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Arteriovenous malformation (AVM) of the head and neck, though rare, can present significant clinical challenges, particularly during dental procedures. This case report details the acute management of a 7-year-old girl with an AVM in the right mandible, with sudden, severe, torrential intraoral hemorrhage during an angioembolization procedure, necessitating immediate airway management and hemodynamic stabilization in a nonoperating room anesthesia (NORA) setting. Persistent bleeding led to a multidisciplinary intervention, including external carotid artery ligation and right hemimandibulectomy, achieving hemostasis. The case underscores the importance of meticulous planning, readiness with resuscitation and airway management equipment, and coordinated efforts among anesthesia and surgical teams in NORA settings to manage such critical situations effectively.

Background and Aims: Pneumoperitoneum creation for laparoscopic surgery increases the intraabdominal pressure and causes alveolar atelectasis. We investigated the influence of an increase in intra-abdominal pressure (IAP) on ventilatory mechanical power (MP) delivery during pneumoperitoneum creation for laparoscopic cholecystectomy. Material and Methods: In a prospective cohort design, we enrolled 42 patients undergoing laparoscopic cholecystectomy. During pneumoperitoneum creation, the IAP was sequentially raised to three predefined IAP levels (8, 11 and 14 mmHg), keeping identical ventilatory settings (timepoints T1, T2, and T3). After that, positive end-expiratory pressure (PEEP) was sequentially raised from 5 to 8 to 11 cmH2O (timepoint T4 and T5). The primary outcome included ventilatory MP delivery at each timepoint. Other variables included respiratory driving pressure (DP), airway resistance (AR), and respiratory compliance (RC). Results: The MP increased linearly with a rise in IAP from T1 to T3 (r = 0.71, P < 0.001); the MP increased by 0.19 per unit rise in IAP (effect size 0.90, P < 0.001). A similar positive correlation was also observed between DP and IAP from T1 to T3 (r = 0.73, P < 0.001); the DP increased by 0.72 per unit rise in IAP (effect size 0.89, P < 0.001). The MP increased significantly on increasing PEEP from T3 to T5, while the DP decreased concomitantly (P < 0.001). The AR increased significantly from T1 to T3, while RC decreased concomitantly; vice-versa was observed at T4 and T5 (P < 0.001). Conclusions: The ventilatory MP delivery rises linearly with an increase in IAP. Targeting an IAP-guided MP level could be an attractive approach to minimize lung injury.

This research presents the results of a fin heat transfer study of three different models of the motorcycle engine. The objective of this study is to minimize the external body temperature because the optimum design will be found when the heat transfer rate is maximized. The study obtains the procurement of a balance between the outer boundary temperature due to convective heat transfer and air-cooled fin design. Heat transfer coefficient varies according to wind velocity (Km/hr) and Nusselt Number. The analysis was performed on three different engine models, named A, B and C. The optimum design was design B through simulation which has lower temperature gain, lower deformation and lower normal stress. DOE (Design of Experiments) was performed on the optimum design of the engine among all with three parameters thickness of fin, size of fin, and shape of fin, and again analysis was performed according to DOE cases. The material used for manufacturing the models was aluminum alloy 6061 which has a thermal conductivity of 200 W/mK. The study was performed on the designed models by taking the outer boundary temperature of 750oC. The heat transfer coefficient was about 77.28 W/m2K at 40 Km/h velocity.

Aim: With only limited treatment options in acute spinal cord injury (SCI) currently available, we aimed to investigate the effect of progesterone on neurological recovery after acute SCI. Material and Methods: Randomised double-blind placebo-controlled single-centre trial on 128 patients of acute SCI (within 24 hours of injury) was conducted at our institute with the approval of the ethics committee. Eligible patients were allocated to the progesterone or placebo arm. Of 133 eligible patients, one from the placebo arm expired in the acute phase while 4 were lost to follow-up, leaving 128 patients in the study.68 patients remained in the progesterone arm and 60 in placebo. Patients in the progesterone arm received intramuscular progesterone while those in the placebo received intramuscular isotonic saline twice daily for five consecutive days. Neurological assessment was done at baseline, day six, first and sixth months using the American Spinal Injury Association (ASIA) score and motor and sensory actual neural recovery (ANR) scores. Results: Baseline characteristics were comparable between the groups. At the end of six months, significant improvement occurred in motor and sensory ASIA scores in the progesterone arm (p=

