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Objectives: To categorize the primary reasons for electronic consults (eConsults) to otolaryngology from primary care physicians (PCPs). To determine how many patients avoided subsequent in-person otolaryngology office visits. Methods: This is a retrospective analysis of a pilot study that took place between 2016 and 2017 regarding eConsults to adult otolaryngology placed by primary care physicians at the University of California, San Diego (UCSD) Medical Center. The complaints were categorized as related to the following: ear, nose, throat or neck. Initial recommendations were classified as (1) providing education only (no intervention), (2) suggesting medical therapy provided by the PCP, or (3) suggesting surgical intervention. Univariate statistics and multinomial logistic regression were used to analyze the association of problem type with the need for follow-up in the otolaryngology offices. The data was analyzed for differences in patient age and gender. Results: The study population included 64 patients (average age 54.6 years, 60.9% male). Within this group, 41% of consults were for ear complaints, 15% for nose complaints, 28% had throat-related complaints, and 16% had neck-related complaints. In-person follow-up was not required for 82.8% of the consults. Overall, 76.9% of ear, 100% of nose, 88.9% of throat, and 70.0% of neck complaints did not require in-person visits. Conclusions: eConsults to otolaryngology were primarily for ear concerns. Of the eConsults, 82.4% did not require in-person follow-up. We therefore conclude that the use of eConsults prevented substantial office visits that would not otherwise be necessary. Efforts should be made to promote the widespread use of eConsults, which may to the more efficient use of resources.

India faces a very challenging strategic environment, with its immediate opponents possessing significant capabilities and militaries that are modernizing rapidly. This article explores the opportunities, challenges and constraints confronting the Indian state in building its military strength to deal with its variegated threat environment. It examines how India has dealt with the use of force and how it seeks to shape its armed forces in the face of new threats and emerging capabilities. This article explores six key areas of enquiry and is correspondingly structured. First, how does the Indian state view the use of force? Second, what has the Indian state's recent experience been with conflict and to what extent has it influenced its thinking? Third, how does the Indian state view the future character of conflict? Fourth, what conclusions has India drawn about the role of alliances and strategic partners in dealing with the nature of the conflict it faces? Fifth, how does the Indian state intend to configure its forces to deal with this evolving nature of conflict? Finally, what do all these factors mean for its defence acquisitions? As an emerging power, India has to contend with these questions and the measures it has put in place are still a work in progress. There remains a fundamental need for greater integration across the Indian security sphere—in interservice arrangements, in procurement processes, and in broader strategic thinking and planning.

Aims Increases in hydrostatic pressure results in endothelial hyperpermeability via eNOS-dependent pathways. Ropivacaine is known to inhibit eNOS activation and to attenuate lung injury. Herein, we sought to determine if ropivacaine regulates pressure-induced lung endothelial hyperpermeability. Main methods The effects of ropivacaine on lung permeability were assessed in two models of acute hypertension (AH): the isolated perfused lung preparation where acute increases in left atrial pressure model the hemodynamic changes of severe hypertension, and an animal model of AH induced by norepinephrine. In the IPL model, whole lung filtration coefficient (Kf) was used as the index of lung permeability; pulmonary artery pressure (Ppa), pulmonary capillary pressures (Ppc), and zonal characteristics (ZC) were measured to assess the effects of ropivacaine on hemodynamics and their relationship to Kf2/Kf1. In vivo, ropivacaine effects were investigated on indices of pulmonary edema (changes in PaO2, lung wet-to-dry ratio), changes in plasma volume and nitric oxide (NO) production. Key findings Ropivacaine provided robust protection from pressure-dependent barrier failure; it inhibited pressure-induced increases in Kf without affecting Ppa, Ppc or ZC. In vivo, ropivacaine prevented pressure-induced lung edema and associated hyperpermeability as evidence by maintaining PaO2, lung wet-to-dry ratio and plasma volume in levels similar to sham rats. Ropivacaine inhibited pressure-induced NO production as evidenced by decreased lung nitro-tyrosine content when compared to hypertensive lungs. Significance Collectively these data show that ropivacaine inhibits pressure-induced lung endothelial hyperpermeability and suggest that ropivacaine may be a clinically useful agent to prevent endothelial hyperpermeability when pulmonary pressure is acutely increased.

The coronavirus disease-2019 (COVID-19) pandemic continues to be a cause of unprecedented global morbidity and mortality. Whilst COVID-19 vaccination has emerged as the only tangible solution to reducing poor clinical outcomes, vaccine hesitancy continues to be an obstacle to achieving high levels of vaccine uptake. This represents particular risk to patients with autoimmune diseases, a group already at increased risk of hospitalization and poor clinical outcomes related to COVID-19 infection. Whilst there is a paucity of long-term safety and efficacy data of COVID-19 vaccination in patients with autoimmune diseases, the current evidence strongly suggests that the benefits of vaccination outweigh the risks of adverse effects and disease flares. Herein, we report the protocol of the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study, an ongoing international collaborative study involving 29 countries and over 110 investigators. Supplementary Information The online version contains supplementary material available at 10.1007/s00296-021-05046-4.

The paper explores the literature on the typology of Human Resources for Health, their equitability in distribution, their role to provide high quality of healthcare and support economic growth in India. This is a slight departure from the traditional analyses which most of the researchers take since we take into account the continuous development of HRH and their future as economy generators.

