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Background: In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs). Methods: After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device. Results: From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV. Conclusion: Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used. [ABSTRACT FROM AUTHOR]

In this article, we study the following Hamiltonian elliptic system with coefficients:$ \begin{align} \notag \left\{\begin{aligned} -\varepsilon^2\Delta u +c(x)u = b(x) |{v}|^{q-1}v, &\, \, \text{ and } -\varepsilon^2\Delta v +c(x)v = a(x) |{u}|^{p-1}u \quad\text{in } \Omega, \\ u>0, \ v>0 \text{ in } \Omega, &\, \, \text{ and }\quad\frac{ \partial u}{ \partial\nu} = 0 = \frac{ \partial v}{ \partial\nu}\quad \text{on } \partial\Omega, \end{aligned} \right. \end{align} $where $ \Omega $ is a smooth bounded domain in $ \mathbb{R}^n, n\ge 3 $. The coefficients $ a(x), b(x), $ and $ c(x) $ are smooth, positive, and bounded. We study the existence of point-concentrating solutions and the influence of the coefficients on their concentration profiles. As an application of this result, we establish the existence of higher-dimensional concentrating solutions for a class of elliptic systems. [ABSTRACT FROM AUTHOR]

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has adversely impacted medical education worldwide. However, its impact on the postgraduate medical thesis and dissertation work is still not evaluated. Through this study, we planned to find out the problems brought by the pandemic and likely alternatives and possible solutions to thrust the academic competence of postgraduate students. Methods: After obtaining institutional ethics committee approval, we sent a 13-item questionnaire to postgraduate medical students in India via various social media online platforms. Data on the impact of the COVID-19 pandemic on thesis work and alternatives/solutions to improve the research competence were collected on a Likert scale and analyzed. Results: We received a total of 398 responses out of which 377 entries were included for final analysis. The majority of participants (88%) reportedly had an adverse impact on the thesis work and out of 25% of the participants who recently submitted their around 45% had to do so without achieving the estimated sample size. The 6-month departmental review for thesis progress was seen in merely 28% of participants. Possible alternatives suggested were the maintenance of log books, task-based assessment of research methodology, departmental audits, and systematic reviews. Solutions suggested for improving the research competence of students were a compulsory research methodology curriculum, a biostatistics department in each institution, permission to conduct thesis work beyond submission time, exclusive time for research work, and financial incentives. Conclusion: Modification in the research aspect of the current postgraduate medical education is the need of the hour and the pandemic has enlightened us regarding the current weaknesses. [ABSTRACT FROM AUTHOR]

Introduction: Chronically critically ill (CCI) patients often have high costs of care and poor outcomes. Disease management programs offering home care may reduce costs but needs buy-in from informal caregivers. An understanding of caregiver burden in this population is lacking. We aimed to study the caregiver burden, its change over time, and factors affecting it, in post-ICU tracheostomized patients. We compared the caregiver burden among CCI carers to that of palliative caregivers. Methods: Informal caregivers of thirty chronically critically ill tracheostomized patients (CGcci) were administered the Caregivers Burden Scale (CBS) tool at discharge, 2 and 4 weeks after discharge. A one-point assessment of burden was made in 30 caregivers of patients enrolled in Pain and Palliative care clinic (CGpc). Linear mixed models for repeated measures were used to analyze score of CGcci over time and compared to the burden in physical, psychologic, economic, time, and social domains between groups. Results: All 60 caregivers were young (33-35 years), predominantly male, and children of the patients. Both CGcci and CGpc had moderate burden score of 60.5 (14.7) vs 61.5 (13), respectively. Physical burden (11.5 vs 8) was greater in CGcci (p = 0.001) compared to psychologic domain (10 vs 12.5) in CGpc (p = 0.01). Burden score over all domains in CGcci decreased rapidly from 67.5 (8) to 55 (16.5) (p = 0.001) in the first month after discharge. Conclusion: Burden of care among caregivers of tracheostomized chronically critically ill patients is comparable to those of palliative caregivers and reduces significantly with time. [ABSTRACT FROM AUTHOR]