Background: Endodontic treatment involves the removal of infected dental pulp and subsequent disinfection of the root canal system. The effectiveness of drug delivery systems in root canal disinfection is critical for successful treatment outcomes. This in vitro study explores the potential of nanoparticles as a novel drug delivery system for endodontic treatment. Materials and Methods: Nanoparticles were synthesized using a biocompatible polymer and loaded with an antimicrobial agent. A total of 60 extracted human teeth were prepared to create standardized root canal infections. The teeth were randomly divided into three experimental groups: (1) conventional irrigation, (2) nanoparticle irrigation, and (3) control (no irrigation). The root canals in each group were irrigated with their respective solutions for 5 minutes. After treatment, microbial samples were collected from the root canals and cultured for colony-forming unit (CFU) analysis. The depth of penetration of nanoparticles into dentinal tubules was assessed using scanning electron microscopy (SEM). Results: The conventional irrigation group showed a reduction in microbial load from an average of 7.8 × 10^5 CFU/mL (SD ± 1.2 × 10^5) to 3.4 × 10^4 CFU/mL (SD ± 7.9 × 10^3) (P < 0.001). In contrast, the nanoparticle irrigation group exhibited a more significant reduction, with a decrease in CFU to 1.2 × 10^3 CFU/mL (SD ± 4.2 × 10^2) (P < 0.001). SEM analysis revealed deep penetration of nanoparticles into dentinal tubules, reaching an average depth of 150 μm. Conclusion: Nanoparticles loaded with antimicrobial agents demonstrated superior efficacy in reducing microbial load within root canals compared to conventional irrigation. Their ability to penetrate dentinal tubules suggests their potential as an innovative drug delivery system for endodontic treatment. Further research and clinical trials are warranted to validate these promising in vitro results and assess the safety and efficacy of nanoparticles in clinical practice.

Objective:Preoperative oral rehydration solution (ORS) supplementation offers wide postoperative benefits, but its role in reducing post-spinal myocardial ischaemia is uncertain. We evaluated this aspect in elective lower limb orthopaedic surgeries and compared it to conventional preoperative fasting.Methods:Prospectively, we randomised 126 patients aged >60 years into two groups: (A) received reconstituted ORS (1000 mL) during the overnight preoperative fasting, continued up to 2 hrs prior to spinal anaesthesia (SA) induction; (B) kept on conventional overnight preoperative fasting. This study evaluated electrocardiographic ischaemic changes at 2, 5, 10, 15, and 30 minutes after SA induction.Results:In total, 27 patients (group A: 7; group B: 20) developed transient electrocardiographic ischaemic changes. On intergroup comparison, group B had a significantly higher incidence at all time points, with highest statistical levels at 5- and 10-minutes ((P < 0.001). The receiver operating characteristic curve at a threshold fasting duration (fluids) of >3 hours, had an area-under-curve of 0.74 to predict such changes within 30 minutes of SA induction (sensitivity 96.30%, specificity 55.56%, accuracy 64.29%, odds ratio 32.50, relative risk 20.80, (P < 0.001). Post-spinal hemodynamic changes were higher in group B than in A; hypotension and tachycardia were statistically significant ((P=0.020). The pleth variability index was significantly higher ((P < 0.001), while perfusion index was significantly lower (P < 0.001) in group B at all time points.Conclusion:Preoperative ORS supplementation significantly reduced post-spinal transient ischaemic electrocardiographic changes in elderly patients than conventional overnight fasting.

Introduction: Neonatal hyperbilirubinemia is a common physiological finding in neonates but sometimes Urinary Tract Infections (UTI) can occur in these neonates and it can be asymptomatic or may lead to complications. Many causative factors are listed out for development of neonatal jaundice but the UTI is less mentioned in previous studies. Aim: To study the prevalence of UTI and its clinical features in the neonates with hyperbilirubinemia. Materials and Methods: This cross-sectional study was conducted in Aakash Healthcare super specialty Hospital, Dwarka, New Delhi, India, between June 2019 and May 2020. Total 116 infants with neonatal hyperbilirubinemia were included in the study. The demographic features including date and time of admission, age at presentation of jaundice, mode of parturition, type of assistance for delivery (if any used), presence of cephalohaematoma, bruising or caput succedaneum, weight at birth, age at onset of jaundice (days of life), baby’s and mother’s blood group, any metabolic diseases in mother and father etc. were studied. A thorough haematological work-up was done and urine was collected in a sterile container by catheterisation. All samples were sent to the laboratory for microscopic analysis and culture. Data was statistically analysed using Mann-Whitney U-test and level of significant p-value was considered as less than 0.05. Results: A total of 116 cases of neonatal hyperbilirubinemia were included in this study. Out of the 116 cases, 66 cases (56.89%) were male neonates and infants and 50 cases (43.11%) were female neonates and infants. In this study, out of 116 neonates with hyperbilirubinemia, only 20 babies showed pus cells >5 //hpf (high power field microscope) (suggesting UTI), out of the 20 babies, 08 babies showed culture negative and pus cells >5 /hpf and remaining 12 babies showed culture positive and pus cells >5 /hpf. Out of 12 cases of culture and sensitivity, 8 cases showed culture for Escherichia coli (E.coli) and remaining four cases, organism cultured was Klebsiella pneumonia. Conclusion: Hyperbilirubinemia may be the initial sign of UTI in neonates; it may be asymptomatic in jaundiced newborns. It is recommended that, evaluation of UTI should be made in cases of asymptomatic hyperbilirubinemia cases which helps the paediatrician for early detection and treatment of these affected newborns reducing the hospital stay and long term complications.

