine bio modifiers groups was also statistically significant ( p < 0.05). The use of dentin bio modifiers such as 5% glutaraldehyde, 6.5% grape seed extract, 0.5% hesperidin, and CPP-ACP in the bonding process for primary teeth did not improve the dentinal bond strength.

Background: Desmoid tumors are fibroblastic lesions which often have an unpredictable and variable clinical course. In the context of familial adenomatous polyposis (FAP), these frequently occur intra-abdominally, especially in the small-bowel mesentery resulting in sepsis, fistulation, and invasion of the abdominal wall and retroperitoneum. In selected cases where other modalities have failed, the most radical option is to perform a total enterectomy and intestinal transplantation (ITx). In this study, we present our center's experience of ITx for desmoid in patients with FAP., Methods: We performed a retrospective review of our prospectively collected database between 2007 and 2022. All patients undergoing ITx for FAP-related desmoid were included., Results: Between October 2007 and September 2023, 144 ITx were performed on 130 patients at our center. Of these, 15 patients (9%) were for desmoid associated with FAP (7 modified multivisceral transplants, 6 isolated ITx, and 2 liver-containing grafts). The median follow-up was 57 mo (8-119); 5-y patient survival was 82%, all with functioning grafts without local desmoid recurrence. These patients presented us with several complex surgical issues, such as loss of abdominal domain, retroperitoneal/abdominal wall involvement, ileoanal pouch-related issues, and the need for foregut resection because of adenomatous disease., Conclusions: ITx is a viable treatment in selected patients with FAP and extensive desmoid disease. The decision to refer for ITx can be challenging, particularly the timing and sequence of treatment (simultaneous versus sequential exenteration). Delays can result in additional disease burden, such as secondary liver disease or invasion of adjacent structures., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2024 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

The geological record encodes the relationship between climate and atmospheric carbon dioxide (CO 2 ) over long and short timescales, as well as potential drivers of evolutionary transitions. However, reconstructing CO 2 beyond direct measurements requires the use of paleoproxies and herein lies the challenge, as proxies differ in their assumptions, degree of understanding, and even reconstructed values. In this study, we critically evaluated, categorized, and integrated available proxies to create a high-fidelity and transparently constructed atmospheric CO 2 record spanning the past 66 million years. This newly constructed record provides clearer evidence for higher Earth system sensitivity in the past and for the role of CO 2 thresholds in biological and cryosphere evolution.

Background: Establishing a strong bond between the pulp capping agent and the restorative material is crucial to the success of the procedure. Without this bond, there is a risk of bacterial infiltration into the pulp, leading to treatment failure. In the past, calcium hydroxide was commonly used for such treatments, but it faced challenges, including poor adhesion to dentin, dissolution over time, and the development of multiple tunnel defects. Mineral trioxide aggregate (MTA), introduced to dentistry in 1993, offered an alternative but came with drawbacks like challenging handling and extended setting times. However, in recent times, several new calcium silicate-based materials have emerged to address MTA's limitations. Two notable examples are Biodentine and MTA Plus. Biodentine, for instance, exhibits excellent sealing ability, while MTA Plus distinguishes itself with a finer particle size compared to traditional MTA. These innovative materials offer promising solutions to enhance the efficacy of pulp capping procedures., Aim: Therefore, in this research, we conducted a comparative analysis of the shear bond strength (SBS) between composite resin and three materials-MTA, MTA Plus, and Biodentine. We examined the effects of applying two distinct adhesive systems in order to evaluate their influence on the bond strength., Materials and Methods: A total of 60 acrylic blocks were evenly distributed into three groups, each containing 20 blocks-group I received Biodentine, group II was assigned MTA, and group III received MTA Plus. The respective test materials were compacted into the holes within the blocks. Following this, the samples were incubated for a period of 72 hours. Subsequently, the samples were divided into two subgroups, each consisting of 10 blocks-the self-etch and the total-etch subgroup. The SBS values were then carefully measured for analysis., Result: The SBS of the Biodentine group demonstrated a significantly higher value when compared to the other groups. It's worth noting that when the self-etch adhesive system was employed, the SBS of all the groups experienced a significant reduction., Conclusion: Biodentine cement proves to be an effective choice for pulp capping procedures, regardless of the specific adhesive system employed. Notably, the total-etch adhesive system consistently yields higher bond strength when compared to the self-etch adhesive system., How to Cite This Article: Kumar V, Showkat I, Manuja N, et al. Comparative Evaluation of Shear Bond Strength of Tricalcium Silicate-based Materials to Composite Resin with Two Different Adhesive Systems: An In Vitro Study. Int J Clin Pediatr Dent 2023;16(S-3):S272-S277., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

