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Double lip or macrocheilitis is a rare facial anomaly, mostly congenital in origin. It commonly involves the upper lip than the lower lip. It may occur in isolation or as part of the Ascher’s syndrome. It results due to deposition of excessive areolar tissue and non-inflammatory hyperplasia of labial mucosa gland of pars villosa. It may be acquired as a result of injury to the lips or lip-biting habit. The double lip becomes conspicuous when the lips are retracted during smiling resulting in the characteristic ‘cupid’s bow’ appearance. This disfigurement can pose aesthetic and functional problems and may result in psychological distress. A surgical intervention is must for restoration of functions and to address the aesthetic concerns. The present article reports a case of non-syndromic double upper lip with triple labial frena and its surgical management with laser on one side and with scalpel on the other side.

Background In the UK, Core Surgical Training (CST) marks the start of a surgical career, but previous experience and skills vary widely. Whilst Individual hospital Trusts offer local inductions, these are generally of a generic, administrative nature rather than advising trainees on how best to harness training opportunities. We designed a regional induction programme, ‘Building Excellence in Surgical Training’ (BEST) to address this, develop essential technical and non-technical skills, and engender support networks. Methods All incoming London Core Surgical Trainees (annual cohort size 90) were invited to participate, during the week prior to commencement of training. Trainees undertook 3 modules (portfolio, surgical skills and human factors-based simulation) and a research paper presentation day. We collected qualitative and quantitative data through a structured evaluation form, pre and post course Likert-scale scores and self-assessment utilising the non-technical skills for surgeons (NOTSS) framework. Results 972 CSTs have completed BEST over the past 12 years. In 2019, significant improvements were seen in: confidence for starting CST, 45% (n = 22/49)-83% (n = 33/40,p = 0.00045); feeling the core programme cared about them, 55% (n = 27/49)-98% (n = 41/42, p = Conclusion BEST equips trainees with the fundamental skills and confidence to safely embark on surgical training and provides tools to navigate the challenges training presents. The ethos of collaboration and support will aid the development of more resilient and empowered surgeons, vital in this era.

Background Stenotrophomonas maltophilia causes opportunistic infections in immunocompromised and patients in intensive care units (ICUs). An outbreak of S. maltophilia in ICU is described which highlights the importance of the risk of infection from contaminated medical devices and suction fluids in ventilated patients. Methods The investigation of the outbreak was carried out. Environmental sampling was done. This was followed by MALDI-TOF MS typing and recA gene-based-phylogeny. Results In February, S. maltophilia was reported from the central line blood of six patients from ICU within a span of two weeks. The peripheral line blood cultures were sterile in all patients. Relevant environmental sampling of the high-touch surface and fluids revealed S. maltophilia strains in normal saline used for suction and in the inspiratory circuit of two patients. The isolated strains from patients and environment (inspiratory fluid) showed a minimum of 95.41% recA gene sequence identity between each other. Strict cleaning and disinfection procedures were followed. Continuous surveillance was done and no further case of S. maltophilia was detected. Timely diagnosis and removal of central line prevented development of central-line associated blood stream infection. Conclusion This outbreak report illustrates that environmental sources like suction fluid and normal saline could be the source of S. maltophilia in ICU patients.

In lung cancer computer-aided diagnosis (CAD) systems, having an accurate ground truth is critical and time consuming. Due to lack of ground truth and semantic information, lung CAD systems are not progressing in the manner these are supposed to. In this study, we have explored Lung Image Database Consortium (LIDC) database containing annotated pulmonary computed tomography (CT) scans, and we have used semantic and content-based image retrieval (CBIR) approach to exploit the limited amount of diagnostically labeled data in order to annotate unlabeled images with diagnoses. We evaluated the method by various combinations of lung nodule sets as queries and retrieves similar nodules from the diagnostically labeled dataset. In calculating the precision of this system Diagnosed dataset and computer-predicted malignancy data are used as ground truth for the undiagnosed query nodules. Our results indicate that CBIR expansion is an effective method for labeling undiagnosed images in order to improve the performance of CAD systems while tested on PGIMER data. Also a little knowledge of biopsy confirmed cases can also assist the physician’s as second opinion to mark the undiagnosed cases and avoid unnecessary biopsies

BACKGROUND AND OBJECTIVES: People receiving maintenance dialysis must often rely on family members and other close persons to make critical treatment decisions toward the end of life. Contemporary data on family members’ understanding of the end-of-life wishes of members of this population are lacking. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Among 172 family members of people undergoing maintenance dialysis, we ascertained their level of involvement in the patient’s care and prior discussions about care preferences. We also compared patient and family member responses to questions about end-of-life care using percentage agreement and the κ-statistic. RESULTS: The mean (SD) age of the 172 enrolled family members was 55 (±17) years, 136 (79%) were women, and 43 (25%) were Black individuals. Sixty-seven (39%) family members were spouses or partners of enrolled patients. A total of 137 (80%) family members had spoken with the patient about whom they would want to make medical decisions, 108 (63%) had spoken with the patient about their treatment preferences, 47 (27%) had spoken with the patient about stopping dialysis, and 56 (33%) had spoken with the patient about hospice. Agreement between patient and family member responses was highest for the question about whether the patient would want cardiopulmonary resuscitation (percentage agreement 83%, κ=0.31), and was substantially lower for questions about a range of other aspects of end-of-life care, including preference for mechanical ventilation (62%, 0.21), values around life prolongation versus comfort (45%, 0.13), preferred place of death (58%, 0.07), preferred decisional role (54%, 0.15), and prognostic expectations (38%, 0.15). CONCLUSIONS: Most surveyed family members reported they had spoken with the patient about their end-of-life preferences but not about stopping dialysis or hospice. Although family members had a fair understanding of patients’ cardiopulmonary resuscitation preferences, most lacked a detailed understanding of their perspectives on other aspects of end-of-life care.

Objectives The objective of this study was to estimate the possible number of cancer cases produced during 2019 in US dental offices from radiography, estimate the possible reduction in those rates resulting from use of intraoral rectangular collimation and selection criteria, and determine the frequency and quality of website radiation risk information and informed consent forms. Study Design An analysis of dental radiation examinations in 2014 to 2015 US national survey data, Nationwide Evaluation of X-ray Trends, and National Council on Radiation Protection and Measurements surveys was performed, in addition to an analysis of 2008 to 2020 Journal of Clinical Orthodontics national orthodontic surveys for radiographic examination frequencies. Lifetime attributable cancer risk estimates from US and European studies were used to generate the total dental and orthodontic office cancer totals. In total, 150 offices were examined online for the quality and frequency of risk information in websites and consent forms. Results The 2019 estimate for all office cancers is 967. Collimation and selection criteria could reduce this to 237 cancer cases. Most cancers arise from intraoral and cone beam computed tomography examinations, with 135 orthodontic cancers over 21 months (average treatment time). Collimation and selection criteria could reduce this to 68. Only 1% of offices use collimators or informed consent for radiography. The website and consent information were of poor quality. Conclusions Dentists are not following selection criteria or using collimators according to guidelines. Up to 75% of cancer cases could be avoided.