Importance During the coronavirus disease 2019 (COVID-19) pandemic, eye care professionals caring for patients with sight-threatening diseases, such as glaucoma, have had to determine whether some patient appointments could safely get postponed, weighing the risk that the patient’s glaucoma could worsen during the interim vs the morbidity risk of acquiring COVID-19 while seeking ophthalmic care. They also need to prioritize appointment rescheduling during the ramp-up phase (when pandemic-associated service reductions are eased). Objective To describe a flexible and scalable scoring algorithm for patients with glaucoma that considers glaucoma severity and progression risk vs the presence of high-risk features for morbidity from COVID-19, using information from a large data repository. Design, Setting, and Participants In this cross-sectional study, patients with upcoming clinic appointments for glaucoma from March 16, 2020, to April 16, 2020, at an academic institution enrolled in the Sight Outcomes Research Collaborative (SOURCE) Ophthalmology Electronic Health Record Data Repository were identified. A risk stratification tool was developed that calculated a glaucoma severity and progression risk score and a COVID-19 morbidity risk score. These scores were summed to determine a total score for each patient. Main Outcomes and Measures Total scores and percentages of clinic appointments recommended for rescheduling. Results Among the 1034 patients with upcoming clinic appointments for glaucoma, the mean (SD) age was 66.7 (14.6) years. There were 575 women (55.6%), 733 White individuals (71%), and 160 Black individuals (15.5%). The mean (SD) glaucoma severity and progression risk score was 4.0 (14.4) points, the mean (SD) COVID-19 morbidity risk score was 27.2 (16.1) points, and the mean (SD) total score was 31.2 (21.4) points. During pandemic-associated reductions in services, using total score thresholds of 0, 25, and 50 points would identify 970 appointments (93.8%), 668 appointments (64.6%), and 275 appointments (26.6%), respectively, for postponement and rescheduling. The algorithm-generated total scores also helped prioritize appointment rescheduling during the ramp-up phase. Conclusions and Relevance A tool that considers the risk of underlying ophthalmic disease progression from delayed care receipt and the morbidity risk from COVID-19 exposure was developed and implemented, facilitating the triage of upcoming ophthalmic appointments. Comparable approaches for other ophthalmic and nonophthalmic care during the COVID-19 pandemic and similar crises may be created using this methodology.

Background Mobile health (mHealth) interventions have the potential to improve health through patient education and provider engagement while increasing efficiency and lowering costs. This raises the question of whether disparities in access to mobile technology could accentuate disparities in mHealth mediated care. This study addresses whether programs planning to implement mHealth interventions risk creating or perpetuating health disparities based on inequalities in smartphone ownership. Methods Video Directly Observed Therapy (VDOT) is an mHealth intervention for monitoring tuberculosis (TB) treatment adherence through videos sent by patients to their healthcare provider using smartphones. We conducted secondary analyses of data from a single-arm trial of VDOT for TB treatment monitoring by San Diego, San Francisco, and New York City health departments. Baseline and follow-up treatment interviews were used to assess participant smartphone ownership, sociodemographics and TB treatment perceptions. Univariate and multivariable logistic regression analyses were used to identify correlates of smartphone ownership. Results Of the 151 participants enrolled, mean age was 41 years (range: 18–87 years) and 41.1% were female. Participants mostly identified as Asian (45.0%) or Hispanic/Latino (29.8%); 57.8% had at most a high school education. At baseline, 30.4% did not own a smartphone, which was similar across sites. Older participants (adjusted odds ratio [AOR] = 1.09 per year, 95% confidence interval [CI]: 1.05–1.12), males (AOR = 2.86, 95% CI: 1.04–7.86), participants having at most a high school education (AOR = 4.48, 95% CI: 1.57–12.80), and those with an annual income below $10,000 (AOR = 3.06, 95% CI: 1.19, 7.89) had higher odds of not owning a smartphone. Conclusions Approximately one-third of TB patients in three large United States of America (USA) cities lacked smartphones prior to the study. Patients who were older, male, less educated, or had lower annual income were less likely to own smartphones and could be denied access to mHealth interventions if personal smartphone ownership is required.

Objectives: Congenital cholesteatomas originate from epithelial tissue present within the middle ear in patients with an intact tympanic membrane, no history of otologic surgery, otorrhea, or tympanic membrane perforation. They are diagnosed by a pearl-like lesion on otoscopy and computed tomography (CT) scan showing an expansile soft-tissue mass. We describe a series of patients with no prior otologic history presenting with progressive unilateral conductive hearing loss and normal otoscopy. The CT scans showed ossicular erosion without obvious soft-tissue mass. Surgery confirmed incudostapedial erosion found to be cholesteatoma. In this study, we characterize the clinical course of patients diagnosed with isolated incudostapedial cholesteatoma (IIC) and review possible pathologic mechanisms. Methods: Retrospective review of IIC cases treated by the Department of Pediatric Otolaryngology, Rady Children’s Hospital, San Diego, 2014 to 2020. Data included patient demographics, clinical features, imaging, surgical findings, and audiologic data. Results: Five patients were diagnosed with IIC (3 [60%] female; mean age at presentation 10.7 years [range 5.5-16.0]). All patients presented with postlingual unilateral conductive hearing loss and normal otoscopy without any past otologic history; delay in diagnosis ranged from 4 months to several years. The CT scans showed ossicular chain erosion with an absent long process of the incus and/or stapes superstructure. All patients underwent middle ear exploration, revealing a thin layer of cholesteatoma in the incudostapedial region, confirmed by histopathology. Mean preoperative speech reception threshold was 55 dB and improved to a mean of 31 dB in the 4 patients who underwent ossicular chain reconstruction. Conclusion: Isolated incudostapedial cholesteatoma should be included as a possible etiology in pediatric patients with insidious onset of unilateral conductive hearing loss with normal otoscopy, unremarkable otologic history, and a CT scan showing ossicular abnormality/disruption without notable middle ear mass. These patients should be counseled preoperatively regarding the possibility of cholesteatoma and should undergo middle ear exploration with possible ossiculoplasty.

