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The current version of the Declaration of Helsinki states that ‘the benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best current proven intervention(s) … ’. This wording implies that it is acceptable for patients to be assigned to receive an unproven new intervention and to be denied a best current proven intervention. We assert that patients being invited to participate in controlled trials cannot, ethically, be expected to forego proven beneficial forms of care. Patients being treated in controlled trials should not knowingly be disadvantaged compared with similar patients being treated in usual clinical care, where they have access to beneficial care. In this article, we have tried to separate for discussion ‘the withholding of effective care from trial participants’, ‘informed consent to treatment’, ‘blinding’ and ‘use of placebos’.

Recent years have seen a paradigm shift in the management of patients with diabetes mellitus. Rather than good glycaemic control being the sole primary aim, the therapeutic focus has broadened to consider potential additional cardiovascular and renal benefits. Sodium-glucose co-transporter 2 inhibitors, such as empagliflozin, canagliflozin and dapagliflozin, have gained increasing prominence, with evidence suggesting significant improvement in outcomes in patients with established cardiovascular and renal disease. Here, we discuss the benefits and relative risks of these novel agents and highlight important clinical issues of relevance to general physicians.

OBJECTIVES: Following the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and the subsequent global spread of the 2019 novel coronavirus disease (COVID-19), health systems and the populations who use them have faced unprecedented challenges. We aimed to measure the impact of COVID-19 on the uptake of hospital-based care at a national level. DESIGN: The study period (weeks ending 5 January to 28 June 2020) encompassed the pandemic announcement by the World Health Organization and the initiation of the UK lockdown. We undertook an interrupted time-series analysis to evaluate the impact of these events on hospital services at a national level and across demographics, clinical specialties and National Health Service Health Boards. SETTING: Scotland, UK. PARTICIPANTS: Patients receiving hospital care from National Health Service Scotland. MAIN OUTCOME MEASURES: Accident and emergency (A&E) attendances, and emergency and planned hospital admissions measured using the relative change of weekly counts in 2020 to the averaged counts for equivalent weeks in 2018 and 2019. RESULTS: Before the pandemic announcement, the uptake of hospital care was largely consistent with historical levels. This was followed by sharp drops in all outcomes until UK lockdown, where activity began to steadily increase. This time-period saw an average reduction of −40.7% (95% confidence interval [CI]: −47.7 to −33.7) in A&E attendances, −25.8% (95% CI: −31.1 to −20.4) in emergency hospital admissions and −60.9% (95% CI: −66.1 to −55.7) in planned hospital admissions, in comparison to the 2018–2019 averages. All subgroup trends were broadly consistent within outcomes, but with notable variations across age groups, specialties and geography. CONCLUSIONS: COVID-19 has had a profoundly disruptive impact on hospital-based care across National Health Service Scotland. This has likely led to an adverse effect on non-COVID-19-related illnesses, increasing the possibility of potentially avoidable morbidity and mortality. Further research is required to elucidate these impacts.

Purpose To describe the use of glycerine in improving media clarity in cases with edematous cornea. Methods Retrospective case-series including patients with posterior segment pathologies needing surgical invention and having corneal edema. Each case was studied for the role of topical application of glycerine instead of viscoelastic agents and the course of surgery. The cases were followed up for minimum 3-months duration. Results Six cases with corneal edema having posterior segment pathology underwent surgery with intraoperative topical application of glycerine. The corneal edema was seen to clear with progression of surgery and was maintained until the end of surgery. Procedures like vitreoretinal surgery, identification of break, internal limiting membrane peeling, intraocular lens explantation, scleral indentation, DSEK graft removal, and subretinal band removal could be performed in these cases. Conclusion Intraoperative glycerine use during vitreoretinal surgeries is helpful in improving the corneal clarity and maintaining it till the end of surgery.