Aim: To evaluate the effect of different add-ons on the flexural strength (FS) of glass ionomer cement (GIC)., Materials and Methods: Around 72 samples were fabricated and divided among the following six different groups: group I-control (conventional GIC-nonmodified), group II-GIC powder modified with 3% titanium dioxide (TiO 2 ) and liquid is unmodified, group III-powder modified with 10% nanohydroxyapatite (nHA) and liquid is unmodified, group IV-powder is unmodified and Liquid is modified with 10% chitosan (CH), group V-powder is modified with 3% TiO 2 and liquid is modified with 10% CH, and group VI-powder is modified with 10% nHA and liquid is modified with 10% CH. The samples were then subjected to a three-point bending test on a universal testing machine for the evaluation of FS. The results obtained were analyzed statistically using the analysis of variance (ANOVA) test., Result: The mean FS value of group V depicts significantly high FS among all groups (29.42 ± 3.35). A significant difference was present in FS amongst all the groups that is groups V>II>IV>VI>III>I., Conclusion: Glass ionomer cement (GIC) powder can be modified with nHA, nanotitanium, and GIC liquid can be modified with CH to improve its FS., Clinical Significance: Glass ionomer cement (GIC) supplemented with additives like nanoparticles (NPs) and CH can be used as an enhanced filling material due to its potential antibacterial properties and in areas with a high masticatory load., How to Cite This Article: Showkat I, Chaudhary S, Sinha AA, et al. Comparative Evaluation of Flexural Strength of Conventional Glass Ionomer Cement and Glass Ionomer Cement Modified with Chitosan, Titanium Dioxide Nanopowder and Nanohydroxyapatite: An In Vitro Study. Int J Clin Pediatr Dent 2023;16(S-1):S72-S76., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

The widely accepted "Milankovitch theory" explains insolation-induced waxing and waning of the ice sheets and their effect on the global climate on orbital timescales. In the past half century, however, the theory has often come under scrutiny, especially regarding its "100-ka problem." Another drawback, but the one that has received less attention, is the "monsoon problem," which pertains to the exclusion of monsoon dynamics in classic Milankovitch theory even though the monsoon prevails over the vast low-latitude (∼30° N to ∼30° S) region that covers half of the Earth's surface and receives the bulk of solar radiation. In this review, we discuss the major issues with the current form of Milankovitch theory and the progress made at the research forefront. We suggest shifting the emphasis from the ultimate outcomes of the ice volume to the causal relationship between changes in northern high-latitude insolation and ice age termination events (or ice sheet melting rate) to help reconcile the classic "100-ka problem." We discuss the discrepancies associated with the characterization of monsoon dynamics, particularly the so-called "sea-land precession-phase paradox" and the "Chinese 100-ka problem." We suggest that many of these discrepancies are superficial and can be resolved by applying a holistic "monsoon system science" approach. Finally, we propose blending the conventional Kutzbach orbital monsoon hypothesis, which calls for summer insolation forcing of monsoons, with Milankovitch theory to formulate a combined "Milankovitch-Kutzbach hypothesis" that can potentially explain the dual nature of orbital hydrodynamics of the ice sheet and monsoon systems, as well as their interplays and respective relationships with the northern high-latitude insolation and inter-tropical insolation differential., Competing Interests: The authors declare no competing interests., (© 2022 The Author(s).)

Our understanding of climate dynamics during millennial-scale events is incomplete, partially due to the lack of their precise phase analyses under various boundary conditions. Here we present nine speleothem oxygen-isotope records from mid-to-low-latitude monsoon regimes with sub-centennial age precision and multi-annual resolution, spanning the Heinrich Stadial 2 (HS2) - a millennial-scale event that occurred at the Last Glacial Maximum. Our data suggests that the Greenland and Antarctic ice-core chronologies require +320- and +400-year adjustments, respectively, supported by extant volcanic evidence and radiocarbon ages. Our chronological framework shows a synchronous HS2 onset globally. Our records precisely characterize a centennial-scale abrupt "tropical atmospheric seesaw" superimposed on the conventional "bipolar seesaw" at the beginning of HS2, implying a unique response/feedback from low-latitude hydroclimate. Together with our observation of an early South American monsoon shift at the HS2 termination, we suggest a more active role of low-latitude hydroclimate dynamics underlying millennial events than previously thought., (© 2022. The Author(s).)

Protracted droughts lasting years to decades constitute severe threats to human welfare across the Indian subcontinent. Such events are, however, rare during the instrumental period ( ca . since 1871 CE). In contrast, the historic documentary evidence indicates the repeated occurrences of protracted droughts in the region during the preinstrumental period implying that either the instrumental observations underestimate the full spectrum of monsoon variability or the historic accounts overestimate the severity and duration of the past droughts. Here we present a temporally precise speleothem-based oxygen isotope reconstruction of the Indian summer monsoon precipitation variability from Mawmluh cave located in northeast India. Our data reveal that protracted droughts, embedded within multidecadal intervals of reduced monsoon rainfall, frequently occurred over the past millennium. These extreme events are in striking temporal synchrony with the historically documented droughts, famines, mass mortality events, and geopolitical changes in the Indian subcontinent. Our findings necessitate reconsideration of the region's current water resources, sustainability, and mitigation policies that discount the possibility of protracted droughts in the future.