PURPOSE The purpose of this study was to assess the relationship between the rate of the glaucomatous visual field (VF) worsening and baseline age and baseline VF mean deviation (MD). DESIGN This study was a retrospective, multisite cohort. PARTICIPANTS A total of 84,711 reliable Swedish Interactive Thresholding Algorithm 24-2 VF tests from 8167 eyes from 5644 patients with ≥6 VF tests, ≥5 years of follow-up, baseline age 18 years or above and baseline MD ≥-10 dB, and at least 2 abnormal VF tests were included from the Glaucoma Research Network Database. METHODS The global mean deviation rates (MDRs) and pointwise total deviation rates (TDRs) of VF progression (dB/y) were calculated for each eye using linear regression. The relationships between MDR and baseline age and MD were determined using linear mixed-effects models and logistic regression, with rapid progression defined as an MDR≤-1.0 dB/y. The relationships between TDR and baseline age and baseline MD were determined using linear mixed-effects models. MAIN OUTCOME MEASURES Coefficients of the regression models. RESULTS In individual mixed-effects models both baseline age (β=-0.0079 dB/y; P

Background Trauma registries are an essential part of trauma quality improvement programs aimed at decreasing morbidity and mortality in high-income countries. In low- and middle-income countries (LMICs), where the burden of injury is disproportionately high, hospitals have faced challenges in adapting trauma registry models implemented in high-income countries. We analyze the barriers to trauma registry implementation in LMICs to inform development of sustainable models in resource-constrained settings. Materials and methods A structured review of published literature was performed. Relevant abstracts were identified using the PubMed, Embase, and CINAHL databases. The search terms included were: “implement registry,” “trauma registry,” “wounds and injuries,” and “injury registry” combined with “Africa,” “Asia,” “low and middle income countries,” “LMIC,” and “developing countries.” Articles describing challenges of trauma registry implementation were reviewed in full and details were abstracted. Results Twenty-eight articles addressed challenges of implementing trauma registries. Data quality (18), lack of resources (6), insufficient prehospital care (3), and difficulty with administrative duties and hospital organization (2) were reported as the most significant barriers to successful implementation. Solutions to the identified barriers were proposed by 15 articles. All 28 studies acknowledged that the presence of at least one local trauma registry improved injury surveillance and promoted better patient outcomes. Conclusions Many LMICs face unique challenges to implementation that must be overcome to create sustainable trauma databases. Understanding these barriers and taking steps to evaluate the effectiveness of proposed solutions may further improve trauma care to address the high burden in these settings.

Objective: To assess the efficacy of coblation in treating laryngeal papillomatosis and its effect on post operative voice outcome. Study Design: This is a retrospective study. Setting: Tertiary referral centre. Subjects and Methods: All the patients diagnosed with laryngeal papillomatosis between January 2013 to December 2016 were included in this study. Preoperative assessment was done with rigid and flexible laryngoscopy. PRAAT software was used for voice analysis. All patients underwent coblation assisted microlaryngeal surgery. Post operatively patients were followed up at 1 week, 15 days, 1 month, 3 months and 6 months with rigid laryngoscopy. Voice analysis was repeated after 3 months to assess the improvement in voice. Results: Coblation was found to be effective in treating laryngeal papillomatosis. In our series of seven patients, three patients underwent repeat procedure with coblation for recurrence. But longterm follow up these patients did not reveal any recurrence of laryngeal papillomatosis. Voice analysis revealed a significant improvement in measures of perturbation and maximum phonation time. Conclusion: Coblation is a promising alternative to the conventional methods for the treatment of laryngeal papillomas as it can achieve satisfactory disease clearance with good voice quality.

Nasal dermoids are congenital midline masses accounting for 1% - 3% of all dermoids. The majority of lesions are superficial with no deep extension; a variable reported percentage might end blindly within the deeper midline structures of the nose or extend intracranially. Sequelae of infection can result in osteomyelitis, meningitis or cerebral abscess. These complications may result from inadequate surgical excision. We report a case of recurrent nasal dermoid that had associated nasal pyramid deformity.

Objective: To assess the number of levels of obstruction on a level 3 home sleep study in patients with obstructive sleep apnea. Study Design: This is a prospective study. Setting: Tertiary referral centre. Subjects and Methods: All the patients with the complaints of snoring, excessive daytime sleepiness, were evaluated for OSA. Complete history was taken and a thorough clinical examination was done followed by fibreoptic nasopharyngoscopy to determine the sites of obstructions. Patients were categorised into group A and group B based on the number of levels of obstruction. A level 3 home sleep study also was done for these patients. We tried to correlate the polysomnographic variables between the two groups. Results: There was a significant difference between the two groups in a number of PSG parameters. Patients in A group had lower number of apnoeas, obstructive apnoeas, hypopneas, AHI index, flow limitation and BMI as compared to patients in group B and the difference was statistically significant. We have devised a score using 3 parameters AHI, Flow limitation with snoring and BMI, the Deenadayal’s (DDS) scoring system. The minimum scoring would be 3 and maximum score would be 6. Based on scoring the probable number of obstructions can be identified. Conclusion: Sleep study report can yield a lot of information regarding the number of levels of obstruction. A critical analysis is required while doing the same. Till date there have been no reports in literature identifying number of levels of obstruction on PSG.

Hemangiopericytomas are vascular tumors arising from the capillary pericytes of Zimmermann present around the capillaries and post capillary venules. Known for a high rate of recurrence, a wide surgical excision is the treatment of choice of these tumors. These tumors are very vascular making surgical excision difficult. The coblation system has made it easier in resection of these vascular tumors. We present a case report of a extensive sinonasal hemangiopericytoma in a old man which was successfully resected with coblation technology.