Background Baseline diaphragmatic dysfunction (DD) at the initiation of non-invasive ventilation (NIV) correlates positively with subsequent intubation. We investigated the utility of DD detected 2 hours after NIV initiation in estimating NIV failure in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients. Methods In a prospective-cohort design, we enrolled 60 consecutive patients with AECOPD initiated on NIV at intensive care unit admission, and NIV failure events were noted. The DD was assessed at baseline (T1 timepoint) and 2 hours after initiating NIV (T2 timepoint). We defined DD as ultrasound-assessed change in diaphragmatic thickness (ΔTDI)

Atrial septal defects (ASDs) measuring

Hepatocellular carcinoma (HCC) is primary hepatic malignancy with a high incidence of recurrence. The risk of recurrence directly correlates to patient’s overall prognosis. Management of advanced HCC involves a combination of surgical resection, locoregional therapy, and systemic treatment. Distant metastases are rare, and intraventricular cardiac metastases are even more infrequent. This brief review details an illustrative case of cardiac metastasis after curative treatment of primary HCC and then summarizes the literature on risk factors, treatment options, and patient prognosis in the setting of distant metastases from HCC. Prognosis of metastasis to the heart is generally poor, and available evidence emphasizes the importance of maintaining regular posttreatment screening for metastases in patients with HCC. Given the variable presentation and high risk of recurrence, it is critical to have individualized multimodality treatment plans.

Background/Purpose: This research aimed to compare the effects of systemically prescribed Lycopene as a monotherapy and as an alternative to scaling and root planing in patients with chronic gingivitis. Materials and methods: The participants were randomly assigned to one of two treatment groups: the experimental group (n = 50), which received 10 mg of Lycopene a day for two weeks, or the control group (n = 50) received a placebo for two weeks. For each category, quadrant distribution was randomized, with two quadrants receiving oral prophylaxis (OP) and two quadrants receiving no care (non-OP). At baseline, 1st, and 2nd weeks, the sulcus bleeding index, plaque index, gingival index, and salivary uric acid level were measured. Results: All clinical criteria, including SBI, PI, GI, and salivary uric acid levels, showed a statistically significant decline in all patient types. Both clinical parameters were significantly reduced (p

Acute ruptured sinus of Valsalva aneurysm may present with chest pain and rapidly worsening dyspnea. A 41-year-old male without known atherosclerotic risk factors presented with ST-segment elevation in leads aVR and V1 on electrocardiogram and elevated cardiac troponins and was diagnosed as acute coronary syndrome. After antiplatelet loading, statin, and heparin, he was referred due to worsening hypotension and tachycardia. Clinical examination and echocardiogram was challenging in the acutely dyspneic restless patient. Transesophageal echocardiography delineated the ruptured aneurysm and assisted in its management. Importance of physical examination and echocardiography in the emergency room is highlighted as manifestations may be varied.

In tobacco use disorders (TUDs), technology-based training of health-care professionals can reduce the treatment gap and bring attitudinal change. The study aimed to assess the practices and determine the change in knowledge and attitude among health-care professionals following an online training program (OTP). Half-day OTP on tobacco cessation using prepost quasi-experimental study design with a structured questionnaire-based assessment was conducted. Among 293 completed surveys, knowledge post-OTP was higher but insignificant (P = 1.2). Post-OTP, participants felt less angry and disappointed toward tobacco users (mean of difference (MOD) =0.21, P = 0.0007); more sympathetic and concerned (MOD = −0.22, P = 0.0005); and acknowledged tobacco users deserve the same medical care as nonusers (MOD = −0.177, P = 0.001). Post-OTP scores in attitudes did not change significantly for the responsibility domain (P < 0.05). In practice, relatively greater number of health-care professionals asked about tobacco use and advised cessation, however lesser assessed, assisted, and referred. To conclude, technology-based training program can result in attitudinal changes toward tobacco users.

Background: Proton pump inhibitors (PPIs) are widely prescribed and may be associated with harm; hypomagnesemia and reduced effectiveness of calcium carbonate phosphate binders may be important in end-stage kidney disease (ESKD). Objectives: Our objectives included (1) discontinuing PPIs and H2 blockers and (2) assessing the impact on serum magnesium and markers of mineral metabolism. Design: Prospective cohort. Setting: Satellite hemodialysis unit of a tertiary care hospital. Patients: Incident and prevalent patients with ESKD treated with hemodialysis. Measurements: We assessed the impact of stopping PPI/H2 blockers in patients who did not have an absolute indication as per guidelines in the general population; serum magnesium, calcium, and phosphate were measured before and approximately 8 weeks later. Analysis of variance (ANOVA) test and Kruskal-Wallis was used to describe the population. Wilcoxon signed rank test for the paired change scores (from pre to post) Methods: The electronic medical record (EMR) was extensively searched for absolute indications for a PPI. Results were reviewed with the primary nephrology team before approaching patients about stopping the PPI. Basic demographic information and select medications were also collected. Results: Electronic medical records were reviewed for 179 patients, 74 had a PPI or H2 antagonist or both on their medication list (43%); 23 (31%) were assessed as appropriate. After primary team and patient review, 29 patients agreed to a trial of PPI withdrawal. Fourteen patients restarted their PPI, most for gastroesophageal reflux disease. Three patients had a GI bleed, 1 fatally. Serum calcium ( P = .17) and the dose of phosphate binders ( P = .075) did not change but serum phosphate increased (1.55 [0.29] to 1.85 [0.34] mmol/L; P = .0005). Serum magnesium also increased (1.01 [0.16] to 1.06 [0.14] mmol/L; P = .01). Limitations: Small patient numbers and observational nature of the study does not establish causation in this population at high risk to experience a gastrointestinal bleed. Conclusions: Our results suggest that PPI deprescribing as recommended in the general population may be associated with harm in patients with ESKD and requires further study. Trial Registration: Not registered.