Background: Subanesthetic intravenous (IV) ketamine acts as an analgesic and has opioid-sparing effects, particularly for acute postoperative pain; however, its effectiveness in children is understudied. The primary aim of this study was to evaluate the non-inferiority of subanesthetic IV ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infra-umbilical surgery. Methods: Children aged < 6 years were enrolled in this single-blind study and randomized to receive either subanesthetic IV ketamine (0.3 mg/kg) or caudal 0.125% bupivacaine (1 ml/kg) along with general anesthesia. Postoperative pain was assessed using the FLACC scale at 30 minutes and 1, 2, 3, and 6 h post-operation. Intra- and postoperative opioid consumption, time to extubation, postoperative vomiting, agitation, sedation, and inflammatory markers were also assessed. Results: Altogether, 141 children completed the study (ketamine group: n = 71, caudal group: n = 70) The cumulative proportion of children without significant postoperative pain (FLACC score < 4) in the first 6 h post-surgery was 45.1% in the ketamine group vs. 72.9% in the caudal group (P < 0.001). More children in the ketamine group required an additional dose of intraoperative fentanyl (33.8% vs. 5.7%, P < 0.001) and postoperative tramadol (54.9% vs. 27.1%, P < 0.001). However, postoperative agitation, sedation, and other secondary outcomes were similar between the groups. Conclusions: Subanesthetic ketamine is inferior to caudal bupivacaine for postoperative analgesia in children aged < 6 years undergoing infra-umbilical surgeries; however, other postoperative outcomes are similar. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine, an alpha-2 agonist, has been used for attenuation of hemodynamic response to laryngoscopy but not through the nebulized route. We evaluated the effects of preoperative dexmedetomidine nebulization on the hemodynamic response to laryngoscopy and intubation and examined the intraoperative anesthetic-analgesic requirements and recovery outcomes. Methods: Overall, 120 American Society of Anesthesiologists I & II adult patients (of either gender) undergoing elective surgeries and requiring tracheal intubation, were randomized to receive nebulized dexmedetomidine (1 µg/kg in 3-4 ml of 0.9% saline) or 0.9% saline (3-4 ml), 30 min before anesthesia induction. Heart rate (HR) and non-invasive systolic blood pressure (SBP) were monitored for 10 min following laryngoscopy. Results: After laryngoscopy, linear mixed effect modelling showed significantly lower trend of increase in HR in the dexmedetomidine group versus saline (P = 0.012); however, there was no difference in the SBP changes between the two groups (P = 0.904). Induction dose of propofol (P < 0.001), intraoperative fentanyl consumption (P = 0.007), and isoflurane requirements (P = 0.013) were significantly lower in the dexmedetomidine group. There was no difference in the 2 h incidence of postoperative nausea and vomiting (PONV) (P = 0.612) or sore-throat (P = 0.741). Conclusions: Nebulized dexmedetomidine at 1 µg/kg attenuated the increase in HR but not SBP following laryngoscopy and reduced the intraoperative anesthetic and analgesic consumption. There was no effect on early PONV, sore-throat, or increase in incidence of adverse effects. Nebulized dexmedetomidine may represent a favorable alternative to the intravenous route in short duration surgeries. [ABSTRACT FROM AUTHOR]

Background: Available options for correction of facial volume loss, such as synthetic fillers, autologous fat and cultured fibroblasts, have limitations viz. temporary effect and high cost.Aim: To assess the use of a novel technique, autologous non-cultured dermal cell suspension transplantation, for correction of localized facial volume loss due to inflammatory pathologies.Methods: It was a pilot study conducted in the Dermatology Outpatient Department, All India Institute of Medical Sciences (AIIMS), New Delhi, India. Autologous non-cultured dermal cell suspension was transplanted in a total of 10 patients, out of which 5 had predominantly dermal loss and the rest had predominantly lipoatrophy. The donor tissue from the gluteal region was digested into a single cell suspension using collagenase-1 and injected into the recipient area. The outcome was assessed subjectively by patients and investigators and objectively using ultrasonography. Cell count, viability testing and measurement of mesenchymal stem cells were also done.Results: On assessment of patients, the median improvement in the predominantly dermal atrophy group at 3 and 6 months was 70% (range: 10-90%) and 80% (range: 0-90%), respectively, and in the predominantly lipoatrophy group, 0% (range: 0-40) and 0% (range: 0-50), respectively. Mean thickness of dermis + subcutis at the baseline was 1.835 mm (range: 0.89-6.04 mm), which increased to 2.912 mm (range: 0.88-7.07 mm, P = 0.03) at 6 months.Limitations: Our pilot study has some limitations such as small sample size and heterogeneity of the recruited patients.Conclusions: Autologous non-cultured dermal cell suspension transplantation appears to be safe and effective in localized facial dermal defects because of inflammatory pathologies, but not effective in deeper defects. [ABSTRACT FROM AUTHOR]