Hypercapnic acidosis (HCA) has beneficial effects in experimental models of lung injury by attenuating inflammation and decreasing pulmonary edema. However, HCA increases pulmonary vascular pressure that will increase fluid filtration and worsen edema development. To reconcile these disparate effects, we tested the hypothesis that HCA inhibits endothelial mechanotransduction and protects against pressure-dependent increases in the whole lung filtration coefficient (Kf). Isolated perfused rat lung preparation was used to measure whole lung filtration coefficient (Kf) at two levels of left atrial pressure (PLA = 7.5 versus 15 cm H2O) and at low tidal volume (LVt) versus standard tidal volume (STVt) ventilation. The ratio of Kf2/Kf1 was used as the index of whole lung permeability. Double occlusion pressure, pulmonary artery pressure, pulmonary capillary pressures, and zonal characteristics (ZC) were measured to assess effects of HCA on hemodynamics and their relationship to Kf2/Kf1. An increase in PLA2 from 7.5 to 15 cm H2O resulted in a 4.9-fold increase in Kf2/Kf1 during LVt and a 4.8-fold increase during STVt. During LVt, HCA reduced Kf2/Kf1 by 2.7-fold and reduced STVt Kf2/Kf1 by 5.2-fold. Analysis of pulmonary hemodynamics revealed no significant differences in filtration forces in response to HCA. HCA interferes with lung vascular mechanotransduction and prevents pressure-dependent increases in whole lung filtration coefficient. These results contribute to a further understanding of the lung protective effects of HCA.

Introduction: Lumbar disc prolapse is most common between 30 and 50 years of age and is associated with severe disability and pain. It commonly occurs at L4/5 and L5/S1. Transforaminal endoscopic discectomy is an emerging technique for treatment of degenerative disc disease. Literature has shown clinical outcomes, comparable to classical open and micro lumbar discectomy. Central disc herniations in lumbar spine pose technical challenge for transforaminal endoscopic decompression due to its location. Existing techniques to access central herniations and ventral epidural space have trajectory related challenges due to the proximity of the retroperitoneal space and abdominal organs and technically difficult for the less experienced surgeon. Materials and Methods: Thirty patients – 19 males and 11 females – with central, multifocal, central-paracentral disc herniations in the lumbar spine operated in 2015 and 2016 were considered in this study. All patients underwent selective endoscopic discectomy under monitored care anesthesia and local anesthesia with modification of the classical technique, medialization of annulotomy, undercutting the nonarticular part of superior articular process (foraminotomy) and use of articulating and long jaw instruments either alone or in combination. Results: In all the thirty patients, we were able to achieve adequate decompression with neurological recovery. All patients improved in their neurological status. Postoperatively, visual analog scale dropped from 7.8 to 1.8 and ODI dropped from 73.46% to 32. 90% of the patients reported excellent and good results. One patient had recurrent herniation and was treated with transforaminal surgery. One patient had persistent back pain and reported poor outcome. Three patients underwent medial branch block for facet joint pain followed by medial branch rhizotomy and reported excellent and good results. Conclusion: Transforaminal endoscopic spine surgery with modifications as described above to reach the dorsal part of the disc in the midline and to access ventral epidural space is safe and effective.

Purpose To assess the agreement between structural (optical coherence tomography [OCT]) and functional (visual field [VF]) glaucomatous damage with an automated method and deviation/probability maps, and to compare this method to a metric method. Methods Wide-field spectral-domain OCT scans, including the disc and macula, and 24-2 and 10-2 VFs were obtained from 45 healthy control (H) eyes/individuals, and 53 eyes/patients with 24-2 mean deviation (MD) better than -6 dB diagnosed as "definite glaucoma" (DG) by experts. Abnormal structure-abnormal function (aS-aF) agreement was assessed with an automated topographic (T) method based upon VF pattern deviation and OCT probability maps. Results were compared to a metric (M) method optimized for accuracy, (abnormal 24-2 glaucoma hemifield test [GHT] or pattern standard deviation [PSD], or 10-2 PSD AND abnormal OCT [quadrant]). Results For the T-method, 47 (88.7%) of the 53 DG eyes showed aS-aF agreement, compared to 2 (4.5%) of the 45 H eyes. The aS-aF agreement for these two H eyes was easily identified as mistaken, and did not replicate on a subsequent test. Without the 10-2, the aS-aF agreement decreased from 47 to 34 (64.2%) of 53 DG eyes. For the M-method, 37 (69.8%) of the 53 DG eyes showed aS-aF agreement, while omitting the 10-2 VF resulted in agreement in only 33 (62.3%) eyes. Conclusions There is good agreement between structural and functional damage, even in eyes with confirmed early glaucomatous damage, if both 24-2 and 10-2 VFs are obtained, and abnormal locations on the VFs are compared to abnormal regions seen on OCT macular and disc scans. This can be done in an objective, automated fashion. (ClinicalTrials.gov number, NCT02547740.).

Benign lesions of the skull base are common in the paediatric population, and are usually congenital in aetiology. Majority of these lesions are treated transcranially exposing the patients to a number of risks. Although endoscopic endonasal surgery (EES) helps avoid many of these potential morbidities, CSF leak with its attendant complication remains a big concern. This study reports the use of the Hadad flap in the reconstruction of skull base defects in infants to prevent this problem. The study was conducted on four infants with a mean age of 7 months, who underwent repairs for CSF leaks associated with congenital lesions like meningocele or meningoencephalocele, using the Hadad flap. Of the four patients, three cases were revision cases and one was primary where the patients presented with complaints such as nasal obstruction and watery nasal discharge. Post surgery, the infants were monitored for a mean period of 23 months and no major complications or recurrent CSF drainage were observed. Minor complications that were observed include vestibulitis and crusting in the nose. The utility of the Hadad flap in the reconstruction of skull base defects in the paediatric age group has been controversial while its utility in infants has not been studied in literature so far. We report here in our series four infant patients in whom we believe that the nasal septum and the skull base will develop proportionally to each other, hence lowering the chances of a short flap and eliminating the occurrence of future complications. The nasoseptal flap is an effective and safe technique for reconstructing skull base defects in infancy. It can be concluded that this technique does not have any potential effect on septal or craniofacial growth as the flap is harvested only on one side with normal mucosal cover on the other side. There is no posterior septectomy or any form of bony or cartilaginous resection that is performed, hence avoiding any effects on bony growth. No studies have been published in literature so far and to the best of our knowledge, this is the first report describing the efficacy of the nasoseptal flap in infants.