Background Predicting difficult intubation (DI) is a key challenge, as no single clinical predictor is sufficiently valid to predict the outcome. We evaluated the effectiveness of four upper airway ultrasonographic parameters in predicting DI. The validity of the models using combinations of ultrasonography-based parameters was also investigated. Methods This prospective, observational, double-blinded cohort trial enrolled 1,043 surgical patients classified as American Society of Anesthesiologists physical status I–III without anticipated difficult airway. Preoperatively, their tongue thickness (TT), invisibility of hyoid bone (VH), and anterior neck soft tissue thickness from the skin to thyrohyoid membrane (ST) and hyoid bone (SH) were measured by sublingual and submandibular ultrasonography. The logistic regression, Youden index, and receiver operator characteristic analysis results were reported. Results Overall, 58 (5.6%) patients were classified as DI. The TT, SH, ST, and VH had accuracies of 78.4%, 85.0%, 84.7%, and 84.9%, respectively. The optimal values of TT, SH, and ST for predicting DI were > 5.8 cm (sensitivity: 84.5%, specificity: 78.1%, AUC: 0.880), > 1.4 cm (sensitivity: 81%, specificity: 85.2%, AUC: 0.898) and > 2.4 cm (sensitivity: 75.9%, specificity: 85.2%, AUC: 0.885) respectively. VH had a sensitivity and specificity of 72.4% and 85.6% (AUC: 0.790). The AUC values of the five models (with combinations of three or four parameters) ranged from 0.975–0.992. ST and VH had a significant impact on the individual models. Conclusions SH had the best accuracy. Individual parameters showed limited validity. The model including all four parameters offered the best diagnostic value.

Background Due to the risk of viral transmission during in-person training, a shift toward online platforms is imperative in the current pandemic. Therefore, we compared the effectiveness of an in-person interactive course with a structurally similar online course designed to improve cognitive skills among clinical health professionals in arterial blood gas analysis, management of electrolyte imbalances, and approaches to mechanical ventilation in critically ill patients. Methods In an observational, outcome assessor-blinded, cohort trial, group A included participants enrolled prospectively in an online course, while group B included those who took part in an in-person course (retrospective arm). The primary objective was comparison of cognitive skills through a pre and post-test questionnaire. Statistical analysis was performed using Student t-test. Results In total, 435 participants were analyzed in group A, while 99 participants were evaluated in group B. The mean pre-test score was 9.48±2.75 and 10.76±2.42, while the mean post-test score was 11.94±1.90 (passing rate, 64.6%) and 12.53±1.63 (passing rate, 73.3%) in groups A and B, respectively. Group B scored significantly higher in both pre-test (P=0.001) and post-test evaluations (P=0.004). The improvement in post-test score was significantly greater (P=0.001) in group A (2.46±2.22) compared to group B (1.77±1.76). The medical specialties fared better in group B, while surgical specialties scored higher in group A. The pre-test vs. post-test scores exhibited a moderate correlation in both groups (P3.5 for most points in both groups. Conclusions The online teaching module exhibited a significant benefit in terms of participant sensitization and knowledge sharing.

Objectives: The objective is to determine utility of SAPS II, APACHE II, SAPS III, and APACHE IV scoring system in assessing outcome in mechanically ventilated patients in respiratory intensive care unit and to predict duration of mechanical ventilation (MV). Materials and Methods: A prospective observational study where 83 mechanically ventilated patients were grouped into Group 1 (n1 = 40, NIV) and Group 2 (n2 = 43, Invasive ventilation) was conducted. SAPS II, APACHE II, SAPS III, and APACHE IV scores based predicted mortality (PM) were collected at day 1, and day 3. Outcomes (on day 7) were grouped into negative and positive. (NIV-negative outcome = Home NIV, intubation or death; positive outcome = NIV free. Invasive group-positive outcome = Extubation; negative outcome = Death). Binary logistic regression was applied to predict duration of MV (> or < 5 days). Results: The data were analyzed using SPSS version 17.0 trials comparisons of PM on day 1 with SAPS II (P < 0.05) and APACHE IV (P < 0.007) were significant predictors of clinical outcomes in Group 1 where as in Group 2, none of the system could predict significantly. On day 3, Group 1 analysis revealed SAPS II (P < 0.002), SAPS III (P < 0.03), and APACHE IV (P < 0.004) based PM as significant predictors of outcome. APACHE II (P < 0.05) and APACHE IV (P < 0.02) PM were significant in Group 2. On day 3, APACHE IV could significantly predict (P < 0.05) duration of MV (>5 or < 5) while A-a gradient (P < 0.09) predicted poorly in Group 1. In Group 2, APACHE IV was a poor predictor (P < 0.09). Two full logistic regression models were also formulated for both the groups. Conclusion: Study concludes that day 3 severity scores are more significant predictors of outcome and duration. APACHE IV scoring system was found more effective than other systems, not only significantly differentiating outcomes of MV but also predicting duration of NIV.