Capturing data in the form of networks is becoming an increasingly popular approach for modeling, analyzing and visualising complex phenomena, to understand the important properties of the underlying complex processes. Access to many large-scale network datasets is restricted due to the privacy and security concerns. Also for several applications (such as functional connectivity networks), generating large scale real data is expensive. For these reasons, there is a growing need for advanced mathematical and statistical models (also called generative models) that can account for the structure of these large-scale networks, without having to materialize them in the real world. The objective is to provide a comprehensible description of the network properties and to be able to infer previously unobserved properties. Various models have been developed by researchers, which generate synthetic networks that adhere to the structural properties of real networks. However, the selection of the appropriate generative model for a given real-world network remains an important challenge. In this paper, we investigate this problem and provide a novel technique (named as TripletFit) for model selection (or network classification) and estimation of structural similarities of the complex networks. The goal of network model selection is to select a generative model that is able to generate a structurally similar synthetic network for a given real-world (target) network. We consider six outstanding generative models as the candidate models. The existing model selection methods mostly suffer from sensitivity to network perturbations, dependency on the size of the networks, and low accuracy. To overcome these limitations, we considered a broad array of network features, with the aim of representing different structural aspects of the network and employed deep learning techniques such as deep triplet network architecture and simple feed-forward network for model selection and estimation of structural similarities of the complex networks. Our proposed method, outperforms existing methods with respect to accuracy, noise-tolerance, and size independence on a number of gold standard data set used in previous studies.

PURPOSE OF REVIEW: Proximal femur fractures are common traumatic injuries treated by orthopedic surgeons. Preparation and positioning for surgical intervention are critical in the proper management of proximal femur fractures. The purpose of this study was to review the current evidence on the various positioning options for patients and to highlight the principles and emerging techniques to help orthopedic surgeons treat this common injury. RECENT FINDINGS: Strategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications. The use of intramedullary devices for the fixation of proximal femur fractures has led to an increased use of the modern fracture table. The fracture table should be used when surgeons are facile with its use to avoid significant complications. Recent best available evidence has suggested increased risk of malrotation associated with the use of the fracture table. The use of the radiolucent table offers the most flexibility, but limits surgeons as multiple assistants are needed to maintain reduction during fixation. SUMMARY: Positioning for proximal femur fractures is an important technique for general and trauma orthopedic surgeons. Surgeons need to be aware of the various techniques for positioning of proximal femur fractures due to the diversity of injury patterns and patient characteristics. Each positioning technique has it benefits and potential complications that every orthopaedic surgeon should be familiar with while treating these injuries. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12178-021-09710-x.

This paper examines whether the quality of corporate governance has a significant impact on sustainable value added by the companies. It uses a value-based measure of corporate performance, that is...

With aim of detecting breast cancer at the early stages using mammograms, this study presents the formulation of five feature types by extending the information set to encompass the concept of an intuitionist fuzzy set. The resulting pervasive information set gives not only the certainty of the pixel intensities of mammograms to a class but also the deficiency in the fuzzy modeling referred to as the hesitancy. The generalized adaptive Hanman Anirban fuzzy entropy function is shown to be equivalent to the hesitancy entropy function. The probability-based fuzzy Hanman transform and the pervasive Information with probability taking the role of hesitancy degree help derive the above five feature types termed as probability-based pervasive Information set features. The effectiveness of each feature type is demonstrated on the mini-MIAS and DDSM databases for the multi-class categorization of mammograms using the Hanman transform classifier. The statistical analysis by ANOVA test proves that the features are statistically significant and the experimental results are shown to be clinically relevant by the expert radiologists. The performance of the five feature types is either superior to or equal to that of some deep learning architectures on comparison but they outperform the state-of-the-art literature methods in the classification of breast cancer using mammograms.

A majority of Wireless Sensor Network (WSN) research at present is focussed on the problems of limited energy supply and its impact on network lifetime. Nevertheless, the plethora of applications conceivable with the help of WSNs often demand for MOO (Multi-Objective Optimization) formulations, where several design goals contend together for the best trade-off solution among them. Therefore, research investigators must also regard other miscellaneous issues in addition to energy efficiency for applicability of WSNs in practical scenarios like Internet of Things. DREAM (Delay-sensitive, Reliable, Energy-Efficient, Adaptive and Mobility-Aware) routing protocol is proposed in the present work, that ameliorates network lifetime (in terms of First Node Death and Last Node Death), throughput (in terms of number of packets sent to Base Station) and latency (average end-to-end delay in seconds) in the network along with enhancing the reliability (in terms of percentage packet loss) of delivered data. The proposed protocol also integrates mobility and heterogeneity of the nodes to cater to the needs of an application-independent general purpose WSN routing protocol, which can be used commercially. Comparative analysis with existing protocols establishes the superiority of the proposed protocol, which is capable of improving the network lifetime by about 3.54% and simultaneously lowering the delay by 35.5%, along with the amelioration of other parameters.

Objective Breast cancer is the most common malignancy among women and often requires surgery for the removal of the tumour. Uncontrolled pain after breast surgeries is a common problem. Serratus anterior plane (SAP) block is a recently designed technique to block the lateral cutaneous branches of the ventral rami of thoracic intercostal nerves and may cover the area of surgical dissection for modified radical mastectomy (MRM). The primary objective of this study was to evaluate the effect of SAP block on the time to first rescue analgesic in the post-operative period in patients undergoing MRM. Methods A randomised, single-blind, parallel group trial was conducted in a single teaching hospital. A total of 100 patients undergoing MRM were randomised in a 1:1 ratio into 2 groups: MRM under general anaesthesia (GA) alone (group G, n=50) or GA with SAP block (group S, n=50). Blocks were performed under ultrasound guidance at the level of the 5th rib in the midaxillary line with 0.4 mL kg-1 of 0.375% ropivacaine. Results The time to request of first rescue analgesia was significantly prolonged in group S compared with group G (p=0.008). Median (interquartile range) for time to rescue analgesia in group S was 120 (60-300) min, whereas in group G, it was 60 (15-120) min. Post-operative pain scores and the number of patients requiring intra-operative additional fentanyl were significantly less in group S. No technique-related adverse events were observed. Conclusion SAP block improved perioperative analgesia in patients undergoing MRM. Clinical trial registry number CTRI/2017/11/010424. (http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=45912.14862).