Background: By increasing immunity, the corona virus disease-19 (COVID-19) vaccine is expected to reduce the rate of infection and severity of infection, as well as the rate of hospitalisation. Healthcare providers (HCPs) can provide a good example when it comes to their health habits. HCPs are believed to have the best vaccine acceptance rates because they are open-minded and informed. By concentrating on COVID-19 vaccine attitudes among HCPs in India, the current study gives a clear picture of vaccine acceptability., Material and Methods: A cross-sectional observational study approach was used. Participants in the study gave their informed permission. Snowball sampling was employed to spread the survey around social media platforms (mostly WhatsApp groups and email IDs). The survey was open from April 1 through April 30, 2021, and a total of 316 responses were received. SPSS software, version 25, was used for statistical analysis (SPSS, Inc., Chicago, IL, USA)., Results: The participants' average age was 32.8 ± 9.7, with 57% of them being male. 16.5% of the 316 individuals had a history of chronic illness. 40.5% had ever experienced COVID-19 symptoms, and 24.1% had been diagnosed with COVID-19 while on duty. Only 16.5% strongly agreed that they could get COVID-19 in the near future, and 48.1% disputed that obtaining COVID-19 infection would make them very unwell. Only 40.5% of participants were concerned about the possible side effects of the vaccine, while 63.2% were not concerned about the possible side effects of the vaccine. Only 39.2% were concerned about the affordability (high price) of vaccines. The majority (95%) of participants agreed to be vaccinated when sufficient information was provided, and only 31.7% agreed to be vaccinated if they were vaccinated free of charge., Conclusion: Due to the high level of current willingness among healthcare professionals to accept COVID-19 vaccines, these data may not be available to the general public. Understanding the complex and interrelated factors that influence vaccination decisions and the determinants of vaccine hesitancy in a particular population is essential to inform interventions to improve immunization coverage., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Background: The prevention of new infections in high-risk groups is a major thrust in National AIDS Control Program. There is enough evidence that many epidemiological and behavioral determinants which make High Risk Group vulnerable to HIV transmission. The most effective means of controlling the spread of HIV is through the implementation of Targeted Interventions (TIs) efforts by which services are catered to them. Furthermore, stigma and marginalization are often linked to this population, which may lead to difficulties while accessing social and health services (SHS) due to behavioral, cultural and language barriers or lack of knowledge of the system. So, finding the sociodemographic & behavioral profile can give a breakthrough in improving the quality of life of HIV high risk groups., Material and Methods: A cross sectional study was conducted during September to December 2019 in two districts (i.e., Raipur & Durg) among HRGs of Chhattisgarh. Training cum sensitization of survey team e.g., peer educators, outreach workers, counselors, project managers prior to the survey was done for data collection., Results: A Total of 3963 HRGs were registered with TI NGOs, 3418 (86.2%) were screened. The mean age of study participants was 27.69 ± 6.1. Compliance of participation was 86.2%. HRGs were observed to have malnutrition (BMI <18.5 &> 25.0). 7 cases of Pulmonary TB were found among IDUs. Prevalence of diabetes and Hypertension was 1.2% and 1.1% respectively. Substance abuse (i.e., for Alcohol and Tobacco) was significantly higher among IDUs and FSWs., Conclusion: This study reinforces the fact that for accessing High Risk Groups and retrieval of relevant information can best be obtained by their care givers i.e., TI NGOs personnel. Also understanding the sociodemographic and behavioral profiles are central to designing targeted HIV prevention interventions for them., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Objective: To present a case of accidental sheath removal of tracheo-bronchial self-expandable metallic airway stent in a patient with endotracheal tumour., Methods: Design: Case Report; Setting: Tertiary care hospital; Patient: One., Results: A 65 years male, follow up case of endotracheal tumor with tracheo-bronchial self-expandable metallic stenting done presented with dry cough and difficulty in breathing since 8-10 days and suddenly coughed out thin whitish paper-like material 2 days back (which later proved as sheath of metallic stent). Direct laryngoscopy with flexible videobronchoscopy was done which showed tracheal stent well placed and intact, coughed out sheath couldn't be replaced back. Procedure was uneventful and patient was discharged in satisfactory condition and is doing well on regular follow up., Conclusion: Self-expandable metallic airway stents (SEMAS) represents a standard method of airways stenting especially when employed for the management of malignant central airway obstruction. Despite the obvious stenting advantages, it may be complicated with stent migration and accidental removal or coughing out of stent especially in high tracheal stenosis. In our case, as a peculiar complication there was accidental removal of the tracheal stent sheath which couldn't be replaced back whereas stent was well in place and intact. We need to be beware of such spurious tracheo-bronchial stents., Competing Interests: Conflicts of interest The authors have none to declare., (Copyright © 2021 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Background and Aims: Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments., Methods: We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment., Results: data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin <0.8 x admission value at day 7), 'static' (bilirubin of >0.9 - <1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p < .001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores., Conclusions: We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

The Liangzhu culture in the Yangtze River Delta (YRD) was among the world’s most advanced Neolithic cultures. Archeological evidence suggests that the Liangzhu ancient city was abandoned, and the culture collapsed at ~4300 years ago. Here, we present speleothem records from southeastern China in conjunction with other paleoclimatic and archeological data to show that the Liangzhu culture collapsed within a short and anomalously wet period between 4345 ± 32 and 4324 ± 30 years ago, supporting the hypothesis that the city was abandoned after large-scale flooding and inundation. We further show that the demise of Neolithic cultures in the YRD occurred within an extended period of aridity that started at ~4000 ± 45 years ago. We suggest that the major hydroclimatic changes between 4300 and 3000 years ago may have resulted from an increasing frequency of the El Niño–Southern Oscillation in the context of weakened Northern Hemisphere summer insolation.

Even though convolutional neural networks (CNNs) are driving progress in medical image segmentation, standard models still have some drawbacks. First, the use of multi-scale approaches, i.e., encoder-decoder architectures, leads to a redundant use of information, where similar low-level features are extracted multiple times at multiple scales. Second, long-range feature dependencies are not efficiently modeled, resulting in non-optimal discriminative feature representations associated with each semantic class. In this paper we attempt to overcome these limitations with the proposed architecture, by capturing richer contextual dependencies based on the use of guided self-attention mechanisms. This approach is able to integrate local features with their corresponding global dependencies, as well as highlight interdependent channel maps in an adaptive manner. Further, the additional loss between different modules guides the attention mechanisms to neglect irrelevant information and focus on more discriminant regions of the image by emphasizing relevant feature associations. We evaluate the proposed model in the context of semantic segmentation on three different datasets: abdominal organs, cardiovascular structures and brain tumors. A series of ablation experiments support the importance of these attention modules in the proposed architecture. In addition, compared to other state-of-the-art segmentation networks our model yields better segmentation performance, increasing the accuracy of the predictions while reducing the standard deviation. This demonstrates the efficiency of our approach to generate precise and reliable automatic segmentations of medical images. Our code is made publicly available at: https://github.com/sinAshish/Multi-Scale-Attention.