Despite rapidly evolving health-care systems, India continues to have a high disease burden for asthma and chronic obstructive pulmonary disease (COPD). The Asia-Pacific Asthma Insights and Management survey clearly revealed that asthma management remains very poor with worst clinical outcomes in India. Potent inhaled corticosteroids (ICS) and quick onset of long-acting beta2-agonist (LABA) are considered to be optimal dual therapy for management of asthma and COPD. Fluticasone's long-term action against inflammation and formoterol's rapid long-term bronchodilator action are vital clinical attributes for optimal asthma maintenance treatment. In an 8- and 12-week trial, dual therapy of fluticasone and formoterol (FF) reported lung function improvements and better control of asthma than its monotherapy. A large clinical study revealed mild adverse events of dual FF than other dual ICS-LABA combinations. Recent pooled analysis of asthma showed that fluticasone shares a lower risk of pneumonia in asthma. Dual ICS-LABA therapies are preferred in COPD individuals with history of exacerbations. Numerous clinical studies showed significant efficacy, dose adjustments/switching, and safety outcomes with dual FF therapy in asthma and COPD. Dual FF inhaler therapy ensures highly potent anti-inflammatory activity and sustained bronchodilation, thus making this a preferred combination in terms of efficacy, safety, and patient adherence in asthma and COPD. This present review focuses on the combination therapy of formoterol and fluticasone for managing asthma and COPD.

The first case of relapsing polychondritis (RP) was described in 1923, and yet it remains a “medical mystery”, a much “overlooked” entity. It is an uncommon systemic disorder causing inflammation of cartilage affecting ear, nose, laryngotracheobronchial tree, eyes, joints, heart, blood vessels, kidney, and skin. Being a rheumatological entity presenting with ear and joint involvement most frequently, these patients land up in Otolaryngology and Rheumatology clinics mostly, though tracheobronchial involvement is among the most serious manifestation causing substantial morbidity and mortality. Herein, we report a case of RP and discuss available diagnostic techniques and airway interventions under the ambit of a pulmonologist, as airway involvement severely limits its prognosis.

Background: Enterococcus faecalis is the most common and important microorganism found in infected root canals associated with persistent periapical periodontitis and failing endodontically treated tooth. Intracanal medicaments used after chemomechanical preparation of an infected root canal play a vital in eradication of this microorganism and pave the way for long-term success of endodontic therapy. Hence, the present in vitro study was conducted to assess the antimicrobial efficacy of calcium hydroxide (Ca(OH)2), triple antibiotic paste (metronidazole 400 mg + minocycline 100 mg + ciprofloxacin 500 mg), and 2% chlorhexidine (CHX) combined with 0.5% cetrimide on eradication of E. faecalis biofilm. Materials and Methods: Eighty dentin specimens were taken and infected extraorally with E. faecalis to induce microbial colonization. The specimens were then divided into four groups of twenty each based on medicaments used and further subdivided into two subgroups based on assessment of live cells done either immediately after the elimination of the medicament or after 24-h incubation in brain–heart infusion (BHI) medium: Group I specimens were treated with Ca(OH)2, Group II with triple antibiotic paste, Group III with 2% CHX combined with 0.5% cetrimide, and Group IV with saline (control) for 7 days at 37°C. Assessment of live cells was done using confocal microscope. Results: 2% CHX combined with 0.5% cetrimide (Group III) and triple antibiotic paste (Group II) showed a statistically significant result with high antimicrobial efficacy and lower percentage of live cells as compared to Ca(OH)2 (Group I). The mean percentage of live cells in Group I immediately after elimination of medicaments was 64.7%, in Group II was 1.52%, in Group III was 1.49%, and in Group IV was 83.4%. After 24 h of incubation in BHI medium, 2% CHX combined with 0.5% cetrimide (Group III) showed a statistically significant (p < 0.05) result of 1.27% mean live cells as compared to 84.2% in Ca(OH)2 (Group I), 1.82% in triple antibiotic paste (Group II), and 94.2% in saline (Group IV control). Conclusion: 2% CHX combined with 0.5% cetrimide exhibited maximum antimicrobial efficacy with least number of mean live cells followed by triple antibiotic paste as compared to Ca(OH)2. Based on these findings, 2% CHX combined with 0.5% cetrimide was most effective in eradicating E. faecalis from the extraorally infected dentine biofilm.

Background: Bispectral index (BIS) has been in practice as an objective tool to measure the depth of conscious sedation. The data on adequate levels for awake fiberoptic nasotracheal intubation (AFNI) is however scarce. We aimed to obtain an optimal level of BIS required for achieving the adequate conscious sedation in AFNI procedure. Methods: In a prospective, observational, outcome assessor blinded cohort trial, 94 consecutive patients with anticipated difficult intubation and undergoing AFNI for any elective surgery were enrolled. The topical anesthesia and sedation were induced with lidocaine and dexmedetomidine, while keeping the patient awake. The sedation levels were targeted to BIS ≤90 and Ramsay sedation score (RSS)≥2 to attempt intubation. Propofol bolus were administered if patients get agitated. The primary outcome was “Stable BIS”, the lowest BIS at which intubation could be feasibly performed. A receiver operator characteristic curve, Youden index, and correlation analysis were used. Results: The optimal criterion for BIS was obtained as ≤86 (AUC: 0.80, sensitivity 88.30%, specificity 61.45%, Youden index 49.74). The stable BIS ranged from 80 to 88, while RSS varied from 1 to 3. The BIS and RSS correlated significantly (r: 0.83). The stable BIS was independent of any baseline characteristics. Six patients had transient untoward events, none requiring any intervention. Conclusion: BIS serves as an effective objective tool for titrating the depth of conscious sedation. We advocate a BIS range of 80–86 for feasibly performing the AFNI procedure.