OBJECTIVES: This study was conducted to assess poultry farmers’ knowledge and practices regarding antibiotics, antimicrobial usage (AMU), and antimicrobial resistance (AMR), and to identify the sociodemographic factors of inappropriate use of antibiotics in commercial poultry farms in Bangladesh. METHODS: A qualitative survey of 140 farmers in Bangladesh was conducted from March to May 2019. A logistic regression model was used to identify factors associated with the inappropriate use of antibiotics. RESULTS: 47.1% of farmers were unable to explain antibiotics, 42.9% used antibiotics for preventive purposes, 4.3% used them as growth promoters, 25.7% used them as suggested by veterinarians, 42.9% used leftover antibiotics, 50% did not maintain antibiotics residual withdrawal period, and 98.6% did not know about AMR. In bivariable regression analysis, sex and primary occupation of poultry farmers, their knowledge about withdrawal periods for antibiotics, and no contact with veterinary surgeons (VS) were found to be significantly associated with the inappropriate use of antibiotics, while only ‘no contact with VS’ was identified in multivariable regression analysis. CONCLUSIONS: The findings suggest an urgent need to improve understanding of antibiotics and AMR. Adequate supervision by veterinarians would ensure adherence to appropriate AMU patterns, and would limit the misuse of antibiotics and associated AMR development in farms.

The last 30 years have seen a revolution in the provision of minimal access surgery for many conditions, and technological advances are increasing exponentially. Many instruments are superseded by improved versions before the NHS and publicly funded health services can offer widespread coverage. Although we tend to think of minimal access surgery as a modern concept, Parts I and II of this series have shown that there is a 5000-year history to this specialty and our predecessors laid down many principles which still apply today. During the 19th and early 20th centuries, minimal access surgery was driven forward by visionary individuals, often in the face of opposition from colleagues and the medical establishment. However, in the last 30 years, innovation has been driven more in partnerships between healthcare, scientific, financial, educational and charitable organisations. There are far too many individuals involved to detail every contribution here, but this third part of the series will concentrate on some of the important themes in the development of minimal access surgery to its current status.

Despite the best efforts of clinicians, traditional healthcare models often struggle to meet the increasingly complex needs of children and young people under the age of 18 years, as well as 21st century challenges such as obesity and mental health problems. Policy makers and clinical leaders have argued that greater integration of primary and secondary care has the potential to meet the ‘Quadruple aim’ of better population health outcomes, patient and family satisfaction, provider satisfaction and reduced costs.1 More integrated services and improved data sharing across organisations are key enablers of child health improvement. However, there is sparse literature on how more integrated care for children and young people might work in practice or contribute to achieving these goals. We present the experience of developing a new model for integrated care delivery for children and young people in North West London, based on a common system of clinical records or dashboards across all providers. It includes case studies that illustrate the development of strong relationships and shared learning experiences between primary and secondary care.

Summary This is the second of a three-part series that charts the history of minimal access surgery from antiquity to current times. Although rapid developments in laparoscopic and robotic surgery have transformed surgical care over the last 30 years, our predecessors made significant advances in their time which set the principles for modern practice. Part I of this series described how ancient medical practitioners developed simple instruments, from metal or wood, for viewing body cavities. Improvements in the use of metal, glass and lighting allowed for inspection of deeper parts of the body. This second part of the series will show how advances in electrical technology allowed the development of improved lighting for endoscopy and laparoscopy along with the use of electrocautery for a wide range of therapeutic procedures.

Cystic hydatid disease or cystic echinococcosis (CE) is a globally endemic zoonosis caused by the larval cyst stage of the tapeworm Echinococcus granulosus. Concomitant presence of CE and hepatocellular carcinoma (HCC) is a rare clinical scenario. A 70-year-old male patient presented with acute abdominal pain to the surgical outpatient department. On evaluation, a cystic lesion with solid components and free fluid in the abdomen was observed, which led to multiple differentials in the working diagnosis. A CT showed the mass to have a delayed enhancement. Surgical exploration revealed a partially ruptured hydatid cyst with daughter cysts in the abdominal cavity and a solid-component mass lesion. We proceeded with a right partial hepatectomy. Pathological evaluation revealed a pale mass lesion with a large collapsed cyst. HCC with unusual dense fibrillar fibrosis and cystic interface with normal parenchyma was observed. This case connects the multimodal assessment of radiology, surgery and pathology.