Dynamic and frequent re-clustering of nodes along with data aggregation is used to achieve energy-efficient operation in wireless sensor networks. But dynamic cluster formation supports data aggregation only when clusters can be formed using any set of nodes that lie in close proximity to each other. Frequent re-clustering makes network management difficult and adversely affects the use of energy efficient TDMA-based scheduling for data collection within the clusters. To circumvent these issues, a centralized Fixed-Cluster Architecture (FCA) has been proposed in this paper. The proposed scheme leads to a simplified network implementation for smart spaces where it makes more sense to aggregate data that belongs to a cluster of sensors located within the confines of a designated area. A comparative study is done with dynamic clusters formed with a distributive Low Energy Adaptive Clustering Hierarchy (LEACH) and a centralized Harmonic Search Algorithm (HSA). Using uniform cluster size for FCA, the results show that it utilizes the available energy efficiently by providing stability period values that are 56% and 41% more as compared to LEACH and HSA respectively.

Acute appendicitis is one of the most common pediatric surgical emergencies. Herewith we present our study to determine the correlation of preoperative laboratory investigations with intraoperative findings and histopathological report in children with appendicitis. A case series analysis of 60 patients undergoing appendicectomy was performed at the Department of Pediatric Surgery in All India Institute of Medical Sciences Jodhpur India from July 2018 to July 2019. Historic records were analyzed. Parameters studied were age, gender, duration of symptoms, total leucocyte counts and C-reactive protein, ultrasonography, intraoperative findings, placement of drain in perforated cases, postoperative duration of antibiotics, and hospital stay. We compared the values of total leucocyte counts and C-reactive protein in perforated and non-perforated cases. Histopathological report of the specimens was retrieved. The mean age of the patients was 11.23 years (range 2–18 years) with a male preponderance of 2:1. The mean total leucocyte count was 16,772 cells/mm3 in the perforated group which was significantly higher than the non-perforated group 10,872cells/mm3 (p value

Background The association of workplace factors on mental health of healthcare workers (HCWs) during the COVID-19 pandemic needs to be urgently established. This will enable governments and policy-makers to make evidence-based decisions. This international study reports the association between workplace factors and the mental health of HCWs during the pandemic. Methods An international, cross-sectional study was conducted in 41 countries. The primary outcome was depressive symptoms, derived from the validated Patient Health Questionnaire-2 (PHQ-2). Multivariable logistic regression identified factors associated with mental health outcomes. Inter-country differences were also evaluated. Results A total of 2527 responses were received, from 41 countries, including China (n = 1213; 48.0%), UK (n = 891; 35.3%), and USA (n = 252; 10.0%). Of all participants, 1343 (57.1%) were aged 26 to 40 years, and 2021 (80.0%) were female; 874 (34.6%) were doctors, and 1367 (54.1%) were nurses. Factors associated with an increased likelihood of depressive symptoms were: working in the UK (OR = 3.63; CI = [2.90–4.54]; p p p p p = 0.040). Workplace factors associated with depressive symptoms were: redeployment to Intensive Care Unit (ICU) (OR = 1.67; CI = [1.14–2.46]; p = 0.009); redeployment with perceived unsatisfactory training (OR = 1.67; CI = [1.32–2.11]; p p p p Conclusion This is the first international study, demonstrating that workplace factors, including PPE availability, staff training pre-redeployment, and provision of mental health support, are significantly associated with mental health during COVID-19. Governments, policy-makers and other stakeholders need to ensure provision of these to safeguard HCWs’ mental health, for future waves and other pandemics.

Background and Aims: Acute loss of smell or anosmia is a common and sometimes the only symptom observed in patients with coronavirus disease-2019 (COVID-19). The objective of the study was to determine the prevalence, time of onset, and duration of anosmia in patients with COVID-19 infection and the association of anosmia with other symptoms and eosinophil count. Material and Methods: Two hundred patients with laboratory-confirmed COVID-19 infection, who were asymptomatic or mildly symptomatic were assessed for olfaction with a nonirritant odor. The presence of anosmia was recorded, and a questionnaire integrating the anosmia reporting tool was filled. Patients with anosmia/hyposmia were followed telephonically at 7 and 14 days for resolution of anosmia and other symptoms. The presence of anosmia was correlated with eosinophil count. Results: Of the 200 COVID-19 patients, 87% were symptomatic. More than half of the patients had fever (56%). Anosmia was observed in 30% of the patients and hyposmia in 4% of patients. In 41% of the patients, olfactory loss was reported before diagnosis. The mean duration of anosmia was 7.8 (± 5) days; 97% of patients recovered with a resolution of symptoms within 2 weeks. Ageusia was the most commonly and significantly associated symptom with anosmia (66%, n = 45) followed by sore throat (41%), and rhinorrhea (28%). The symptoms in both the sexes were comparable. Absolute eosinophil count of

Fungal choroidal abscesses are rarely reported entities on routine retinopathy of prematurity screenings done on neonates. With the increasing use of broad-spectrum intravenous antibiotics on preterm neonates during their stay in neonatal intensive care unit who are already immunodeficient, we hereby bring this case into notice so as to keep fungal etiologies as a close differential in comparison to bacterial choroidal abscesses, the latter being more common in the older age group. The late diagnosis of fungal choroidal abscess and the lack of systemic treatment for the same could possibly lead to acquired hydrocephalus and other systemic complications.

Introduction: The popularity of robot-assisted surgeries has accelerated since its advent in 1990s. Recently, we procured da Vinci surgical system in our institution; and here, we present our initial experience of robot-assisted surgeries at our hospital. We also discuss the stepwise approach for successful implementation of the robotic surgical programme at our institute. Moreover, the importance of efficient use of this advanced but expensive technology has been highlighted. Materials and Methods: Retrospective analysis of the medical record of all the paediatric patients between the age ranges of 1–18 years who had undergone robotic-assisted laparoscopic surgery during April 2019–April 2019 was done. Medical record was reviewed for descriptive data, clinical presentation, investigations, operative details and follow-up. Statistical data were also obtained from medical superintendent office. Results: During April 2018–April 2019, total of 111 cases were operated across six specialities. Approximately 73% of cases (81/111) belonged to adult urology and gynaecology speciality. Less than 5% (5/111) of patients were in paediatric age group. The department of paediatric surgery performed one pyeloplasty, 3 ureteric reimplantation and 1 bladder diverticulum excision with robot assistance. The operative duration of the cases was comparable to the standard laparoscopic techniques. All patients are asymptomatic on follow-up visits. Conclusion: The robotic surgery is feasible in paediatric population and has favourable post-operative outcomes. Detailed planning and stepwise approach is key to the establishment of new robotic surgery programme in any institute.