Introduction By Dr. Ashish Sinha, MD, PhD, DABA, MBA, FASA As a Program Director of a just established anesthesia program, one faces enough challenges. A curve ball that I was not expecting was one of my residents to inform me on July 3rd that he was feeling feverish with chills, had myalgia and a headache. First response in my mind, that I didn't verbalize was, "Anosmia too?" I arranged COVID testing ASAP in a drive-by setting, which we could avail immediately. My resident had driven from New Orleans, LA to Riverside, CA, making a few stops along the way, (food, gas, rest) utilizing the best safety he could practice. To no one's surprise the test came back positive. My resident needed to not feel abandoned by program, co-residents or institution. To keep him involved, while quarantined, I asked him to join us in all academic activities by Zoom and further gave him this introspective assignment. He took on this task with enthusiasm and provided a great piece, or at least I think so!, Competing Interests: Conflicts of Interest The authors declare they have no conflicts of interest., (© 2020 HCA Physician Services, Inc. d/b/a Emerald Medical Education.)

Background: The optimal choice of prophylactic drugs to decrease postoperative sore throat is unclear. The objective of this network meta-analysis (NMA) was to compare and rank 11 topical agents used to prevent postoperative sore throat., Methods: Various databases were searched independently for randomized-controlled trials (RCTs) comparing topical agents used for the prevention of postoperative sore throat. Inclusion criteria were parallel group studies comparing intervention with active or inactive control and reporting postoperative sore throat. The primary outcome was postoperative sore throat at 24 hr. Secondary outcomes were early sore throat at 4-6 hr, cough, and hoarseness at 24 hr., Results: Evidence was synthesized from 70 RCTs reporting 7,141 patients. Topical application of lidocaine, corticosteroids, ketamine, magnesium, benzydamine, water-based lubricant, and liquorice applied along the tracheal tube, to the tracheal tube cuff, gargled or sprayed were compared with intracuff air and each other. Bayesian NMA showed that magnesium (odds ratio [OR], 0.10; 95% credible interval [CrI], 0.03 to 0.26), liquorice (OR, 0.14; 95% CrI, 0.03 to 0.55), and steroid application (OR, 0.11; 95% CrI, 0.06 to 0.22) most effectively prevented postoperative sore throat at 24 hr. Topical lidocaine was the least effective intervention., Conclusion: Topical application of magnesium followed by liquorice and corticosteroids most effectively prevented postoperative sore throat 24 hr after endotracheal intubation.

Madagascar and the Mascarene Islands of Mauritius and Rodrigues underwent catastrophic ecological and landscape transformations, which virtually eliminated their entire endemic vertebrate megafauna during the past millennium. These ecosystem changes have been alternately attributed to either human activities, climate change, or both, but parsing their relative importance, particularly in the case of Madagascar, has proven difficult. Here, we present a multimillennial (approximately the past 8000 years) reconstruction of the southwest Indian Ocean hydroclimate variability using speleothems from the island of Rodrigues, located ∼1600 km east of Madagascar. The record shows a recurring pattern of hydroclimate variability characterized by submillennial-scale drying trends, which were punctuated by decadal-to-multidecadal megadroughts, including during the late Holocene. Our data imply that the megafauna of the Mascarenes and Madagascar were resilient, enduring repeated past episodes of severe climate stress, but collapsed when a major increase in human activity occurred in the context of a prominent drying trend., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution NonCommercial License 4.0 (CC BY-NC).)

The Younger Dryas (YD), arguably the most widely studied millennial-scale extreme climate event, was characterized by diverse hydroclimate shifts globally and severe cooling at high northern latitudes that abruptly punctuated the warming trend from the last glacial to the present interglacial. To date, a precise understanding of its trigger, propagation, and termination remains elusive. Here, we present speleothem oxygen-isotope data that, in concert with other proxy records, allow us to quantify the timing of the YD onset and termination at an unprecedented subcentennial temporal precision across the North Atlantic, Asian Monsoon-Westerlies, and South American Monsoon regions. Our analysis suggests that the onsets of YD in the North Atlantic (12,870 ± 30 B.P.) and the Asian Monsoon-Westerlies region are essentially synchronous within a few decades and lead the onset in Antarctica, implying a north-to-south climate signal propagation via both atmospheric (decadal-time scale) and oceanic (centennial-time scale) processes, similar to the Dansgaard-Oeschger events during the last glacial period. In contrast, the YD termination may have started first in Antarctica at ∼11,900 B.P., or perhaps even earlier in the western tropical Pacific, followed by the North Atlantic between ∼11,700 ± 40 and 11,610 ± 40 B.P. These observations suggest that the initial YD termination might have originated in the Southern Hemisphere and/or the tropical Pacific, indicating a Southern Hemisphere/tropics to North Atlantic-Asian Monsoon-Westerlies directionality of climatic recovery., Competing Interests: The authors declare no competing interest., (Copyright © 2020 the Author(s). Published by PNAS.)