A term large-for-gestational-age neonate was born via an uncomplicated normal vaginal delivery at a peripheral hospital. The neonate was referred to our tertiary centre due to concerns regarding the appearance of the right hand. On examination at 6 hours of life there was cyanotic discolouration

Myasthenia gravis (MG) is an autoimmune condition affecting the neuromuscular junction characterised by weakness and fatiguability, carrying a high morbidity if treatment is delayed. A clear association with thymoma has led to management with thymectomy as a common practice, but MG presenting post-thymectomy has rarely been reported. We present a case of an 82- year-old woman developing fatigue, ptosis and dysarthria 3 months after thymectomy. After a clinical diagnosis of MG was made, she responded well to prompt treatment with prednisolone and pyridostigmine. Her anti-acetylcholine receptor antibody (anti-AChR) subsequently came back positive. Our systematic review reveals that post-thymectomy MG can be categorised as early-onset or late-onset form with differing aetiology, and demonstrated correlation between preoperative anti-AChR titres and post-thymectomy MG. The postulated mechanisms for post-thymectomy MG centre around long-lasting peripheral autoantibodies. Clinicians should actively look for MG symptoms in thymoma patients and measure anti-AChR preoperatively to aid prognostication.

Objective Intra-procedural WEB device migration is a scarcely reported complication that necessitates prompt intervention. Case Presentation Endovascular treatment of two broad necked flow-related aneurysms was planned aided by WEB-SL (Woven EndoBridge-single layer) devices in a 71-year-old female with known left temporal arteriovenous malformation. Inadvertent distal migration occurred while performing a control angiogram with an automated iodine injector. Immediate retrieval was successfully performed using a Solitaire stent-retriever. Conclusion To our knowledge, we report for the first time the successful retrieval of a distally migrated WEB using a stent-retriever device.

Background Five to ten percent of the global population have unruptured intracranial aneurysms, and ruptured brain aneurysms cause approximately 500,000 deaths a year. Flow-diverting stent treatment is a less invasive intracranial aneurysm treatment that induces aneurysm thrombosis. The imaging characteristics of a novel primarily bioresorbable flow-diverting stent (BFDS) are assessed in comparison to the leading metal stent using fluoroscopy, CT, and MRI. Methods X-ray/fluoroscopic images of stents were taken using a human cadaveric skull model. CT and MRI were acquired using silicone flow models of residual aneurysms. Images were analyzed with Likert scales in anonymous surveys by neurointerventionalists. Quantitative measurements of radiographic density (CT) and artifact boundary size (CT & MRI) were also obtained. Results Visibility of the BFDS on X-ray was less than the metal stent but deemed adequate for deployment and intraprocedural assessment. The metal stent was more radiopaque than the BFDS on CT, but qualitative assessment was not significantly different for the two stents. MRI imaging was significantly better using the BFDS in terms of overall artifact and intraluminal assessment. Conclusions The BFDS has adequate visualization on X-ray/fluoroscopy and should be clinically acceptable for fluoroscopic deployment. On MRI, there is less quantitative artifact as well as overall improved qualitative assessment that will allow for more detailed non-invasive imaging follow-up of treated aneurysms, potentially reducing the need for digital subtraction catheter angiography.

Background Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF. Case presentation A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve. Conclusion CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.