The prevalence of superficial mycotic infection worldwide is 20-25% of which dermatophytes are the most common agents. Recent developments in understanding the pathophysiology of dermatophytosis have confirmed the central role of cell-mediated immunity in countering these infections. Hence, a lack of delayed hypersensitivity reaction in presence of a positive immediate hypersensitivity (IH) response to trichophytin antigen points toward the chronicity of disease. Diagnosis, though essentially clinical should be confirmed by laboratory-based investigations. Several new techniques such as polymerase chain reaction (PCR) and mass spectroscopy can help to identify the different dermatophyte strains. Management involves the use of topical antifungals in limited disease, and oral therapy is usually reserved for more extensive cases. The last few years have seen a significant rise in the incidence of chronic dermatophyte infections of skin which have proven difficult to treat. However, due to the lack of updated national or international guidelines on the management of tinea corporis, cruris, and pedis, treatment with systemic antifungals is often empirical. The present review aims to revisit this important topic and will detail the recent advances in the pathophysiology and management of tinea corporis, tinea cruris, and tinea pedia while highlighting the lack of clarity of certain management issues. [ABSTRACT FROM AUTHOR]

This paper deals with global compactness and the multiplicity of positive solutions to problems of the type −Δ픹Nu − λu = a(x)|u|2∗−2u + f(x)in 픹N, u ∈ H1(픹N), where 픹N denotes the ball model of the hyperbolic space of dimension N ≥ 4, 2∗ = 2N N−2, N(N−2) 4 < λ < (N−1)2 4 and f ∈ H−1(픹N) (f≢0) is a nonnegative functional in the dual space of H1(픹N). The potential a ∈ L∞(픹N) is assumed to be strictly positive, such that limd(x,0)→∞a(x) = 1, where d(x, 0) denotes the geodesic distance. We establish profile decomposition of the functional associated with the above equation. We show that concentration occurs along two different profiles, namely, hyperbolic bubbles and localized Aubin–Talenti bubbles. For f = 0 and a ≡ 1, profile decomposition was studied in Bhakta and Sandeep [Poincaré–Sobolev equations in the hyperbolic space, Calc. Var. Partial Differential Equations 44 (2012) 247–269]. However, due to the presence of the potential a(.), an extension of profile decomposition to the present set-up is highly nontrivial and requires several delicate estimates and geometric arguments concerning the isometry group (Möbius group) of the hyperbolic space. Further, using the decomposition result, we derive various energy estimates involving the interacting hyperbolic bubbles and hyperbolic bubbles with localized Aubin–Talenti bubbles. Finally, combining these estimates with topological and variational arguments, we establish a multiplicity of positive solutions in the cases: a ≥ 1 and a < 1 separately. The equation studied in this paper can be thought of as a variant of a scalar-field equation with a critical exponent in the hyperbolic space, although such a critical exponent problem in the Euclidean space ℝN has only a trivial solution when f ≡ 0, a(x) ≡ 1 and λ < 0. [ABSTRACT FROM AUTHOR]

Prone ventilation is used to manage patients with refractory hypoxia in the critical care unit. Complex chest trauma and chest drains have been a considered relative contraindication to prone ventilation. To the best of our knowledge, it is hitherto unreported in patients having traumatic floating sternum and acute respiratory distress. We present a brief case report of a patient with floating sternum (complete disruption of sternum) managed successfully by prone position ventilation. [ABSTRACT FROM AUTHOR]

Snake bite is very common in India. Ischemic stroke after snake bite has been described in the literature sparsely. Furthermore, the onset of stroke and its clinical reversibility is a rarity. Here, we present a case of snake bite with ischemic stroke which has clinically reversible outcome. [ABSTRACT FROM AUTHOR]

A case study of a 32-year-old woman, gravida 2 para 2, presented with multiple, asymptomatic, pedunculated, soft polypoidal growths is discussed. It is mentioned that lesions had gradually increased in number and size over the past 20 years. A clinical diagnosis of linear vulvar acrochordons was considered and in a single sitting by radio-frequency ablation under local anaesthesia, all the lesions were removed.

Background: The paucity of state-supported rehabilitation for chronically ill patients with long-term tracheostomies has ramifications of prolonged hospital-stay, increased burden on acute-care resources, and nosocomial infections. Few interventions describe home rehabilitation of adult tracheostomized patients. Almost none involve stakeholders. This paper describes the All-India Institute of Medical Sciences (AIIMS) ICU rehabilitation (AIR) healthcare intervention developed to facilitate home rehabilitation of chronically ill tracheostomized patients., Methods: The AIR intervention development was based on the experience-based codesign theory (EBCD). A core research-committee studied prevalent knowledge and gaps in the area. Patients-carer and health-care stakeholders' experiences of barriers and facilitators to home care resulted in an intervention with interlinked components: family-carer training, equipment bank, m-health application, and follow-up, guided by the Medical Research Council (MRC) framework. Healthcare stakeholders (doctors, nurses, medical equipment vendors) and patient-carer dyads were engaged to gather experiences at various stages to form smaller codesign teams for each component. Multiple codesign meetings iteratively allowed refinement of the intervention over one year. The Template for Intervention Description and Replication (TIDieR) checklist was used to report the AIR intervention., Results: The first component comprised a minimum of three bedside hands-on training sessions for carers relating to tracheostomy suction, catheter care, monitoring oxygenation, enteral feeding, skincare, and physiotherapy, buttressed by pictorial-books and videos embedded in a mobile-application. The second was an equipment-bank involving a rental-retrieval model. The third component was a novel m-health tool for two-way communication with the core group and community of other patient-carers in the project for follow-up and troubleshooting. Home visits on days 7 and 21 post-discharge assessed patient hygiene, nutrition, physiotherapy, and established contact with the nearest primary healthcare facility for the future., Conclusions: Findings support the EBCD-based development using active feedback from stakeholders. Assessment of feasibility, process and effectiveness evaluation will follow., Competing Interests: No competing interests were disclosed., (Copyright: © 2024 Tripathy S et al.)