Background: Poorer patient outcomes for emergency general surgery have been observed in patients admitted to hospital over the weekend. This paper reports the outcomes of a Consultant-delivered service model for weekend admissions and its impact for patients undergoing emergency laparotomy., Methods: Operative data was analysed from a prospectively collected database over 5-years. Primary outcome measures were 30-day all-cause mortality and Clavien-Dindo class ≥2 morbidity. Secondary outcomes included time from admission to diagnostic imaging and time to surgery, post-operative length of stay and requirement for Intensive Care Unit admission., Results: 263 patients underwent an emergency laparotomy. Overall 30-day mortality was 4.6% and all-cause morbidity was 55.9%. The most common indications for laparotomy were mechanical small bowel obstruction (32.7%) and hollow viscus perforation (30.4%) of the 263 emergency laparotomies, 92 patients in the cohort were weekend admissions (Saturday or Sunday). There was no significant difference amongst patients admitted during the weekend in ASA grade, age, gender, or proportion of patients receiving a pre-operative computed tomography scan, when compared to those during the week. Compared to weekdays, weekend admission was not associated with a significant difference in mortality (5.3% and 3.3%, respectively p = 0.458), all-cause morbidity (p = 0.509), post-operative length of stay (p = 0.681), or Intensive Care Unit admission (p = 0.761)., Conclusion: A Consultant Surgeon delivered emergency service can avoid the poor patient outcomes associated with weekend admissions and the 'weekend effect'., Competing Interests: None., (© 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.)

Background: We aimed to evaluate comparative outcomes of robotic and laparoscopic total mesorectal excision (TME) in patients with rectal cancer., Methods: We systematically searched electronic data sources with application of combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Perioperative clinical and short-term oncological outcomes were evaluated. Trial Sequential Analysis of the outcomes was conducted., Results: Nine randomised-controlled trials reporting 1463 patients evaluating outcomes of robotic TME (n = 728) and laparoscopic TME (n = 735) were included. Although the robotic approach was associated with significantly longer operative time (MD 31.64, P = 0.002), it was associated with significantly longer DRM (MD 0.8, P = 0.004) and shorter time to soft diet (MD - 0.50, P = 0.03) compared to the laparoscopic approach. Moreover, there was no significant difference in intraoperative (RR 1.07, P = 0.76)) and postoperative (RR 0.97, P = 0.81) complications, anastomotic leak (RR 0.93, P = 0.69), conversion to open rate (RR 0.46, P = 0.05), blood loss (MD 19.65, P = 0.74), time to first flatus (MD - 0.30, P = 0.37), LARS (RR 0.83, P = 0.41), ileus (RR 0.72, P = 0.39), positive CRM (RR 0.82, P = 0.49), PRM (MD - 0.5, P = 0.55), number of harvested lymph nodes (MD 0.33, P = 0.58), or length of stay (MD - 0.60, P = 0.12) between two groups. The Trial Sequential Analysis demonstrated that the risk of type 1 and type 2 errors was minimal in most outcomes., Conclusions: Moderate-quality evidence suggested that robotic and laparoscopic TME may be comparable in terms of clinical and short-term oncological profile but the robotic approach may be associated with longer procedure time. Future high-quality randomised studies are encouraged to compare the functional, long-term oncological, and cost-effectiveness outcomes of both approaches.

Competing Interests: Conflict of interest The author declares that he has no conflict of interest.

Northern Iraq was the political and economic center of the Neo-Assyrian Empire (c. 912 to 609 BCE)-the largest and most powerful empire of its time. After more than two centuries of regional dominance, the Neo-Assyrian state plummeted from its zenith (c. 670 BCE) to complete political collapse (c. 615 to 609 BCE). Earlier explanations for the Assyrian collapse focused on the roles of internal politico-economic conflicts, territorial overextension, and military defeat. Here, we present a high-resolution and precisely dated speleothem record of climate change from the Kuna Ba cave in northern Iraq, which suggests that the empire's rise occurred during a two-centuries-long interval of anomalously wet climate in the context of the past 4000 years, while megadroughts during the early-mid seventh century BCE, as severe as recent droughts in the region but lasting for decades, triggered a decline in Assyria's agrarian productivity and thus contributed to its eventual political and economic collapse., (Copyright © 2019 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution NonCommercial License 4.0 (CC BY-NC).)