The formation of an intraperitoneal pseudocyst as a complication of ventriculoperitoneal shunts is well known. However, the formation of a pseudocyst at the subcutaneous extraperitoneal abdominal space is unusual and likely secondary to the migration of the peritoneal catheter. We present a 53-year-old male who had placement of a ventriculoperitoneal shunt for hydrocephalus secondary to a vestibular schwannoma. Five months later, he presented with an enormously distended abdomen. Investigations showed the peritoneal catheter in the extraperitoneal space within a large right lower quadrant abdominal wall pseudocyst. The patient was taken to the operating theatre, and the shunt was externalised at the original abdominal incision. Approximately 3 L of cerebrospinal fluid were aspirated from the distal peritoneal catheter. After negative cultures, a new peritoneal catheter was placed intraperitoneally at the contralateral lower abdominal quadrant. The contralateral quadrant was utilised to prevent fluid accumulation into the old extraperitoneal cavity.

Uterine rupture can be associated with severe maternal and neonatal morbidity and mortality. It should be considered as a differential diagnosis in all pregnant women who present with acute abdomen, haemoperitoneum and have specific risk factors, even during the first trimester. This is a case report of a 25-year-old woman who presented to emergency department with abdominal pain and vaginal bleeding at approximately 6–8 weeks gestation. She developed an acute surgical abdomen and required urgent surgical management. Despite intervention, she had massive haemorrhage, disseminate intravascular coagulation, admission to intensive care unit and prolonged hospital stay as complications. Posterior uterine wall rupture while rare, must be considered as a differential diagnosis as early intervention is crucial to prevent bad outcomes.

We present the case of a female teenager who sustained nitrous oxide burns to the medial aspect of both thighs from contact with a nitrous oxide canister being used to fill balloons. There was a delay in presentation as the injury was not initially recognised. These burns were initially assessed as being superficial partial-thickness burns but took a prolonged time to heal despite regular wound care. This was complicated by a lack of adherence to recommended treatment for much of the patient care as well as the patient testing positive for COVID-19 during their management, which prevented surgery and significantly extended time to healing. While small numbers of similar cases have been previously described this is the first reported case outside of the Netherlands and in a child. Being aware of such cases ensures early referral to specialist burn care for appropriate management to give patients the best possible outcome.

Summary Surgeons and their patients recognise that one of the major advances in surgical technique over the last 20 years has been the growth of minimal access surgery by means of laparoscopic and robotic approaches. Partnerships with industry have facilitated the development of advanced technical instruments, light sources, recording devices and optics which are almost out of date by the time they are introduced to surgical practice. However, lest we think that technological innovation is entirely a modern concept, we should remember that our predecessors were masters of their craft and able to apply new technologies to surgical practice. The history of minimal access surgery can be traced back to approximately 5000 years ago and this review aims to remind us of the achievements of historical doctors and engineers, as well as bring more modern developments to wider attention. This review will comprise a three-part series: Part I 3000BC to 1850 Early instruments for viewing body cavities Part II 1850 to 1990 Technological developments Part III 1990 to present Organisational issues and the rise of the robots

Bruck syndrome is an autosomal recessive disease characterised by the clinical combination of both osteogenesis imperfecta and arthrogryposis multiplex congenita (AMC). It is caused due to collagen miss-folding and cross-linking defect resulting from a deletion in FKBP10 (OMIM #259450) and/or PLOD2

Mandibular fractures are rare in infants, and diagnosis can be easily missed due to the difficulty in obtaining an adequate history and the subtle signs. A high index of suspicion and detailed history taking from the caregiver are mandatory to pick up these cases.There are a plethora of management options that have been reported in dealing with such fractures. They range from conservative management to internal fixation by absorbable plates. While conservative management does not interfere with mandibular growth and teeth development, any surgical intervention can carry this risk. Nevertheless, a severely displaced fracture may need anatomical reduction and fixation to allow early nutrition.This study reports a 3-month-old male infant with a fracture in the mandibular symphysis who underwent reduction of the fracture and circummandibular fixation using immobilisation by an acrylic splint for 4 weeks. His long-term follow-up after 20 months showed adequate dentition with proper healing of the fracture site.