Purpose: Ophthalmologists often need to use a compound microscope to see slides of corneal scrapings, Demodex blepharitis, histopathology, or tear ferning test for diagnostic purposes. While such a microscope may be available in tertiary care centers, most eye clinics do not have it due to cost, space required, and infrequent use. These tests are often not done or delayed till a tertiary referral is possible. We demonstrate an alternative method using smartphone and an inexpensive attachment. Materials and Methods: Using the smartphone microscope attachment, the authors were able to capture excellent photographs and videos of corneal scrapings, histopathology, and Demodex. Photographs of the same slides were taken with a standard compound microscope as well. Trypan blue dye was used for staining the corneal scraping specimens to make the fungal hyphae in it clearly visible. Results: Photographs and videos captured by the smartphone microscope were compared with those from a compound microscope and found to be of adequate quality. They were determined to be good enough for diagnostic use. Conclusions: We determined that smartphone microscope attachment can be a useful adjunctive diagnostic tool for eye clinics corneal scrapings, histopathology, and Demodex, perhaps even for more applications.

Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease with no approved treatments. C-C chemokine receptor types 2 and 5 (CCR2/CCR5) play an important role in inflammation and fibrosis and are potential therapeutic targets for PSC. We evaluated the efficacy and safety of cenicriviroc (CVC), a dual antagonist of CCR2 and CCR5, for the treatment of PSC. This was a single-arm, open-label, exploratory study of CVC in adults with a clinical diagnosis of PSC, serum alkaline phosphatase (ALP) ≥1.5 times the upper limit of normal (ULN), with or without inflammatory bowel disease, across eight sites in the United States and Canada. The primary endpoint was percent change in ALP over 24 weeks; key secondary efficacy endpoints were proportion of participants who achieved ALP normalization and overall response (decrease to

The surgical referral policies for patients with trigger finger, ganglion removal and Dupuytren’s disease were collected for all Clinical Commissioning Groups in England. The aim was to assess whether there was variation in the policies across England, resulting in inequality in patients’ access to surgery. Data were collected between October 2018 and January 2019 and compared with national guidelines. Analysis of the results showed that for all three conditions, surgical commissioning policies varied depending on the locality. The results also show that despite the existence of national guidelines, they are not implemented. This has the potential to lead to variation in surgical referral and access to services for patients in different localities in England. Level of evidence: III

This study endeavours to comprehensively the study the spectrum of ENT manifestations in mild and asymptomatic COVID-19 and observe the natural course of anosmia and dysgeusia consequent to SARS-Cov-2 infection. A prospective cohort study was undertaken at a tertiary care centre in India on admitted patients with RT-PCR proven COVID-19. Patients were included provided the baseline National Early Warning Score (NEWS) was less than 4. Patients were screened for ENT manifestations using a questionnaire at baseline, 7 days, 14 days and 28 days. 225 patients were included in the study. Of these complete data at 4 weeks was available for 210. Out of 145 patients with mild COVID-19 (asymptomatic = 80), ENT manifestations accounted for 66.2% of all symptoms. Smell and taste disturbance had an overall incidence of 20% and 45% of ENT manifestations. Temporal trends of the recovery rate of anosmia and dysgeusia were 53.6% and 66.7% at 2 weeks, respectively. Corresponding rates at 3 weeks were 89.29% and 86.7%, respectively. By the end of 4 weeks 96% of the patients had recovered completely. The incidence of anosmia and dysgeusia in this study parallels the rates reported from other Asian countries, albeit, lower than the rates quoted from the Western Hemisphere. We recommend structured reporting of all ENT manifestations especially smell and taste disturbances to accurately identify individuals infected with SARS-Cov-2.

Background/Aims In 2014, the Royal College of Surgeons expressed concern that a postcode lottery was determining the commissioning of procedures of limited clinical value. The research was carried out to assess whether there is variation in the clinical commissioning of hallux valgus surgery in England. Methods The commissioning policies for clinical commissioning groups were identified. Data were analysed to assess both adherence to the British Orthopaedic Association guidelines for surgery and the minimum criteria that a patient must fulfil for surgery. Results Variation was recorded in commissioning policies and in the number of criteria a patient must fulfil to be offered surgery. Conclusions There is currently no standardised national commissioning policy for hallux valgus surgery. Referral guidelines have been produced by leading national bodies but their implementation is varied. This can lead to variation in referral patterns in England for patients requiring hallux valgus surgery.

Background & Objective: Wireless communication technologies are continually growing in diverse areas, which are providing unexampled research opportunities in the areas of networking. One such speedily developing orbit is Wireless Sensor Networks. The ability of these networks to operate in human-inaccessible terrains and hazardous locations have attracted a lot of research for addressing various difficulties presented by these networks at different layers. Routing is a challenge due to the unpredictable topology of WSNs. Further, there exists a wide range of applications employing WSNs which operate in a hostile environment. The presence of a hostile environment literally means that the operating devices fail quite frequently and it is practically infeasible to repair them and replenish their energy resources. Further, many real-time applications of WSN do not tolerate any latency in the network. In general, designing an energy-efficient routing scheme that can tradeoff between different design metrics, like delay, is a crucial issue in WSNs. Due to a great deal of speculations and future prognoses regarding the Internet of Things, WSN design faces various design goals that often conflict with each other, such as short delay, high throughput, minimal energy consumption, and low cost. Network design for futuristic applications must consider many factors for achieving trade-offs among multiple objectives to achieve optimal performance for network. Methods: This paper proposes a routing protocol named Delay Aware and Lifetime Enhanced Sectoring (DALES) for joint optimization of lifetime and delay in a heterogeneous WSN. It alters the CH selection process by sectoring the WSN field, barring certain nodes from participating in clustering and selecting an optimal number of CHs by use of modified probability equations. Conclusion: Simulation results establish that proposed solution ameliorates in terms of network lifetime and delay as compared to other routing protocols.

The incidence of renal cell carcinoma (RCC) has increased over the years in the Western hemisphere. There are an estimated 56,000 cases of renal cancers which are diagnosed and 13,000 deaths which occur yearly in the United States. Up to 20–40% of patients may develop metastases after radical nephrectomy, and therefore monitoring with imaging for recurrent or metastatic disease is critical. Imaging varies with each specific suspected site of disease with CT/MRI of the abdomen and pelvis being the mainstay modalities, and osseous and central nervous system imaging is reserved for only symptomatic patients. Radiologic reporting is also evolving to reflect effects of systemic therapy on lesion morphology. For monitoring systemic treatment of metastatic lesions, some studies suggest imaging interpretation may be better tailored to cytostatic agents’ effects by addressing markers of vascularity rather than size criteria alone. In the future, nuclear medicine studies may compliment routine imaging as newer agents such as PSMA are evaluated for more accurate tumor staging. Imaging research continually aims to fill gaps in treatment selection and monitoring of treatment response in metastatic RCC.