Paraesophageal hernia repairs are complex surgical cases frequently performed on patients of advanced age with multiple comorbidities, both of which create difficulties in the anesthetic management. Preoperative evaluation is challenging because of overlapping cardiopulmonary symptoms. The patient's symptoms and anatomy lead to an increased aspiration risk and the potential need for a rapid sequence induction. Depending on the surgical approach, lung isolation may be required. Communication with the surgeon is vital throughout the case, especially when placing gastric tube and bougies. Multimodal analgesia should include regional and/or neuraxial techniques, in addition to the standard intravenous and oral pain medications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Paired measurements of 14 C/ 12 C and 230 Th ages from two Hulu Cave stalagmites complete a precise record of atmospheric 14 C covering the full range of the 14 C dating method (~54,000 years). Over the last glacial period, atmospheric 14 C/ 12 C ranges from values similar to modern values to values 1.70 times higher (42,000 to 39,000 years ago). The latter correspond to 14 C ages 5200 years less than calibrated ages and correlate with the Laschamp geomagnetic excursion followed by Heinrich Stadial 4. Millennial-scale variations are largely attributable to Earth's magnetic field changes and in part to climate-related changes in the oceanic carbon cycle. A progressive shift to lower 14 C/ 12 C values between 25,000 and 11,000 years ago is likely related, in part, to progressively increasing ocean ventilation rates., (Copyright © 2018 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Background: Dexamethasone has many desirable pharmacologic properties for perioperative use. Its antiemetic potential has been a focus of many recent trials., Methods: Trials comparing dexamethasone to 5-HT3-receptor antagonists (5HT3-RA) for 24 h postoperative vomiting incidences published till August 2017 were searched in the medical database. Comparisons for antiemetic efficiency variables (vomiting incidence, nausea incidence, rescue antiemetic need, and patients with complete response) during early (until 6 h) and late postoperative phase were made. Comparative analgesic requirements were also evaluated., Results: Twenty randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar (Fixed-effects, P = 0.86, I 2  = 2.94%). Trial sequential analysis (TSA) confirmed non-inferiority of dexamethasone for 24-h vomiting incidence. (α = 5%, β = 20%, δ = 10%) with "information size" being 1619 (required > 573). Equivalence was also verified from early and delayed nausea rate as well using TSA. Pooled results did not demonstrate superiority/inferiority of 5-HT3-RAs over dexamethasone in all other antiemetic efficacy variables (early and delayed). Heterogeneity was found to be low in all of the comparisons. Linear-positive dose-response curve for dexamethasone 24-h vomiting and nausea incidence was seen (correlation coefficient being 0.21 and 0.28, respectively). Dexamethasone reduced the analgesic need (MH-odds of 0.64 (95% CI being 0.44 to 0.93) P = 0.02, I2 = 0)). Possibility of publication bias could not be ruled out (Egger's test, X-intercept = 1.41, P = 0.04)., Conclusions: Dexamethasone demonstrates equal antiemetic efficacy compared to 5-HT3 receptor antagonists. The agents perform equally well both in early postoperative phase and up to 24 h after surgery. Use of dexamethasone replacing 5-HT3 RAs offers an additional advantage of lowering the opioid requirements during the perioperative period.

In southeastern China (SEC), the precipitation amount produced by the East Asian summer monsoon (EASM) is almost equivalent to that during the non-summer monsoon (NSM) period, both of them significantly affecting agriculture and socioeconomy. Here, we present a seasonally-resolved stalagmite δ 18 O record (δ 18 O s ) for the interval 1810-2009 AD from E'mei cave, Jiangxi Province, SEC. The comparison between δ 18 O s and instrumental data indicates that the δ 18 O s variability is primarily controlled by the precipitation seasonality (i.e., the ratio of EASM/NSM precipitation) modulated by the El Niño/Southern Oscillation (ENSO) on interannual to interdecadal timescales. Higher (lower) δ 18 O s values thereby correspond to lower (higher) EASM/NSM ratios associated with El Niño (La Niña) events. Significant correlations with ENSO and the Pacific Decadal Oscillation (PDO) indicate that the precipitation seasonality in SEC is remarkably influenced by ocean-atmosphere interactions, with lower (higher) EASM/NSM ratios during warm (cold) phases of ENSO/PDO. The progressive increase in δ 18 O s since 2005 AD may reflect a strengthening of the central Pacific El Niño under continued anthropogenic global warming. The relationship between seasonal precipitation and δ 18 O s with ENSO/PDO requires further studies.

Haloperidol is an antipsychotic with well-known antiemetic potential. It is underutilized for postoperative nausea vomiting due to reported corrected QT interval (QTc) prolongation. This meta-analysis evaluates its safety and efficacy as an antiemetic in the perioperative period. Trials comparing haloperidol to 5-HT 3 -receptor antagonists (5-HT 3 -RA) for 24 postoperative vomiting incidences published up to May 2017 were searched in the medical database. Comparisons were made for antiemetic efficiency variables (vomiting incidence, rescue antiemetic need, and patients with complete response) during early (until 6 hours) and late postoperative phases. Eight randomized controlled double-blinded trials were included in the final analysis. Twenty-four-hour vomiting incidence was similar in groups (fixed effects, P = 0.52, I 2 = 0%). Trial-sequential analysis confirmed noninferiority of haloperidol over 5-HT 3 -RAs (α = 5%, β = 20%, δ = 10%), with "information size" being 859 (required > 812). Pooled results did not demonstrate superiority/inferiority of 5-HT 3 -RAs over haloperidol in all other antiemetic efficacy variables (early and delayed). Negligible heterogeneity was found in all the comparisons made. Pooled Mantel Haenszel odds ratio for QTc prolongation was equivalent in both groups (fixed effects, P = 0.23, I 2 = 0%). The mean dose of haloperidol used was 1.34 mg, and no trial reported extrapyramidal side effects. Trial-sequential analysis showed statistical equivalence (α = 5%, β = 20%, δ = 10%), with information size being 745 (required > 591). Publication bias was unlikely (Egger test, X-intercept = 2.07, P = 0.10). We conclude that haloperidol is equivalent to the well-established 5-HT 3 -RAs in preventing vomiting during the first day after surgery. The incidence of QTc prolongation with haloperidol is statistically equivalent to 5-HT 3 -RAs and thus should not be the factor that discourages its use for treatment/prophylaxis of postoperative nausea vomiting., (© 2017, The American College of Clinical Pharmacology.)