Environmental awareness consists in the way human beings understand the environment. We observe that relation between humans and the natural environment is a concern related to the currently environmental and social. Thus, this paper aims to identify what we call as environmental perception in students from a 6th grade elementary state school in Sorriso, Mato Grosso. For this case study, we used a semi structured questionnaire with open and closed questions for a group of 63 students. After the answer’s analysis phase, for some previously selected questions, were created categories and tabulated, for other questions, data’s were analyzed and demonstrated in charts. As results, as quoted by several authors, we observed that the environmental and sight perception of the students are coherent for schoolchildren in this age, however, the authors reinforce that the development of projects concerning environmental education are still needed., A percepção ambiental consiste na forma como o ser humano compreende o meio ambiente. Observando a relação do homem com o ambiente natural é uma preocupação pertinente ao quadro ambiental e social, o presente trabalho tem como objetivo identificar aquilo que chamamos de percepção ambiental de alunos de 6° ano do ensino fundamental de uma escola estadual de Sorriso, Mato Grosso. Para este estudo de caso, foi utilizado um questionário semiestruturado com perguntas fechadas e abertas, para um grupo de 63 estudantes. Após a análise do conteúdo das respostas, para algumas questões previamente selecionadas, foram criadas categorias e tabeladas, para outras, os dados foram analisados e demonstrados em tabelas. Foi possível observar que a percepção ambiental dos alunos e a visão de meio ambiente é coerente com o citado por diversos autores para estudantes dessa idade, no entanto, reforçam que ainda há uma necessidade de desenvolvimento de projetos voltados à educação ambiental.

Housing in Algeria is experiencing a multi-dimensional crisis: crisis in design (standardization of housing), construction, financing, management, etc., which has a negative impact on user comfort, poor housing quality and high energy consumption.This article focuses on the study of the impact of different thermal insulation str ategies on energy consumption (heating and cooling) of a residential building situated in semi arid climate (Constantine northeast of Algeria) using thermal dynamic simulation tool (TRNSYS 16)

This article deals with the numerical simulation of a two-dimensional instantaneous heat and mass transfer processes within a commonly used intermetallic compound (a.k.a. Mischmetal) packed in a unit disc of an annulus-disc reactors, during hydrogen gas desorption. Using the finite volumes technique bundled in the OpenFOAM® CFD code, temperature and amount of desorbed hydrogen and their time-averaged quantities inside the metal-hydride packed bed are obtained for various temperatures of fluids used in heat transfer, and several outlet pressure magnitudes. Using a set of numerical simulations, we have emphasized the impacts of both parameters on metal-hydride reactor performance related to discharging time. An excellent accord was recorded for the present simulations results compared against the literature-reported experimental data [20].

Background: We aimed to develop census-linked longitudinal mortality data for Japan and assess their validity as a new resource for estimating socioeconomic inequalities in health. Methods: Using deterministic linkage, we identified, from national censuses for 2000 and 2010 and national death records, persons and deceased persons who had unique personal identifiers (generated using sex, birth year/month, address, and marital status). For the period 2010–2015, 1,537,337 Japanese men and women aged 30–79 years (1.9% in national census) were extracted to represent the sample population. This population was weighted to adjust for confounding factors. We estimated age-standardized mortality rates (ASMRs) by education level and occupational class. The slope index of inequality (SII) and relative index inequality (RII) by educational level were calculated as inequality measures. Results: The reweighted sample population’s mortality rates were somewhat higher than those of the complete registry, especially in younger age-groups and for external causes. All-cause ASMRs (per 100,000 person-years) for individuals aged 40–79 years with high, middle, and low education levels were 1,078 (95% confidence interval [CI], 1,051–1,105), 1,299 (95% CI, 1,279–1,320), and 1,670 (95% CI, 1,634–1,707) for men, and 561 (95% CI, 536–587), 601 (95% CI, 589–613), and 777 (95% CI, 745–808) for women, respectively, during 2010–2015. SII and RII by educational level increased among both sexes between 2000–2005 and 2010–2015, which indicates that mortality inequalities increased. Conclusion: The developed census-linked longitudinal mortality data provide new estimates of socioeconomic inequalities in Japan that can be triangulated with estimates obtained with other methods.