Internet of Things (IoT) paradigm is going to imbue and become ubiquitous in everyday living, ranging from generic household, healthcare, public utility to defence applications. The IoT as a technology realm is witnessing advancement at a lightning speed. Consequently, there is a growing number of IoT-related reference architectures, frameworks, guidelines, platforms and standards. For IoT vendors and original equipment manufacturers (OEMs), however, such evolving IoT landscape means bountiful amounts of both opportunities and risks. The same holds for the consumers who are going to buy such products. We present an IoT framework and protocol that is unconditionally forward compatible. Our work defines the minimal criteria for a device to qualify as an IoT-enabled device, which could be taken as reference by IoT OEMs to build their IoT devices accordingly, across varied applications and domains. Such knowledge could help them make an informed choice amongst various available target hardware. With this protocol, it is possible to generate user interface/s on the fly, as per the devices’ functionalities.

Objectives Cognitive deficits caused by extra-axial benign brain tumors like meningiomas and the course of these deficits after surgery is not well known. The aim of the study is to assess the pre-operative and post-operative cognitive functions in patients with meningiomas in the supratentorial compartment. Materials and methods In this prospective study, patients with clinico-radiological diagnosis of supratentorial meningioma, operated upon and later confirmed by histopathological examination, were included. The patients were evaluated for cognitive deficits before and after surgery. The various clinical and radiological factors influencing the cognitive status were evaluated. Results A total of 57 patients were enrolled into the study. Out of 57, 22 were males and 35 were females. The frontal group had 22 patients, the parietal group had 10 patients, the temporal group had 10 patients, the occipital group had 6 patients, and the suprasellar group had 9 patients. Meningiomas, although extra-axial, caused significant cognitive deficits in 42 patients (73.7%). The highest frequency of cognitive deficits is seen in the frontal and temporal group of meningiomas (90% each). Frontal meningiomas with volume greater than 35cc and peritumoral edema greater than 40cc caused a higher frequency of cognitive deficits. Also, patients with raised ICP had significant cognitive deficits. Postoperatively there was a significant improvement in the cognitive functions in the frontal and temporal groups. Conclusion Meningiomas cause cognitive deficits in 73.7% of patients. Anatomical location of meningioma, elevated ICP, the volume of meningioma and extent of peritumoral edema significantly influence the incidence of cognitive deficits. Post-operatively, the cognitive deficits improve significantly in the frontal and temporal group.

Objective: The aim is to review the effectiveness of sialendoscopy in treating various salivary gland disorders related to the duct. Methods: A total of 133 patients who underwent sialendoscopy were included in this study. Data was collected from case records of patients and was analysed. A detailed history examination was taken and the operative findings were analysed. Causes of obstructive sialadenitis were evaluated and treated. Results: A total of 159 glands were subjected to sialendoscopy and pathology was identified in 149 glands. Forty one submandibular glands had calculi and twelve had non-calcular obstruction. Fifteen parotid glands had calculi and 81 had non-calcular obstruction, of which stricture was the most common. Calculi retrieval or dilation of stricture was achieved with a sialendoscope in 112 glands. In 23 patients, the calculi were retrieved by combined approach. In three patients, the calculi were fragmented with intra luminal Holmium laser and the fragments were removed. All these patients had a good relief from their symptoms. Duct perforation was seen in two patients and a false passage was formed in one. Conclusion: Sialendoscopy was a safe and effective procedure for managing ductal pathologies of salivary glands.

Objective: The objective is to assess patients complaining of dysphagia with fibreoptic endoscopic evaluation of swallowing [FEES]. Study design: It is a prospective study. Setting: The study is conducted at Tertiary referral hospital. Methods: In our study, twenty patients with complaints of dysphagia were evaluated with fibreoptic endoscopic evaluation of swallowing. Patients with pharyngeal cause of dysphagia were identified and recommended dietary modifications or positional manoeuvre. Results: A total of twenty patients were evaluated with FEES. Patients were categorised into two groups based on the etiological factor: neurological and non-neurological patients. In eleven of the neurological patients, premature spillage was seen in four patients. Pooling for solids was seen in one patient and for liquids in four patients, pooling for both solids and liquids was seen in six patients, penetration was seen in 1 patient and aspiration in one patient. All these patients were diagnosed to have a pharyngeal cause of dysphagia. In the nine of the non-neurological group, pooling of liquids was seen in four patients, and aspiration was seen in one patient. None of the patients of this group had spillage. One patent had penetration. Five patients had pharyngeal cause of dysphagia. Remaining four patients had normal study. These patients with pharyngeal cause were advised dietary modification or positional manoeuvre or a combination of both. Conclusion: FEES is an effective and valuable tool for evaluating pharyngeal dysphagia, and is helpful in guiding the patients for diet and rehabilitation. It is essential to assess the safety of swallowing in patients to prevent silent aspiration and aspiration pneumonia.