Aims: This study aims to examine the accuracy and comparative correlation of three regression equation-based mixed dentition analysis in children of Moradabad city, North Uttar Pradesh., Settings and Design: Tanaka-Johnston, Bernabe-Flores-Mir, and Ling-Wong regression equations were developed from a sample of North European, Peru, and Southern Chinese children population, respectively. Hence, it becomes questionable when applied to children of Moradabad city situated in North Uttar Pradesh, India., Subjects and Methods: The study was conducted on a sample of 100 school going children, age range is 11-14 years with complete permanent teeth except third molars. The mesiodistal crown dimensions of all erupted incisors, canines, premolars, and molars were measured with digital calipers with a calibration accuracy of 0.01 mm. The actual tooth measurements were then compared with predicted values using Tanaka-Johnston, Bernabe-Flores-Mir, and Ling-Wong regression equations, respectively using paired t-test., Results: The mean difference between the actual and estimated values of canines and premolars using Tanaka-Johnston, Bernabe-Flores-Mir, and Ling-Wong were clinically and statistically significant (P< 0.001)., Conclusions: Mesiodistal dimensions of male samples are larger than female samples. All the three regression equations are not accurately applicable to this population., Competing Interests: There are no conflicts of interest

Background: Thoracic interfascial plane blocks and modification (PECS) have recently gained popularity for analgesic potential during breast surgery. We evaluate/consolidate the evidence on opioid-sparing effect of PECS blocks in comparison with conventional intravenous analgesia (IVA) and paravertebral block (PVB)., Materials and Methods: Prospective, randomized controlled trials comparing PECS block to conventional IVA or PVB in patients undergoing breast surgery published till June 2017 were searched in the medical database. Comparisons were made for 24-h postoperative morphine consumption and intraoperative fentanyl-equivalent consumption., Results: Final analysis included nine trials (PECS vs. IVA 4 trials and PECS vs. PVB 5 trials). PECS block showed a decreased intraoperative fentanyl consumption over IVA by 49.20 mcg (95% confidence interval [CI] =42.67-55.74) ( I 2 = 98.47%, P < 0.001) and PVB by 15.88 mcg (95% CI = 12.95-18.81) ( I 2 = 95.51%, P < 0.001). Postoperative, 24-h morphine consumption with PECS block was lower than IVA by 7.66 mg (95% CI being 6.23-9.10) ( I 2 = 63.15, P < 0.001) but was higher than PVB group by 1.26 mg (95% CI being 0.91-1.62) ( I 2 = 99.53%, P < 0.001). Two cases of pneumothorax were reported with PVB, and no complication was reported in any other group., Conclusions: Use of PECS block and its modifications with general anesthesia for breast surgery has significant opioid-sparing effect intraoperatively and during the first 24 h after surgery. It also has higher intraoperative opioid-sparing effect when compared to PVB. During the 1 st postoperative day, PVB has slightly more morphine sparing potential that may however be associated with higher complication rates. The present PECS block techniques show marked interstudy variations and need standardization., Competing Interests: There are no conflicts of interest.

The vast Indo-Gangetic Plain in South Asia has been home to some of the world's oldest civilizations, whose fortunes ebbed and flowed with time-plausibly driven in part by shifts in the spatiotemporal patterns of the Indian summer monsoon rainfall. We use speleothem oxygen isotope records from North India to reconstruct the monsoon's variability on socially relevant time scales, allowing us to examine the history of civilization changes in the context of varying hydroclimatic conditions over the past 5700 years. Our data suggest that significant shifts in monsoon rainfall have occurred in concert with changes in the Northern Hemisphere temperatures and the discharges of the Himalayan rivers. The close temporal relationship between these large-scale hydroclimatic changes and the intervals marking the significant sociopolitical developments of the Indus Valley and Vedic civilizations suggests a plausible role of climate change in shaping the important chapters of the history of human civilization in the Indian subcontinent.

Background: Previous studies have described the clinical impact of infection in alcoholic hepatitis (AH) but none have comprehensively explored the aetiopathogenesis of infection in this setting. We examined the causes, consequences and treatment of infection in a cohort of patients with AH., Methods: We undertook a retrospective cohort study of patients with AH admitted between 2009 and 2014 to seven centres in Europe and the USA. Clinical and microbiological data were extracted from medical records. Survival was analysed with Kaplan-Meier analysis and Cox proportional hazards analysis to control the data for competing factors. Propensity score matching was used to examine the efficacy of prophylactic antibiotics administered in the absence of infection., Results: We identified 404 patients with AH. Of these, 199 (49%) showed clinical or culture evidence of infection. Gut commensal bacteria, particularly Escherichia coli and Enterobacter species, were most commonly isolated in culture. Fungal infection was rarely seen. Cultured organisms and antibiotic resistance differed markedly between centres. Infection was an independent risk factor for death (hazard ratio for death at 90 days 2.33, 95% confidence interval 1.63-3.35, p < 0.001). Initiation of antibiotic therapy on admission in the absence of infection did not reduce mortality or alter the incidence of subsequent infections. Corticosteroid use increased the incidence of infection but this did not impact on survival., Conclusions: In this large real-world cohort of patients with AH, infection was common and was associated with reduced short-term survival. Gram-negative, gut commensal bacteria were the predominant infective organisms, consistent with increased translocation of gut bacteria in AH; however, the characteristics of infection differ between centres. Infection should be actively sought and treated, but we saw no benefits of prophylactic antibiotics.