Background and Aims: Identifying an ideal intraoperative ventilation strategy remains an area of research. We evaluated the effect of ultrasound-guided–pressure-controlled ventilation (UG-PCV) on the blood-gas and ventilatory parameters, during both two-lung ventilation (TLV) and one-lung ventilation (OLV) for thoracic surgery of unilateral pulmonary disease, compared with volume-targeted PCV (VT-PCV). Methods: In a prospective, parallel-group and double-blinded design, 40 consecutive patients were randomised into two groups. Group A: Received VT-PCV at a tidal volume (TV) of 9 mL/kg for TLV and 5 mL/kg for OLV; group B: Received UG-PCV at an inspiratory pressure (2 cmH2O increments every 15 s) targeted to achieve the alveolar aeration at the base of the dependent lung (ultrasound-guided), for both TLV/OLV, respectively. Primary outcome included arterial oxygen partial pressure (PaO2) measured at baseline before anaesthesia induction (T1), at 30 min immediately before conversion from TLV to OLV (T2), at 30 min on OLV (T3) and before terminating OLV at the end of surgery (T4). Statistical tool included Mann-Whitney test. Results: The PaO2 (mmHg) was significantly higher in group B (374.5 ± 25.9, 321.7 ± 35.2 and 357.0 ± 24.7) as compared to group A (353.3 ± 38.1, 272.6 ± 37.9 and 295.3 ± 40.1), at T2, T3 and T4, respectively. The acid-base status remained preserved in group B, while gradual respiratory acidosis was observed in group A. The bicarbonate levels remained uniform in all patients. The TV and airway pressures were marginally higher in group B, with no intraoperative complications. Conclusion: The UG-PCV mode offered better oxygenation, homogenous acid-base balance and individualised alveolar ventilation for thoracic surgery.

Introduction: Regeneration, in the field of endodontics, is the process of restoring and maintaining both architectural form and biological functions of damaged tooth. Presently, regenerative endodontics is not hypothetical and is an alternative to conventional apexification procedures. There is a deficient knowledge concerning the role of intracanal medicaments and their effect on dental stem cells. Aim: The aim of this study was to evaluate the effectiveness of commonly used intracanal medicaments on the viability of dental stem cells of the apical papilla (SCAPs). Materials and Methods: SCAPs were cultured and subjected to various concentrations including triple antibiotic paste, double antibiotic paste, Augmentin, and calcium hydroxide (Ca(OH)2). Viable percentage of stem cell counts was obtained 3 days after treatment. Results: All three antibiotics used hereby significantly decreased SCAP cell survival at particular concentrations, whereas Ca(OH)2 showed stimulating effect on SCAP survival. Conclusion: As per results obtained within limitations of this study, use of Ca(OH)2 in regenerative endodontics in comparison to different commonly used antimicrobial combinations is recommended. Hereby, for clinical use, we suggest adequate concentrations of antimicrobials with adequate antibacterial efficacy should be used.

Abstract Background Parkinson's disease (PD) is the second most common neurodegenerative disorder whose prevalence is rapidly increasing worldwide. The molecular mechanisms underpinning the pathophysiology of sporadic PD remain incompletely understood. Therefore, causative therapies are still elusive. To obtain a more integrative view of disease‐mediated alterations, we investigated the molecular landscape of PD in human post‐mortem midbrains, a region that is highly affected during the disease process. Methods Tissue from 19 PD patients and 12 controls were obtained from the Parkinson's UK Brain Bank and subjected to multi‐omic analyses: small and total RNA sequencing was performed on an Illumina's HiSeq4000, while proteomics experiments were performed in a hybrid triple quadrupole‐time of flight mass spectrometer (TripleTOF5600+) following quantitative sequential window acquisition of all theoretical mass spectra. Differential expression analyses were performed with customized frameworks based on DESeq2 (for RNA sequencing) and with Perseus v.1.5.6.0 (for proteomics). Custom pipelines in R were used for integrative studies. Results Our analyses revealed multiple deregulated molecular targets linked to known disease mechanisms in PD as well as to novel processes. We have identified and experimentally validated (quantitative real‐time polymerase chain reaction/western blotting) several PD‐deregulated molecular candidates, including miR‐539‐3p, miR‐376a‐5p, miR‐218‐5p and miR‐369‐3p, the valid miRNA‐mRNA interacting pairs miR‐218‐5p/RAB6C and miR‐369‐3p/GTF2H3, as well as multiple proteins, such as CHI3L1, HSPA1B, FNIP2 and TH. Vertical integration of multi‐omic analyses allowed validating disease‐mediated alterations across different molecular layers. Next to the identification of individual molecular targets in all explored omics layers, functional annotation of differentially expressed molecules showed an enrichment of pathways related to neuroinflammation, mitochondrial dysfunction and defects in synaptic function. Conclusions This comprehensive assessment of PD‐affected and control human midbrains revealed multiple molecular targets and networks that are relevant to the disease mechanism of advanced PD. The integrative analyses of multiple omics layers underscore the importance of neuroinflammation, immune response activation, mitochondrial and synaptic dysfunction as putative therapeutic targets for advanced PD.