Background Postpartum depression (PPD) has been associated with adverse health outcomes including maternal suicide. Mode of delivery has been suggested to be a risk factor for PPD, but no large cohort study has examined the association between mode of delivery and PPD. We aimed to examine the association between mode of delivery and risks of PPD at 1 and 6 months after childbirth. Methods In a nationwide study of 89,954 mothers with a live singleton birth, we examined the association between mode of delivery and risks of PPD. PPD was measured by the Edinburgh Postnatal Depression Scale (≥13) at 1 and 6 months after childbirth. Odds ratios (ORs) with 95% confidence intervals (CIs) of PPD were calculated using multivariable logistic regression analyses after adjustment of antenatal physical, socioeconomic, and mental factors. Results Among 89,954 women, 3.7% and 2.8% had PPD at 1 and 6 months after childbirth, respectively. Compared with unassisted vaginal delivery, cesarean section (CS) was marginally associated with PPD at 1 month, but not at 6 months; adjusted ORs were 1.10 (95% CI, 1.00-1.21) and 1.01 (95% CI, 0.90-1.13), respectively. The association with PPD at 1 month was evident in women with antenatal psychological distress: adjusted OR was 1.15 (95% CI, 1.03-1.28). The observed associations were attenuated after adjusting for infant feeding method. Conclusions Women who had antenatal psychological distress and underwent CS delivery may be regarded as a target for monitoring PPD.

BackgroundBreast cancer is the most common malignancy among Iranian women. In recent years, the study of dysfunction in the expression of cell-cell junction genes and the related proteins in the malignant process has been at the center of attention. MethodsIn this study, 50 patients were selected who had both cancerous tissue and adjacent healthy tissue. The expression of the desmoglein 2 gene was evaluated. Healthy and cancerous tissue were compared using routine hematoxylin and eosin staining. The total protein was also compared between these two groups. The ultrastructural examination was performed.ResultsThe real-time polymerase chain reaction results showed a decrease in the expression of the desmoglein 2 gene in all tumor samples compared to the healthy samples (p-value ConclusionOverall, the findings showed that the association between desmoglein 2 gene expression and alterations in cellular connections leads to impaired cellular connections, which is an important risk factor for breast cancer. This result proposed the understudy gene as a new biomarker in the development of breast cancer.

Background Stress coping strategies are related to health outcomes. However, there is no clear evidence for sex differences between stress-coping strategies and mortality. We investigated the relationship between all-cause mortality and stress-coping strategies, focusing on sex differences among Japanese adults. Methods A total of 79,580 individuals aged 35-69 years participated in the Japan Multi-Institutional Collaborative Cohort Study between 2004 and 2014 and were followed up for mortality. The frequency of use of the five coping strategies was assessed using a questionnaire. Sex-specific, multivariable-adjusted hazard ratios (HRs) for using each coping strategy "sometimes," and "often/very often" (versus "very few" use) were computed for all-cause mortality. Furthermore, relationships were analyzed in specific follow-up periods when the proportion assumption was violated. Results During the follow-up (median: 8.5 years), 1,861 mortalities were recorded. In women, three coping strategies were related to lower total mortality. The HRs (95% confidence intervals) for "sometimes" were 0.81 (0.67-0.97) for emotional expression, 0.79 (0.66-0.95) for emotional support-seeking, and 0.80 (0.66-0.98) for disengagement. Men who "sometimes" used emotional expression and sometimes or often used problem-solving and positive reappraisal had a 15-41% lower HRs for all-cause mortality. However, those relationships were dependent on the follow-up period. There was evidence that sex modified the relationships between emotional support-seeking and all-cause mortality (p for interaction = 0.03). Conclusions In a large Japanese population, selected coping strategies were associated with all-cause mortality. The relationship of emotional support-seeking was different between men and women.