Brain tumor detection from magnetic resonance (MR)images is a tedious task but vital for early prediction of the disease which until now is solely based on the experience of medical practitioners. Multilevel image segmentation is a computationally simple and efficient approach for segmenting brain MR images. Conventional image segmentation does not consider the spatial correlation of image pixels and lacks better post-filtering efficiency. This study presents a Renyi entropy-based multilevel image segmentation approach using a combination of differential evolution and whale optimization algorithms (DEWO) to detect brain tumors. Further, to validate the efficiency of the proposed hybrid algorithm, it is compared with some prominent metaheuristic algorithms in recent past using between-class variance and the Tsallis entropy functions. The proposed hybrid algorithm for image segmentation is able to achieve better results than all the other metaheuristic algorithms in every entropy-based segmentation performed on brain MR images.

Image fusion has emerged as a major area of research in the past few decades due to its extended applications. While progressing in the field of image fusion, a large number of techniques-based image transforms and spatial filters have been devised for both general and specific sets of images. The primary criterion of image fusion technique is to deliver high-quality visual perception besides giving a considerable objective evaluation rate. In this study, an information fusion rate-based study is done on recent, most researched, and high-performing state-of-the-art techniques using visible and infrared image datasets. These techniques have been chosen carefully, owing to their superiority in performance on both objective and subjective scales of evaluation and have been discussed in terms of their respective advantages and disadvantages. It is clearly evident that some rather primitive techniques can perform well as well as techniques based on a hybrid of various domains can significantly boost the information fusion rate.

In this paper, a double image encryption mechanism for iris template protection using 3D Lorenz chaotic system with modified equal modulus decomposition in the hybrid transform domain is proposed. ...

Given increasing demand for primary knee arthroplasties, revision surgery is also expected to increase, with periprosthetic joint infection (PJI) a main driver of costs. Recent data on national trends is lacking. We aimed to assess trends in PJI in total knee arthroplasty revisions and hospitalization costs. From the National Inpatient Sample (2003–2016), we extracted data on total knee arthroplasty revisions (n = 782,449). We assessed trends in PJI prevalence and (inflation-adjusted) hospitalization costs (total as well as per-day costs) for all revisions and stratified by hospital teaching status (rural/urban by teaching status), hospital bed size (≤299, 300–499, and ≥500 beds), and hospital region (Northeast, Midwest, South, and West). The Cochran–Armitage trend test (PJI prevalence) and linear regression determined significance of trends. PJI prevalence overall was 25.5% (n = 199,818) with a minor increasing trend: 25.3% (n = 7,828) in 2003 to 28.9% (n = 19,275) in 2016; p

Image fusion in neuro diagnosis is intimidating due to its complexity. The heterogeneous natures of the original brain images make intermodal transmission difficult during fusion. Medical image fusion using complementary modalities results in loss of vital salient information. Poor fusion, colour deficiencies result due to similar processing for both the modalities. A dual technique is proposed using discrete fractional wavelet transform (FRWT) and non-subsampled directional filter banks for better extraction of salient image elements for improved diagnosis. The sparsity character of the coefficients FRWT is controlled by optimising the parity operator using Grey Wolf optimisation algorithm. Four sets of neurological multimodal magnetic resonance imaging and single photon emission computed tomography (CT) brain images are used from benchmark database for validation. The objective evaluation has been conducted using five metrics. The main values obtained from objective metrics based on the proposed technique are 6.3213 for Shannon entropy, mutual information is computed to be 2.7582, fusion factor is 1.9095, standard deviation is 0.1310, and edge strength is 0.76122 indicating improved diagnostic information and superior image quality. Subjective evaluation by a medico validates the findings with finer visual output and enhanced contrast in comparison with recent and state-of-the-art methods.

This study evaluates the 6-month safety and efficacy of micropulse transscleral cyclophotocoagulation (MP-TSCPC) in cases of uncontrolled glaucoma/ocular hypertension using a reduced energy protocol. Retrospective analysis of patients undergoing MP-TSCPC from January–April 2018 was carried out. Patients received up to 90 s of laser with settings of 2000 mW/Cm2 and a duty cycle of 31.3%. A total of 29 patients were included, with a mean age of 64.7 ± 15.1 years. The most common diagnosis was primary open angle glaucoma (41.4%) with a mean Logmar visual acuity of 1.5 ± 1.2. All subjects had either undergone intraocular surgery (58.6% filtration surgery) or continuous wave diode laser prior to micropulse treatment. Mean pre-laser IOP was 26.2 ± 11.1 mmHg. There was a significant reduction (p

Background Despite improvements in techniques and management of liver transplant patients, numerous perioperative complications that contribute to perioperative mortality remain. Models to predict intraoperative massive blood transfusion, prolonged mechanical ventilation, or in-hospital mortality in liver transplant recipients have not been identified. In this study we aim to identify preoperative factors associated with the above mentioned complications. Methods A retrospective observational analysis was conducted on data collected from 124 orthotopic liver transplants performed at a single institution between 2014 and 2017. A multivariable logistic regression using backwards elimination was performed for three defined outcomes (massive transfusion ≥ 10 units packed red blood cells (PRBC), prolonged mechanical ventilation > 24 h, and in-hospital mortality) to identify associations with preoperative characteristics. Results Statistically significant (P < 0.05) associations with massive transfusion ≥ 10 units PRBC were hepatocellular carcinoma and preoperative transfusion of PRBC. Significant associations with prolonged mechanical ventilation > 24 h were hepatitis C, alcoholic hepatitis, elevated preoperative alanine aminotransferase, and hepatorenal syndrome. Male gender was protective for requiring prolonged mechanical ventilation. End-stage renal disease and hepatitis B were significantly associated with increased in-hospital mortality. Conclusions This study identified risk factors associated with common perioperative complications of liver transplantation. These factors may assist practitioners in risk stratification and may form the basis for further investigations of potential interventions to mitigate these risks.

BackgroundHypoxia in patients with COVID-19 is one of the strongest predictors of mortality. Silent hypoxia is characterized by the presence of hypoxia without dyspnea.. Silent hypoxia has been shown to affect the outcomes in previous studies.Research QuestionAre the outcomes in patients presenting with silent hypoxia different from those presenting with dyspneic hypoxia?Study design and MethodsThis was a retrospective study of a cohort of patients with SARS-CoV-2 infection who were hypoxic at presentation. Clinical, laboratory, and treatment parameters in patients with silent hypoxia and dyspneic hypoxia were compared. Multivariate logistic regression models were fitted to identify the factors predicting mortality.ResultsAmong 2080 patients with COVID-19 admitted to our hospital, 811 patients were hypoxic with SpO2P=0.202). The odds ratio of death was 1.1 (95% CI 0.41-2.97) in the patients with silent hypoxia after adjusting for baseline characteristics, laboratory parameters, treatment, and in-hospital complications, which did not reach statistical significance (P=0.851).InterpretationSilent hypoxia may be the only presenting feature of COVID-19. Since the case fatality rate is comparable between silent and dyspneic hypoxia, it should be recognized early and treated as aggressively. Since home isolation is recommended in patients with COVID-19, it is essential to use pulse oximetry at the home setting to identify these patients.