Objective: To assess the outcomes of hearing and vertigo in patients with Meniere’s disease who were treated with intratympanic methylprednisolone. Study Design: Retrospective study. Setting: Tertiary referral hospital. Methods: In our study with 151 patients [191 ears] were diagnosed as Menieres as per 1995 AAO-HNS guidelines. As an office based procedure these patients were treated with intratympanic methyl prednisolone. Results: There was a 98.6% improvement in the vertigo control rate, a 73.82% improvement in hearing and 29.31% had a definitive improvement in tinnitus. Conclusion: We conclude from our study that intratympanic steroid injection significantly controls vertigo, tinnitus and improves hearing in Meniere’s disease with minimal complications. Hence, it can be tried as a first line treatment for patients with Meniere’s disease.

Objective: The aim of the study is to look for indicators of Tuberculous Otitis Media in all cases of chronic suppurative otitis media. Study Design: This is a retrospective study. Setting: This study was conducted in a tertiary care centre. Subjects and Methods: Detected cases of tuberculous otitis media (TBOM) cases studied retrospectively from January 2011 to December 2013 were included in the study. Investigations for tuberculosis were considered in the cases showing suspicious pale granulation tissue in the external auditory canal and middle ear and also in cases showing exuberant pale granulation tissue during mastoid surgery where Zeihl Nielson staining, histopathology, molecular genetic study was done. Cases showing positive result were included in the study. Results: During the study period 751 cases of CSOM were seen in outpatient room of which 18 cases of TBOM were diagnosed. Three patients were diagnosed preoperatively and 181 underwent surgery of which 15 cases were diagnosed positive, from the tissue obtained during the procedure. Direct smear was positive in four cases, concentration techniques in seven cases. Line probe assay was taken as diagnostic in all the cases. None of the cases were positive on histopathology. Conclusion: Tuberculous otitis media is often missed as the classical features are not seen in all cases of TBOM. The absence of these should not stop the clinician from diagnosing the disease. Suspicious tissue should therefore be tested properly to avoid missing the diagnosis and to prevent any complications.

Objective: To assess the outcomes of intratympanic steroids in the management of idiopathic sudden sensorineural hearing loss. Study Design: Retrospective study. Setting: Academic tertiary care medical centre. Materials and Methods: A total of 67 patients with idiopathic sudden sensorineural hearing loss were included in our study. Pre- and post-injection audiograms were taken to assess the outcomes in improvement in hearing. Hearing outcomes were assessed with respect to duration of onset of treatment and age of the patient. Improvement in the speech discrimination score was also assessed. Results: A total of 67 patients were included in our study of which unilateral cases were 59 and bilateral cases were 8. Subjectively 35 patients reported improvement in hearing after the therapy while objectively we found 44 ears [41 patients] had improvement. The mean PTA pre ITS was 62.7 and after ITS it was 56.3. Maximum improvement was noted at 2000 Hz and 1000 Hz. Conclusion: Intratympanic steroids can be offered as a first line therapy for idiopathic sudden sensorineural hearing loss as it is minimally invasive, and can be performed as an office based procedure with no systemic side effects. No major complications have been reported in our study and results have been satisfactory.

Objective: To assess the role of stroboscopy in the diagnosis of vocal cord lesions. Study Design: Prospective interventional study. Setting: Academic tertiary care medical centre. Materials and Methods: 50 patients with complaints of hoarseness of voice were clinically evaluated and diagnosis was made using Rigid Videolaryngoscopy, Flexible Videolaryngoscopy and Videostroboscopy. Patients underwent microlaryngeal surgery and a final diagnosis made with histopathological examination. The intra-operative findings and the final histopathological diagnosis were compared with the diagnosis made with rigid, flexible videolaryngoscopy and stroboscopy. Results: Intra-operative findings correlated with stroboscopic findings in 84% of patients, with fibreopticlaryngo-pharyngoscopic diagnosis in 54% of patients and with rigid video-laryngoscopy in 46% of patients. Videostroboscopy showed the highest diagnostic co-relation on histopathology (80%) as compared to rigid videoendoscopy (56%) and flexible videolaryngoscopy (58%). Videostroboscopy also elucidated vocal fold abnormalities that were missed on rigid or flexible laryngoscopic examinations. Conclusion: Videostroboscopy is a valuable complement to a thorough vocal history and physical examination. Videostroboscopy is superior to constant light laryngeal examination in diagnosis of vocal cord lesions.

Granular cell tumors, also called Abrikossoff tumors, are benign, slowly growing neoplasms. They may occur anywhere in the body, but head and neck accounts to 45% - 65% of these cases. The most common site is the tongue. Larynx is relatively an uncommon location for these tumours, accounting for approximately three to 10 per cent of the reported cases. Laryngeal granular cell tumour is extremely rare accounting for only 19 reported cases under the age of 17 years. As many as 10% of patients experience multifocal synchronous or metachronous tumors. We present a rare case report of granular cell tumour of the larynx.

Purpose To develop an automated/objective method for topographically comparing abnormal regions on optical coherence tomography (OCT) and visual field (VF) tests of eyes with early glaucoma. Methods A custom R program was developed that allows for both visualization and automatic assessment of the topographical agreement between functional (24-2 and/or 10-2 VF) and structural (widefield OCT retinal nerve fiber layer and/or retinal ganglion cell layer) deviation/probability maps. It was optimized using information from 98 eyes: 53 diagnosed as “definitely glaucoma” (DG) and 45 recruited as healthy (H) controls. Different pairs of abnormal VF (P

Background: Eberconazole, a newer Imidazole derivative, antimycotic drug. Similarly, sertaconazole and luliconazole are also newer antifungal which all exhibit fungicidal, fungistatic and anti-inflammatory actions. But, sertaconazole in addition have antipruritic effect also.Methods: Randomized, open-labelled, prospective study comprising of 75 patients divided into three equal groups A, B, C of 25 patients each. Group A received eberconazole 1%, Group B received sertaconazole 2% and Group C received luliconazole 1% for twice daily topical application for 4 weeks. Patients were asked to review at 2nd and 4th week to record clinical and mycological cure.Results: In this study out of 75, seventy patients completed the complete course of treatment whereas, five patients were not reported for review citing personal reasons. Parameters included are pruritus, erythema, scaling and vesicles in all three groups. In this study, marked relief of pruritus was achieved clinically with eberconazole (72.7%) followed by luliconazole and sertaconazole with 50.0% and 33.3% respectively at 4th week of treatment phase and reduction of scaling was achieved more with eberconazole (90.9%), sertaconazole (87.5%) and luliconazole (83.3%). All three groups of patients showed successful mycological cure by confirming with negative 10% potassium hydroxide examination at the end of treatment course.Conclusions: Eberconazole 1% cream was better than sertaconazole 2% cream and luliconazole 1% cream in relieving symptoms like pruritus and scaling at the end of treatment phase and follow up.