Fixing a femoral neck fracture in elderly patients restores their independent mobility, and decreases the associated mortality and morbidity. Perioperative stroke is the most undesired complication in such patients, having a miserable outcome. We report a similar case where the patient developed ischaemic stroke in the immediate post-operative period, where a diagnostic workup revealed the presence of a new-onset pulmonary arterial hypertension with suspected embolism, in the absence of cardiopulmonary shunt, visible thrombus or embolus of cardiac origin. This case highlights the diagnostic dilemma in evaluating the cause of post-operative stroke and emphasises the need for a multimodal approach to investigate the suspected acute pulmonary embolism and to identify the possible sites for the origin of an embolus.

Bone is a complex hierarchical tissue composed of organic and inorganic materials that provide structure, support, and protection to organs. However, there are some critical size defects that are unable to regenerate on their own and therefore require clinical repair. Bone graft substitutes allow repair by providing a temporary resorbable device. Among the common filler materials that aid in regeneration is hydroxyapatite particles of either animal or human origin which is used to fill or reconstruct periodontal and bony defects in the mouth. However, particulate graft substitutes suffer from localized migration away from the implantation site, necessitating the use of a barrier membrane. In this study, we designed InterOss Collagen, combining bovine hydroxyapatite granules with porcine-skin derived collagen to form a bone filler composite. Physiochemical properties of InterOss Collagen and a commercially available product, OsteoConductive Substitute-Bovine (OCS-B) Collagen, referred to as OCS-B Collagen, were examined. We found two bone graft substitutes to be mostly similar, though InterOss Collagen showed comparatively higher surface area and porosity. We conducted an in vivo study in rabbits to evaluate local tissue responses, percent material resorption and bone formation and showed that the two materials exhibited similar degradation profiles, inflammatory and healing responses following implantation. Based on these results, InterOss Collagen is a promising dental bone grafting material for periodontal and maxillofacial surgeries.

Introduction: Radial Arterial Puncture (AP) is much needed procedure in critical care setting but pain associated during AP makes patients anxious and stressed. Aim: To evaluate the efficacy of ethyl chloride spray versus ice pack application in decreasing pain during puncture of radial artery for Arterial Blood Gas (ABG) analysis. Materials and Methods: A randomised controlled parallel group design study was conducted in a tertiary care hospital in critical care units among 60 participants during November 2018 to December 2018. Seventy-two participants were initially recruited for this study who had to undergo ABG analysis out of them 12 were excluded and finally 60 participants were randomly allocated to ethyl chloride spray group (n=30) and ice pack application group (n=30). The assigned treatment was given just prior to radial AP. The primary outcome variable was to assess the level of pain score, which participants experienced during AP and measured by pain numerical rating scale while secondary outcome variable was incidence of haematoma within two hours after procedure. Data were presented in frequency, percentages, chi-square, Mann-Whitney U and Fisher’s-exact test. The statistical computer package, IBM Statistical Package for the Social Sciences (SPSS 23.0) was used for statistical analysis. Results: The mean pain score was 2.5±1.2 in the ethyl chloride group and 3.1±1.8 in ice pack application group (p=0.113); while incidence of haematoma was significantly high in ice pack application group as compared to ethyl chloride group (33.3% vs. 6.66%; p=0.01). Conclusion: Ethyl chloride spray and ice pack application have no significant difference in reducing pain intensity due to radial AP.

Alpha-synuclein (aSyn) is the major protein component of Lewy bodies and Lewy neurites, the typical pathological hallmarks in Parkinson's disease (PD) and Dementia with Lewy bodies. aSyn is capable of inducing transcriptional deregulation, but the precise effect of specific aSyn mutants associated with familial forms of PD, remains unclear. Here, we used transgenic mice overexpressing human wild-type (WT) or A30P aSyn to compare the transcriptional profiles of the two animal models. We found that A30P aSyn promotes strong transcriptional deregulation and increases DNA binding. Interestingly, COL4A2, a major component of basement membranes, was found to be upregulated in both A30P aSyn transgenic mice and in dopaminergic neurons expressing A30P aSyn, suggesting a crucial role for collagen related genes in aSyn-induced toxicity. Finally, we observed that A30P aSyn alters Golgi morphology and increases the susceptibility to endoplasmic reticulum (ER) stress in dopaminergic cells. In total, our findings provide novel insight into the putative role of aSyn on transcription and on the molecular mechanisms involved, thereby opening novel avenues for future therapeutic interventions in PD and other synucleinopathies.