Existing methods for Table Structure Recognition (TSR) from camera-captured or scanned documents perform poorly on complex tables consisting of nested rows / columns, multi-line texts and missing cell data. This is because current data-driven methods work by simply training deep models on large volumes of data and fail to generalize when an unseen table structure is encountered. In this paper, we propose to train a deep network to capture the spatial associations between different word pairs present in the table image for unravelling the table structure. We present an end-to-end pipeline, named TSR-DSAW: TSR via Deep Spatial Association of Words, which outputs a digital representation of a table image in a structured format such as HTML. Given a table image as input, the proposed method begins with the detection of all the words present in the image using a text-detection network like CRAFT which is followed by the generation of word-pairs using dynamic programming. These word-pairs are highlighted in individual images and subsequently, fed into a DenseNet-121 classifier trained to capture spatial associations such as same-row, same-column, same-cell or none. Finally, we perform post-processing on the classifier output to generate the table structure in HTML format. We evaluate our TSR-DSAW pipeline on two public table-image datasets -- PubTabNet and ICDAR 2013, and demonstrate improvement over previous methods such as TableNet and DeepDeSRT., 6 pages, 1 figure, 1 table, ESANN 2021 proceedings, European Symposium on Artificial Neural Networks, Computational Intelligence and Machine Learning. Online event, 6-8 October 2021, i6doc.com publ., ISBN 978287587082-7

IEEE had many sensor activities in the 1990s, mostly in its technical societies, but the activities had no focus. For example, IEEE had no journal devoted to sensors. My main purpose in founding the IEEE Sensors Council was to create a sensor focus primarily through the creation of the IEEE Sensors Journal and the IEEE SENSORS Conference.

COVID-19 has resulted in restrictions on travelling and public get-togethers. Amid the pandemic, one of the industries to be the most severely affected is the hotel industry. In the post-covid period, the industry is struggling for its subsistence due to mounting debts, change in behavior and perception of consumers, and lack of cash flows. This has resulted in loss of employment and has also negatively impacted allied industries. However, hotel entrepreneurs have shown resilience amid the crisis and have begun to explore novel opportunities. Hotels have adopted innovative technological and digital ways to satisfy the needs of the consumers for a contactless experience. The objective of this chapter is to explore the responses of the Indian hotel industry to the pandemic and risks associated with it. It explores the new paradigm and challenges for the industry and explains the resultant new trends in the hotel industry. The emphasis is on the exploration of long-term recovery and resilience of the hotel industry in India along with the policy measures and implications for the hotel industry.

Recommender Systems (RS) tend to recommend more popular items instead of the relevant long-tail items. Mitigating such popularity bias is crucial to ensure that less popular but relevant items are part of the recommendation list shown to the user. In this work, we study the phenomenon of popularity bias in session-based RS (SRS) obtained via deep learning (DL) models. We observe that DL models trained on the historical user-item interactions in session logs (having long-tailed item-click distributions) tend to amplify popularity bias. To understand the source of this bias amplification, we consider potential sources of bias at two distinct stages in the modeling process: i. the data-generation stage (user-item interactions captured as session logs), ii. the DL model training stage. We highlight that the popularity of an item has a causal effect on i. user-item interactions via conformity bias, as well as ii. item ranking from DL models via biased training process due to class (target item) imbalance. While most existing approaches in literature address only one of these effects, we consider a comprehensive causal inference framework that identifies and mitigates the effects at both stages. Through extensive empirical evaluation on simulated and real-world datasets, we show that our approach improves upon several strong baselines from literature for popularity bias and long-tailed classification. Ablation studies show the advantage of our comprehensive causal analysis to identify and handle bias in data generation as well as training stages.

in this time, wind energy generation technology has been grown rapidly. With the corporation of Wind farms together with the help of the electrical grid, it is important for the system handler to know about the behavior and performance of the wind farm in all conditions. In a power system, there are many areas of interest such as wind speed calculation, modeling, control, and stability analysis of wind energy systems connected with the electric grid. In this research paper we reduce the harmonics in wind farm integration with the grid by using the UPFC method due to this we also increase system stability. In which we use a 20 MW wind farm connected to the grid and this all simulation is done by using MATLAB/SIMULINK.

Introduction Multidisciplinary foot care services contribute to the reduction in amputations from foot ulceration secondary to diabetes. The COVID-19 pandemic pressurised services and required a pause of elective care. This study reports the patient’s experience of foot care provision during the first wave where self-care, virtual appointments and patient directed appointments were utilised. Method Diabetic foot patients were retrospectively identified over a one-month period booked for MDT care (in hospital, OPD, diabetic foot clinic, community podiatry clinic or at home). All patients>16 years of age diagnosed with a new or previous diabetic foot ulcer or post-operative foot wound were included. Data was collated via a patient survey form and descriptive statistics were used to characterize the study population and responses. Results 63 patients were identified (1/10 – 30/10) with data collated from 51 respondents (81%). 78% (40/51) were male. Median age was 69 years (IQR 59–76). 86% were comfortable attending a hospital appointment. 92% reported continuing to receive an appropriate level of care. All of the patients felt well supported and knew how to access the foot care service. 29% utilised virtual care. 82% (42/51) considered face to face appointments were more suitable for follow up rather than virtual/phone appointments. Conclusions It was possible to continue to provide safe diabetic foot care despite the COVID-19 pandemic but careful patient selection and communication is the key.

Aim Higher Surgical training was decimated by the COVID-19 pandemic with cessation of elective care. Trainees raised concerns that the elective restart and need for higher theatre activity to clear backlogs would impact on training opportunities. This study evaluated the resumption of training associated with a ring-fenced elective centre (EC). Methods The EC was established in July 2020 and three time periods were determined: pre-COVID (10/19-2/20), 1st wave of COVID (3/20-7/20) and post EC go-live (8/20-12/20). Data was collated from the E-Logbooks of General Surgery Registrars. Results The normal all-speciality pre COVID theatre-activity averaged 1052 cases/month. During the first wave elective activity decreased to 254 cases/month (24% of normal activity). Within 5 weeks of establishment of the EC, theatre activity was near normal despite a reduced number of theatres (with higher theatre utilisation). Pre COVID, trainees accessed 22.9 cases per month which then dropped to 7.7 cases during the first wave of COVID. Post the go live of the EC, trainees were able to operate on 20 cases per month almost back to normal training levels. Prior to the impact of the second wave, each trainee had developed a deficit of 90 cases during the 5 months pause. Conclusion The ring-fenced elective centre has protected training opportunities for higher surgical trainees. However, the pause in training requires a targeted training recovery plan to overcome the deficit secondary to the first and subsequent waves of COVID to ensure that the JCST target of 1200 cases can be met for CCT.