In this work, an algorithm for detecting the interlocking nodes in the temporal networks has been proposed. Interlocking nodes are set of nodes joining together in same set of networks. These nodes make change in the structural changes of the temporal network. Different techniques exist in the literature to identify structural changes of the temporal network. Structural changes are essential elements for identifying patterns and events in temporal social networks. A method for finding structural changes and the events related to communities is presented in the paper. These events can be used for pattern detection in networks with evolving communities.

We report the clinical details, imaging findings, and management for a 39-year-old female presenting with recurrent episodes of pain in abdomen due to systemic lupus erythematous vasculitis associated with spontaneous isolated inferior mesenteric dissection. Spontaneous mesenteric artery dissection is an uncommon cause of mesenteric ischemia. Symptomatic spontaneous isolated inferior mesenteric artery (IMA) dissection is a rare condition, and its association with systemic lupus erythematosus is not previously described in the English literature. The optimal treatment options are debatable and include medical management, surgical reconstruction, and endovascular therapy. We wish to highlight spontaneous isolated IMA dissection as a rare etiology for chronic mesenteric ischemia and its management by endovascular methods.

OF THE THESIS DESIGN AND IMPLEMENTATION OF A WEB BASED SHOP FLOOR CONTROL SYSTEM TO MAINTAIN SCHEDULE FEASIBILITY IN A DYNAMIC JOB SHOP ENVIRONMENT by Anil Bommakanti Florida International University Professor Chin-Sheng Chen, Major Professor The effective control of production activities in dynamic job shop with predetermined resource allocation for all the jobs entering the system is a unique manufacturing environment, which exists in the manufacturing industry. In this thesis a framework for an Internet based real time shop floor control system for such a dynamic job shop environment is introduced. The system aims to maintain the schedule feasibility of all the jobs entering the manufacturing system under any circumstance. The system is capable of deciding how often the manufacturing activities should be monitored to check for control decisions that need to be taken on the shop floor. The system will provide the decision maker real time notification to enable him to generate feasible alternate solutions in case a disturbance occurs on the shop floor. The control system is also capable of providing the customer with real time access to the status of the jobs on the shop floor. The communication between the controller, the user and the customer is through web based user friendly GUI. The proposed control system architecture and the interface for the communication system have been designed, developed and implemented.

We describe a method called META RNA profiling (for “modular early-tagged amplification”) that can quantify a broad panel of microRNAs or mRNAs simultaneously across many samples – and requires far less sequence depth than existing digital profiling technologies. The method assigns quantitative tags during reverse-transcription to permit up-front sample pooling before competitive amplification and deep sequencing. This simple, scalable, and inexpensive approach brings large-scale gene expression studies within more practical reach.

Background: The skin diseases are affected by various factors. The rural population is more vulnerable because of illiteracy. Therefore an attempt has been made to screen the population of five villages to know pattern of skin diseases. Aims of the study were to assess the prevalence of skin diseases, determine the pattern of skin diseases in the study population in rural community of Medchal mandal and compare previous studies so that inferences can be drawn for the benefit of society. Methods: The study was aimed to include the total population of 5930 consisting of 5 villages. The present study was carried out during a period of one and half year in 5 villages of Medchal mandal. The total population of all the 5 villages comprises of 7726, out of which 5930 persons participated in the present study. In all villages house to house survey was done. A complete dermatological assessment of the study population was done and findings were recorded on the standard study proforma. Results: The total number of 5930 persons was screened during the period of study. Among which 1172 (19.76%) persons were noted to have skin diseases. out of which 533 (45.48%) were males and 639 (54.52%) were females. The majority of population with skin disease was in the age group of 31-40 years with 289 cases (24.65%) and least in 71-80 age groups with 7 cases (0.59%). The prevalence of Non-infectious diseases (705 cases, 60.15%) was more than that of Infectious diseases (467 cases, 39.85%). Among non-infectious conditions Eczema / Allergy was the common disease followed by Pigmentary disorders other conditions like alopecia areata, seborrheic dermatitis and senile xerosis, Papulosquamous disorders, acne and acneiform dermatoses, polymorphous light eruptions and bite and stings, Eczemas followed by lichen simplex chronicus and allergic contact dermatitis. Among infectious conditions, bacterial infections were most common diseases followed by parasitic infestations, fungal infections and viral infections. Among Bacterial infections, secondary Pyodermas followed by folliculitis, impetigo and furunculosis. Based on occupation the majority of population was in the students followed by farmers, labour other than agriculture, housewives and petty business. Based on education, the majority of population was in the primary group (class 1 to 5) followed by secondary (class 6 to 8) and high school and above. Conclusions: Based on the outcome of this study, the common skin problems existing in this area are to be carefully looked for and health education regarding the hygiene, nutrition and healthy life styles is to be stressed for better standard of living by the rural population.