Responding to a healthcare crisis such as COVID-19 requires a practiced, nimble incident command structure. Our medical center is in one of the areas in the US that was hardest hit by the initial wave. Effective leadership of incident command was critical in our response.

Background Early initiation of breastfeeding (EIBF) within 1 h of birth is crucial in preventing newborn deaths and plays a vital role in early infant nutrition. Promoting and supporting breastfeeding is an integral part of midwifery. The objective of the study was to improve the EIBF rate in neonates born through a Cesarean Section (CS) from 0% to 50% within six months through a quality improvement (QI) process and to assess the maternal experience of EIBF in operation theatre (OT). Methods Six Plan-Do-Study-Act (PDSA) cycles were conducted to test the change ideas proposed by the team members for a month to improve EIBF. Participants of the study were the stable term newborns delivered by CS under spinal anesthesia. Results The EIBF rate improved from 0% to 88% after the sixth PDSA cycle. The effect was sustained for six months. Mothers of 51 neonates (98%) who received EIBF reported that their newborns were breastfed successfully, and it was not physically tiring to feed immediately in the OT. Conclusions A quality improvement (QI) initiative was able to improve and sustain the improved EIBF rate after CS. Early skin-to-skin contact to be initiated with EIBF for better neonatal outcomes.

Background Hospital administrators are often challenged with overcrowding at hospitals. The study hospital receives referred patients; however, they have to wait in long queues even for getting registered. This was a cause of concern for hospital administrators. The study was undertaken to find an amicable solution to the queues at registration using Queuing Theory. Method This observational and interventional study was carried out in a tertiary care ophthalmic hospital. In the first phase, data of service time and arrival rate was collected. The queuing model was built using the coefficient of variation (CoV) of the observed times. Server utilization for new patient registration was found to be 1.21 and was 0.63 for revisit patients. Scenario-based simulation carried out using free software for optimal utilization of both types of servers. Recommendations made to combine the registration process and to increase one server were implemented. In the second phase, after one year, patient registration data were collected and compared for the number of patients registered using SPSS 17. Results Number of patients registered within the registration timings increased whereas the number of patients registered after the registration timings decreased significantly at 95% CI with a p-value of less than 0.001. Queues finished early and more number of patients were registered in the same time. Conclusion Using queuing theory, the bottleneck of the systems can be identified. Scenario and software-based simulations provide solutions to the problem of queues. The study is an application of Queuing Theory with a focus on efficient resource utilization. It can be replicated in an organization with limited resources facing the challenge of queues.

Purpose To highlight a case of chorioretinitis sclopetaria, with concomitant macular hole formation and orbital emphysema, caused by a commercial-grade pressure washer. Patient A 19-year-old male presented to the emergency department with a left eye injury, incurred after being sprayed with a commercial-grade pressure washer. He endorsed ipsilateral blurred vision, pain, and linear floaters. Left eye visual acuity was 20/40. Dilated fundus exam showed inferior vitreous hemorrhage, retinal whitening, and pre-, intra-, and sub-retinal hemorrhages, consistent with chorioretinitis sclopetaria. Optical coherence tomography revealed a full-thickness macular hole. Computed tomography scan of the orbits showed subcutaneous and post-septal orbital emphysema. Two months following injury, vitreous and retinal hemorrhages and macular hole resolved. Five months following injury, visual acuity improved to 20/20. Discussion Chorioretinitis sclopetaria is defined as a full-thickness chorioretinal disruption resulting from a high-velocity projectile passing adjacent to or into the orbit without penetrating the globe. Chorioretinal deformation and ocular comorbidities are influenced by the velocity of the missile and its spatial relationship to the orbit. While this pattern of injury is typically associated with indirect trauma to the globe by a BB or a bullet, this is the first report of chorioretinitis sclopetaria precipitated by a high-velocity liquid missile.