Aim COVID had an unprecedented effect on the NHS elective surgical care. To overcome the deficit created due to the pandemic, the concept of a ‘COVID protected zone’ gave birth to the ‘hospital within the hospital’. This included 9 elective theatres, 28 ring fenced elective beds, a surgical enhanced care unit, a canteen and a separated entrance. Of the fundamentals of the model were enhanced infection control and PPE guidance for staff. The aim of our study was to evaluate the recovery of elective activity brought about by this elective centre. Methods Theatre activity data was collected weekly (7/20 to 1/21) through the business informatics system. This was used to compare the activity achieved during the recovery phase from COVID after the first and subsequent wave. Results Pre COVID-19, 11 theatres were operating. These managed an average of 263 cases were per week. In the first week of operation of elective centre, 31% of theatre capacity was achieved. By week 7, 106% of pre COVID was recorded and 130% by week 11. During the 2nd wave the capacity was reduced to 42% as opposed to 0% during the first wave. This was only possible due to our model elective centre. Conclusion This model elective centre has enabled elective care to return to above normal levels, with increased efficiencies. This has not only shortened patient waiting times and cleared the back-log but also delivered training to surgical trainees without compromising safety.

Introduction Elective care in the UK came to a standstill with the advent of the COVID-19 pandemic. A restart could only be enabled with ‘green site’ separation and a ‘covid protected’ zone. A ‘hospital within the hospital’ concept was developed including 9 elective theatres, 28 ring fenced elective beds, a surgical enhanced care unit, a canteen, and a separated entrance. This model was underpinned with PPE, enhanced infection control and guidance for staff. The study documented the ability to recover elective activity and therefore provide a training environment for surgical trainees. Method Data was collected weekly (7/20 to 1/21) through the business informatics system with regard to theatres cases completed compared to the activity achieved in the 11-theatre elective estate pre COVID-19. Results Pre COVID-19, an average of 263 cases were completed per week. In the first week of operation, 31% of theatre capacity was achieved. By week 7, 106% of pre COVID was recorded and 130% by week 11. This was maintained until the impact of the second wave where activity has reduced to 50% but is not anticipated to reduce further as local anaesthetic and blocks maybe utilised. Conclusions This ‘hospital within the hospital’ has enabled elective care to return to above normal levels, with increased efficiencies. This has enabled a rapid return to a training environment for trainees disheartened with deployment to critical care in the first wave.

PurposeAlthough unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse.MethodsIn this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and mortality records.ResultsForty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27–74) days. The median (range) time to hospital discharge was 53.5 (10–85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03).ConclusionIn patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.

Introduction The Royal College of Surgeons of England have committed themselves to championing diversity in surgery in light of recent socio-political events. Although there are now more trainees from underrepresented backgrounds entering the profession, this is not reflected in leadership roles which are key in establishing attitudes and cultures. This study evaluated whether an event showcasing surgeons from underrepresented groups holding leadership positions could improve student perceptions of diversity in surgical leadership. Method Participants attended an online event hosted by a student surgical society, where speakers with surgical leadership experience from a range of marginalised backgrounds highlighted topics of diversity and discrimination in surgery. Pre- and post-event questionnaires comprising Likert scales were completed to evaluate student perceptions of surgeons holding a leadership role from the following underrepresented groups: women (or gender non-conforming), BAME, LGBTQ+ and individuals with disabilities. Statistical significance was assessed using a Mann-Whitney U test with p Results The event significantly increased attendee confidence in the idea of a surgeon being seen in a leadership role from all underrepresented groups evaluated: 9.3% for female/gender non-conforming individuals (p Conclusions Attendees felt significantly more confident in the belief that surgeons from underrepresented backgrounds could hold leadership positions following the event, indicating the benefit of such role-modelling initiatives. More investment is necessary in exploring factors dissuading specific underrepresented groups from pursuing surgical careers and for novel strategies to support these communities accordingly.

BackgroundDue to the unprecedented speed of SARS-CoV-2 vaccine development, their efficacy trials and issuance of emergency use approvals and marketing authorizations, additional scientific questions remain that need to be answered regarding vaccine effectiveness, vaccination regimens and the need for booster doses. While long-term studies on the correlates of protection, vaccine effectiveness, and enhanced surveillance are awaited, studies on breakthrough infections help us understand the nature and course of this illness among vaccinated individuals and guide in public health preparedness.MethodsThis observational cohort study aimed at comparing the differences in clinical, biochemical parameters and the hospitalization outcomes of 53 fully vaccinated individuals with those of unvaccinated (1,464) and partially vaccinated (231) individuals, among a cohort of 2,080 individuals hospitalized with SARS-CoV-2 infection.ResultsCompleting the course of vaccination protected individuals from developing severe COVID-19 as evidence by lower proportions of those with hypoxia, abnormal levels of inflammatory markers, requiring ventilatory support and death compared to unvaccinated and partially vaccinated individuals. There were no differences in these outcomes among patients who received either vaccine type approved in India.ConclusionWith a current rate of only 9.5% of the Indian population being fully vaccinated, efforts should be made to improve the vaccination rates as a timely measure to prepare for the upcoming waves of this highly transmissible pandemic. Vaccination rates of the communities may also guide in the planning of the health needs and appropriate use of medical resources.Research in contextEvidence before this studyThe Government of India started vaccinating its citizens from the 16thof January 2021, after emergency use authorization had been received for the use of two vaccines, BBV152, a COVID-19 vaccine based on the whole-virion SARS-CoV-2 vaccine strain NIV-2020-770, (Covaxin) and the recombinant replication-deficient chimpanzee adenovirus vector encoding the spike protein ChAdOx1 nCoV-19 Corona Virus Vaccine (Covishield). These have been approved by the Indian regulatory authority based on randomized controlled studies. In these studies, was found that the vaccines led to more than 90% reduction in symptomatic COVID-19 disease. However, there is scarce evidence of the efficacy of these vaccines in real-world scenarios. A few studies have looked at vaccinated cohorts such as health care workers in whom the vaccines had an efficacy similar to the RCTs. In a study of patients with SARS-CoV-2 infection admitted to a tertiary care hospital in New Delhi, it was found that mortality in fully vaccinated patients was 12.5% as compared to 31.5% in the unvaccinated cohort.Added-value of this studyThis cohort of hospitalized patients with SARS-CoV-2 infection was studied during the peak of the second wave of COVID-19 in India during which the delta variant of concern was the predominant infecting strain and had 26% patients who were partially vaccinated and 71.4% who were unvaccinated. Only 3% of the patients were fully vaccinated and developed a breakthrough infection. At the time of presentation, 13% of the individuals with breakthrough infection and 48·5% in the non-vaccinated group were hypoxic. Inflammatory markers were significantly lower in the completely vaccinated patients with breakthrough infection. The need for use of steroids and anti-viral agents such as remdesivir was also significantly low in the breakthrough infection group. A significantly less proportion of the individuals with breakthrough infection required oxygen supplementation or ventilatory support. Very few deteriorated or progressed to critical illness during their hospital stay. Only 3 individuals (5.7%) out of the 53 who developed breakthrough infection succumbed to illness while case fatality rates were significantly higher in the unvaccinated (22.8%) and partially vaccinated (19.5%) groups. Propensity score weighted multivariate logistic regression analysis revealed lower odds of developing hypoxia, critical illness or death in those who were completely vaccinated.Implications of all the available evidenceThe real-world effectiveness of the vaccines against SARS-CoV-2 seems to be similar to the randomized controlled trials. The vaccines are very effective in reducing the incidence of severe COVID-19, hypoxia, critical illness and death. The reduced need for oxygen supplementation, mechanical ventilation and the requirement of corticosteroids or other expensive medications such as anti-viral drugs could go a long way in redistributing scarce health care resources. All nations must move forward and vaccinate the citizens, as the current evidence suggests that ‘prevention is better than cure’.