Background: Venepuncture is an essential component of anaesthesia services. However, this invites pain generating the first negative experience with anaesthesia. Hence, relief of this pain carries considerable importance. Efficacy of ethyl chloride spray although studied, there is no consensus for the best way of application., Objectives: The present study was conducted to find an effective technique/method of ethyl chloride spray application to reduce venepuncture pain., Methods: Adult patients posted for different anaesthesia procedures were randomised into three groups. Venepuncture was done either after installation of distilled water or spray of ethyl chloride either once to twice. Venepuncture pain was assessed with a 0-100 Numeric Rating Scale., Results: The analysis showed significant differences among the groups ( F [2,96] = 66.27, P < 0.05). The twice sprayed group experienced the least pain ([mean ± standard deviation [SD]] 16.67 ± 10.21), lower in the once spray group ([mean ± SD] 27.58 ± 13.24), and the controls had the highest pain score ([mean ± SD] 49.09 ± 11.28). Post hoc Tukey's tests showed all the three groups differed significantly. The effect size was large, and the variability of the spray on the reduction of pain scores is 58% (η 2 = 57.99)., Conclusion: Ethyl chloride spray effectively reduces the pain on venepuncture, especially when the vapocoolant is sprayed twice each over 5 s, and from a distance of 5 cm perpendicular to the skin., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Anesthesia: Essays and Researches.)

Background: Various airway gadgets have been devised to overcome difficult airway scenario in anesthesia practice. It includes simple rigid laryngoscope to complex fiber-optic intubating devices; however, there is weak evidence to support the superiority of one device over the other., Aims and Objective: The ease of intubation, time and the hemodynamic variability between two groups during intubation are considered as the primary outcome measures., Materials and Methods: In this prospective study, 60 patients of either sex undergoing elective surgery who required tracheal intubation were included. All the patients of age between 20 and 50 years with the American Society of Anesthesiologists Classes I and II were divided into the following two groups: Group AT ( n = 30): the intubation was performed using AT laryngoscope and Group-MC ( n = 30); the intubation was performed using MC laryngoscope. The following intubating parameters were recorded: ease of intubation (Grade-I-IV), mean time of laryngoscopy and intubation, Cormack-Lehane grade, and the percentage of glottis opening (POGO) score. The vital parameters such as heart rate (HR) and mean arterial blood pressure (MABP) were recorded only after premedication, and it was taken as the baseline value. These parameters were again recorded at 1 min, 3 min, 5 min, and 10 min after laryngoscopy and intubation. The incidences of sore throat were recorded just before discharge from the recovery room till 24 h of surgery. All these parameters were compared between these two groups using the Student's t -test and Chi-square test., Results: There was no significant difference in age, sex, weight, and Mallampati grading between the two groups. More than 30% of patients in Group AT were intubated without an external aid than the Group MC ( P < 0.05). In Group AT, the mean time of intubation was 13.5 ± 5.72 s when compared to 15.63 ± 7.28 s in Group MC ( P > 0.05). The Cormack-Lehane grade and POGO score were better in the AT group than that of the MC group. The HR at 1 min in Group AT was 101.83 ± 14.50 and in Group MC, it was 108.93 ± 12.86 ( P < 0.05) and after 3 min, it was 98.66 ± 12.60 and 111.53 ± 11.67 ( P < 0.05), respectively. The MABP was 107.17 ± 9.03 in Group AT compared to 116 ± 10.12 in Group MC ( P < 0.05) at 1 min postintubation. The incidences of sore throat were similar in both the groups., Conclusion: The AT laryngoscope is better than MC in terms of the ease of intubation, better glottis view, and hemodynamic stability. However, the incidences of sore throat in both groups were comparable., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Anesthesia: Essays and Researches.)

Competing Interests: There are no conflicts of interest.