Sensorineural hearing loss (SNHL) is an extraordinarily common disability, affecting 466 million people across the globe. Half of these incidents are attributed to genetic mutations that disrupt the structure and function of the cochlea. The human cochlea’s interior cannot be imaged or biopsied without damaging hearing; thus, everything known about the morphologic correlates of hereditary human deafness comes from histopathologic studies conducted in either cadaveric human temporal bone specimens or animal models of genetic deafness. The purpose of the present review is to a) summarize the findings from all published histopathologic studies conducted in human temporal bones with known SNHL-causing genetic mutations, and b) compare the reported phenotypes of human vs. mouse SNHL caused by the same genetic mutation. The fact that human temporal bone histopathologic analysis has been reported for only 22 of the nearly 200 identified deafness-causing genes suggests a great need for alternative and improved techniques for studying human hereditary deafness; in light of this, the present review concludes with a summary of promising future directions, specifically in the fields of high resolution cochlear imaging, intracochlear fluid biopsy, and gene therapy.

Sensorineural hearing loss is the most common sensory deficit worldwide, yet our understanding of the underlying pathophysiology is limited by the challenges of access to the inner ear in a safe and reliable manner. We present a novel microneedle device for trans-round window membrane liquid biopsy, which utilizes controlled depth of perforation and microliter aspiration control to safely biopsy fluids of the inner ear. Of eleven devices tested in fresh frozen human temporal bones, seven demonstrated alignment between electrical, visual and tactile detection of round window membrane perforation, and nine were successful in aspiration of meaningful diagnostic samples from the perilymphatic space. Purity of the average perilymph sample was 69% for a 5 μL sample volume, equivalent to 3.5 μL attributable to perilymph. Diagnostic success was shown both by transmastoid facial recess and transcanal tympanotomy approach. This device can enable new advances in the understanding of inner ear pathology, and brings us one step closer to liquid biopsy of the inner ear becoming a routine part of clinical care.

Objectives: To evaluate the various scoring systems, APACHE II, SOFA, SAPS II and MPM for the prediction of prognosis of the obstetric critically ill patients admitted in a well supported ICU unit. Material and methods: A prospective, observational study was conducted among all the obstetric patients admitted to the ICU between October 2011 and December 2012, during a period of 15 months. The data collected were of three categories: demographic, obstetric and ICU related. Results and Analysis: The patients admitted in the postpartum period (n = 28, 53.84%) were more than the antenatal admissions (n = 24, 46.16%). 32.69% of admissions were in the third trimester. The most common mode of delivery was emergency caesarean section (n = 27/40, 67.5%). Total caesarean deliveries were 35/40 = 87.5% in ICU patients. The mortality prediction scores were calculated for 41 patients only as acid blood gas analysis was not available for the rest. Patients required ventilation—51.92%, hemodialysis—19.23%, inotropic support—38.46%, blood transfusion—50%. Analysis of the statistical data for ICU parameters has shown that hospital stay (p = 0.011) and ventilation days (p = 0.014) are significant predictors of maternal outcome. Age (p = 0.789), ICU stay (p = 0.701) and RRT (p = 0.632) are not significant. Among the obstetric ICU admissions, hypertensive disorders of pregnancy (30.76%) was the predominant cause followed by obstetric haemorrhage (23.07%). Discussion: HELLP syndrome and eclampsia (n = 4, 57%) were the major causes of maternal deaths with anaesthetic mishaps accounting for 29% (n = 2). One (14%) death was due to Eisenmenger’s syndrome. In one case of H1N1 admitted with ARDS, caesarean section was done in MICU for worsening respiratory distress. The maternal mortality in this series of cases was 7/52 = 13.46%, excluding the unavoidable cases of maternal death (3 cases brain dead at admission and one cardiac arrest in emergency room), our maternal mortality rate is 3/48 = 6.25%. The predicted mortality as measured by all scoring systems (for 41 patients) was between 17% and 30%. The observed mortality was around 17%. Hence a reduction in mortality of 40% has been achieved due to intensive care. Conclusions: Leading cause of maternal mortality was HELLP syndrome. Hypertensive disorders of pregnancy were the most common cause of admission to ICU. In this study, all the scores were equally significant in predicting maternal mortality. Amongst the interventions done for these patients mechanical ventilation seems to have an influence on the overall outcome.

Introduction Bortezomib, a proteasome inhibitor, has synergistic antitumor activity with gemcitabine, an antimetabolite, in preclinical and clinical studies. The safety of this combination has not yet been established in elderly patients; therefore, this dose-escalation study was designed to assess the maximum-tolerated dose of bortezomib and gemcitabine in patients aged 70 years or older with advanced-stage solid tumors. Patients and methods Gemcitabine was administered intravenously (800 to 1000 mg/m) over 30 minutes on days 1 and 8, followed 60 minutes later by bortezomib administered as an intravenous push over 3 to 5 seconds (1.0 to 1.8 mg/m) on a 21-day cycle. This study used a standard phase 1 dose-escalation design with 3 or 6 patients per dose level. Results Seventeen patients with stage IV solid tumors were treated. Median age was 73 years (range: 70 to 87 y). All patients had an Eastern Cooperative Oncology Group (ECOG) performance status less than 2. Median number of earlier chemotherapy regimens was 2 (range: 0 to 6). Dose-limiting toxicities were seen in 2 of 8 patients enrolled at the second dose level of gemcitabine (1000 mg/m) and bortezomib (1.0 mg/m), which consisted of grade ≥3 lower extremity edema, thrombocytopenia, fatigue, and dehydration. The most common grade ≥3 toxicities included thrombocytopenia (n=9), neutropenia (n=6), and anemia (n=5). Partial response (n=3) or disease stabilization (n=3) was seen in 6 of 14 evaluable patients. Conclusions Concurrent weekly gemcitabine (800 mg/m) and bortezomib (1 mg/m) is the recommended schedule for future phase 2 trials in elderly patients with stage IV solid tumors.