Early and clear recovery from anesthesia is the crux for preventing perioperative complications in the obese undergoing bariatric surgery. Volatile inhalation agents by virtue of high lipid solubility are expected to produce residual anesthetic effects. Prospective randomized trials comparing desflurane and sevoflurane used for anesthesia maintenance (electroencephalograph guided) during bariatric surgery published till 1st of July 2017 were searched in the medical database. Comparisons were made for surrogate markers of recovery from anesthesia that included time to eye-opening (TEo), time to tracheal-extubation (TEx), and Aldrete scores on immediately shifting to recovery (Ald-I). Five trials were included in the final analysis. Patients receiving desflurane began to respond faster by opening eyes on command (five trials) by 3.80 min (95%CI being 1.83-5.76) (random effects, P < 0.01, I 2  = 78.61%), and tracheal extubation was also performed earlier (four trials) by 4.97 min (95%CI being 1.34-8.59). This meant a reduction of 37% in TEo and 33.60% in TEx over sevoflurane. Ald-I scores were higher/better with desflurane by 0.52 (95%CI being 0.19-0.84) (Fixed-effects, P < 0.01, I 2  = 6.67%). Publication bias is likely for TEo (Egger's Test, X-intercept = - 8.57, P = 0.02). No airway-related complications were reported with desflurane's expedited recovery. Use of desflurane compared to sevoflurane for maintenance of anesthesia in morbidly obese patients allows attaining verbal contact faster, and tracheal extubating can be performed earlier without compromising safety. The benefits of better recovery extend into the immediate postoperative phase with patients being more awake upon shifting to the recovery.

Background: Opioid-sparing analgesia for bariatric surgery in morbidly obese can potentially prevent catastrophic airway complications. Our meta-analysis attempts to consolidate the evidence on dexmedetomidine evaluating its analgesic and safety profile., Methods: Trails comparing perioperative dexmedetomidine infusion to conventional analgesic regimens for bariatric surgery were searched. Comparisons were made for 24-hour and postanesthesia care unit (PACU) morphine consumed, PACU pain scores, postoperative nausea and vomiting pain scores, and heartrate. Meta-regression was performed for length of stay to evaluate various analgesic control subgroups., Results: Six trials were included in the final analysis. Dexmedetomidine infusion (reported in 5 intraoperative subgroups and 2 postoperative subgroups) decreased 24-hour morphine by 18.13±6.11 mg (random effects: P<.001, I 2 = 95.48%). Despite the small number of included studies, the sample size for avoiding a false positive result was adequate as the trial sequential analysis found the present sample size (362) to be well past the required "sample size" (n = 312) for 85% power. Meta-regression for infusion dose on morphine consumption difference found a predictability of 49% (coefficient = 39.93, random-effects, Tau 2 = 396.08), and predictability of the model improved to 68% on inclusion of time of initiation of infusion. The dexmedetomidine group had lower PACU morphine consumption (by 6.91±1.19, I 2 = 34.37%), lower pain scores (scale of 0-10±2.27, I 2 = 88.14%), lower postoperative nausea and vomiting incidence (odds ratio =±0.26, I 2 = 0%), and lower heart rate (73.25 versus. 83.50) (mean difference =±10.15 I 2 = 94.04%). No adverse events were reported across trials., Conclusion: Perioperative dexmedetomidine infusion in obese patients undergoing bariatric surgery is a promising and safe alternative. Both intraoperative or postoperative infusions lead to significant opioid sparing in early and extend postoperative recovery phase. Morbidly obese patients receiving perioperative dexmedetomidine infusions have overall better pain control and lower incidence of postoperative nausea-vomiting. All the aforementioned merits come with a stable hemodynamic profile and without any reported major adverse events., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The precipitation variability associated with the East Asian summer monsoon (EASM) has profound societal implications. Here, we use precisely dated and seasonally-resolved stalagmite oxygen isotope (δ 18 O) records from Shihua Cave, North China to reconstruct the EASM variability over the last 145 years. Our record shows a remarkable weakening of the EASM strength since the 1880s, which may be causally linked to the warming of the tropical Pacific and Indian Oceans. The δ 18 O record also exhibits a significant ~30-year periodicity, consistent with the instrumental, historical and proxy-based rainfall records from North China, plausibly driven by the Pacific Decadal Oscillation (PDO). Together, these observations imply that ~30-year periodicity is a persistent feature of the EASM, which remains significant with or without anthropogenic forcing. If indeed, the EASM rainfall in North China might decline significantly in the near future, which may affect millions of people in this region.

Background: The frequency of metabolic and bariatric surgery (MBS) is increasing worldwide, with over 500,000 cases performed every year. Obstructive sleep apnea (OSA) is present in 35%-94% of MBS patients. Nevertheless, consensus regarding the perioperative management of OSA in MBS patients is not established., Objectives: To provide consensus based guidelines utilizing current literature and, when in the absence of supporting clinical data, expert opinion by organizing a consensus meeting of experts from relevant specialties., Setting: The meeting was held in Amsterdam, the Netherlands., Methods: A panel of 15 international experts identified 75 questions covering preoperative screening, treatment, postoperative monitoring, anesthetic care and follow-up. Six researchers reviewed the literature systematically. During this meeting, the "Amsterdam Delphi Method" was utilized including controlled acquisition of feedback, aggregation of responses and iteration., Results: Recommendations or statements were provided for 58 questions. In the judgment of the experts, 17 questions provided no additional useful information and it was agreed to exclude them. With the exception of 3 recommendations (64%, 66%, and 66% respectively), consensus (>70%) was reached for 55 statements and recommendations. Several highlights: polysomnography is the gold standard for diagnosing OSA; continuous positive airway pressure is recommended for all patients with moderate and severe OSA; OSA patients should be continuously monitored with pulse oximetry in the early postoperative period; perioperative usage of sedatives and opioids should be minimized., Conclusion: This first international expert meeting provided 58 statements and recommendations for a clinical consensus guideline regarding the perioperative management of OSA patients undergoing MBS., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)