BackgroundThe second wave of the COVID-19 pandemic hit India from early April 2021 to June 2021 and more than 400,000 cases per day were reported in the country. We describe the clinical features, demography, treatment trends, baseline laboratory parameters of a cohort of patients admitted at the All India Institute of Medical Sciences, New Delhi with SARS-CoV-2 infection and their association with the outcome.MethodsThis was a retrospective cohort study describing the clinical, laboratory and treatment patterns of consecutive patients admitted with SARS-CoV-2 infection. Multivariate logistic regression models were fitted to identify the clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay and death.FindingsA total of 2080 patients were included in the study. The case fatality rate was 19.5%. Amongst the survivors, the median duration of hospital stay was 8 (5-11) days. Out of 853 (42.3%%) of patients who had COVID-19 Acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged 45-60 years [OR (95% CI): 1.8 (1.2-2.6)p =0.003] and those aged >60 years [OR (95%CI): 3.4 (2.3-5.2), p500 mg/dL [OR (95% CI): 3.2 (2.2-4.6), p 0.5 mg/L [OR (95% CI): 3.8 (1.1-13), p=0.037] had higher odds of death. Patients who were admitted in the second week had lower odds of death and those admitted in the third week had higher odds of death.InterpretationThis is the largest cohort of patients admitted with COVID-19 from India reported to date and has shown that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Strategies should be made to improve vaccination rates and early admission of patients with moderate and severe COVID-19 to improve outcomes.Research in contextEvidence before this studyThe COVID-19 pandemic has been ravaging the world since December 2019 and the cases in various regions are being reported in waves. We found that the case fatality rates ranging from 1.4% to 28.3% have been reported in the first wave in India. Older age and the presence of comorbidities are known predictors of mortality. There are no reports regarding the effectiveness of vaccination, correlation of mortality with the timing of admission to the health care facility and inflammatory markers in the ‘second wave’ of the COVID-19 pandemic in India.Added-value of this studyThis study reports the real-world situation where patients get admitted at varying time points of their illness due to the mismatch between the availability of hospital beds and the rising number of COVID-19 patients during the pandemic. It reports the odds of developing severe hypoxia necessitating oxygen therapy and death thus helping identify priority groups for admission.Implications of all the available evidenceThis study found increased odds of requiring oxygen support or death in patients older than 45 years of age, with comorbidities, and those who had hyper-inflammation with raised C-reactive peptide, d-dimer or leukocytosis. Patients who were admitted in the second week of illness had lower odds of death as compared to those admitted in the third week implying that treatment with corticosteroids in the second week of the illness during the ‘inflammatory phase’ could lead to reduced mortality. These findings would help triage patients and provide guidance for developing admission policy during times where hospital beds are scarce. Vaccination was found to reduce the odds of deterioration or death and should be fast-tracked to prevent further ‘waves’ of the pandemic.

Purpose: This work aims to determine whether patient satisfaction with oral sedation is noninferior to intravenous (IV) sedation in vitrectomy surgery. Methods: This prospective, randomized, double-masked, noninferiority clinical trial measured patient satisfaction in 84 participants receiving oral or IV sedation during vitrectomy surgery under monitored anesthesia care. Patients were excluded if they were unable to receive benzodiazepines. Results: The primary outcome was patient satisfaction. Secondary outcomes included surgeon and anesthesia provider satisfaction, need for supplemental anesthesia, and surgical complications. Among the 84 patients (46 [54.8%] men; mean [SD] age, 57.0 [12.7 years]), mean patient satisfaction scores were 5.22 ± 0.81 (range, 3.08-6; scale 1-6) with oral and 5.25 ± 0.63 (range, 3.83-6; scale 1-6) with IV sedation. With an a priori noninferiority margin of 0.5 and a difference in mean scores between the groups of 0.03 (1-tailed 95% CI, infinity to 0.29), our results demonstrated the noninferiority of oral sedation ( P = .002). There were no significant differences in surgeon or anesthesia satisfaction or major intraoperative complications. Five patients receiving oral (11.9%) and 3 receiving IV (7.1%) sedation required supplemental IV sedation (difference, 4.8%; P = .46). Conclusions: Patient satisfaction for oral sedation was noninferior to IV sedation for vitrectomy surgery.

Introduction Duodenal obstruction due to annular pancreas is a rare entity. Among the causes of neonatal obstruction described by Robert Gross, annular pancreas comprises less than 1% of total group (Gross and Chisholm, 1944) [ 1 ]. Herewith, we present a case of annular pancreas causing duodenal obstruction in a neonate for which we performed laparoscopic duodeno-jejunostomy and placed a trans anastomotic naso-jejunal feeding tube. Technique description A 2-day old neonate presented with complaints of bilious vomiting since birth. Clinical findings and radiological imaging were suggestive of duodenal obstruction. The patient was planned for diagnostic laparoscopy. Intraoperatively, a large annular pancreas was noted to obstruct the second part of duodenum. Duodeno-jejunal anastomosis was performed using polydioxanone 5-0 in a single layer. After completion of the posterior layer, a 6Fr infant feeding tube was placed trans anastomotic reaching mid jejunum. The patient tolerated the procedure well and feeds were started on POD 2 via the naso-jejunal trans-anastomotic tube. Conclusion Laparoscopic duodeno-jejunostomy with the placement of a trans-anastomotic tube is beneficial for the patient as feeds can be started within 48 hours or even earlier. Moreover, laparoscopic approach increases precision in dissection due to greater magnification, decreases overall morbidity and improves cosmesis. Laparoscopic duodeno-jejunostomy, though technically challenging, is feasible in the neonatal age group.