Parkinson’s disease (PD) is the second-most-frequent neurodegenerative disorder worldwide. One major hallmark of PD is the degeneration of dopaminergic (DA) neurons in the substantia nigra. Glial cell line-derived neurotrophic factor (GDNF) potently increases DA neuron survival in models of PD; however, the underlying mechanisms are incompletely understood. MicroRNAs (miRNAs) are small, non-coding RNAs that are important for post-transcriptional regulation of gene expression. Using small RNA sequencing, we show that GDNF specifically increases the expression of miR-182-5p and miR-183-5p in primary midbrain neurons (PMNs). Transfection of synthetic miR-182-5p and miR-183-5p mimics leads to increased neurite outgrowth and mediates neuroprotection of DA neurons in vitro and in vivo, mimicking GDNF effects. This is accompanied by decreased expression of FOXO3 and FOXO1 transcription factors and increased PI3K-Akt signaling. Inhibition of endogenous miR-182-5p or miR-183-5p in GDNF-treated PMNs attenuated the pro-DA effects of GDNF. These findings unveil an unknown miR-mediated mechanism of GDNF action and suggest that targeting miRNAs is a new therapeutic avenue to PD phenotypes.

Summary: Physical exercise in combination with cognitive training is known to enhance synaptic plasticity, learning, and memory and lower the risk for various complex diseases including Alzheimer’s disease. Here, we show that exposure of adult male mice to an environmental enrichment paradigm leads to enhancement of synaptic plasticity and cognition also in the next generation. We show that this effect is mediated through sperm RNA and especially miRs 212/132. In conclusion, our study reports intergenerational inheritance of an acquired cognitive benefit and points to specific miRs as candidates mechanistically involved in this type of transmission. : Environmental enrichment (EE), a combination of physical and mental exercise, has been shown to increase cognitive abilities in mice and in humans. Benito et al. find that offspring of male mice subjected to EE also show this increase. This effect is dependent on sperm RNA and involves microRNA212/132. Keywords: epigenetics, brain, microRNA, memory, intergenerational, transgenerational, exercise, environmental enrichment, cognition

Abstract Background In this research article, we evaluate the use of sub-periosteal tunneling (tunnel technique) combined with alloplastic in situ hardening biphasic calcium phosphate (BCP, a compound of β-tricalcium phosphate and hydroxyapatite) bone graft for lateral augmentation of a deficient alveolar ridge. Methods A total of 9 patients with deficient mandibular alveolar ridges were included in the present pilot study. Ten lateral ridge augmentation were carried out using the sub-periosteal tunneling technique, including a bilateral procedure in one patient. The increase in ridge width was assessed using CBCT evaluation of the ridge preoperatively and at 4 months postoperatively. Histological assessment of the quality of bone formation was also carried out with bone cores obtained at the implant placement re-entry in one patient. Results The mean bucco-lingual ridge width increased in average from 4.17 ± 0.99 mm to 8.56 ± 1.93 mm after lateral bone augmentation with easy-graft CRYSTAL using the tunneling technique. The gain in ridge width was statistically highly significant (p = 0.0019). Histomorphometric assessment of two bone cores obtained at the time of implant placement from one patient revealed 27.6% new bone and an overall mineralized fraction of 72.3% in the grafted area 4 months after the bone grafting was carried out. Conclusions Within the limits of this pilot study, it can be concluded that sub-periosteal tunneling technique using in situ hardening biphasic calcium phosphate is a valuable option for lateral ridge augmentation to allow implant placement in deficient alveolar ridges. Further prospective randomized clinical trials will be necessary to assess its performance in comparison to conventional ridge augmentation procedures.

We incorporate thermal effects for injection currents ranging up to 150 mA in order to model the tuning behavior of a two-section, all-active distributed-Bragg-reflector (DBR), ridge-waveguide semiconductor laser utilized for a single-mode operation. In particular, we investigate wavelength tuning as a function of injected currents within the grating and phase/gain sections of the laser cavity and examine how any athermal lasing conditions may arise. The effect of thermal drift on the resonant wavelength due to a change in refractive index as well as thermal expansion of the laser cavity is included within a traveling wave analysis (TWA). From the TWA, the spatial distribution of gain along the active region of the laser is also derived in order to help describe the tuning behavior for a high-order (37th) grating previously optimized to minimize linewidth. A comparative analysis with a single mirrored, active-passive DBR laser is also included. Results show a good agreement with reported experimental data and compare well with the wavelength stability of other laser devices.

Temporomandibular joint ankylosis is one of the most challenging airway disorders associated with varying anatomical abnormalities like adenotonsillar hypertrophy, craniofacial malformations, macroglossia, etc. This case highlights the intubation difficulties confronted during the airway management of a 10-year-old girl presenting lately with bilateral temporomandibular joint ankylosis, hypoplastic mandible, and adenoid hypertrophy. This patient was intubated successfully by using a suction catheter assembly to negotiate the endotracheal tube across the adenoid, and an unmatched-size flexible intubation fiberscope through a “separate insertion” technique and external laryngeal manipulation. This case emphasises the significance of a comprehensive preoperative evaluation in preparing the anaesthetic plan of an anticipated difficult airway in a paediatric population, having diverse anatomical hurdles presenting concurrently.

Abstract Alzheimer's disease is a devastating neurodegenerative disease eventually leading to dementia. An effective treatment does not yet exist. Here we show that oral application of the compound anle138b restores hippocampal synaptic and transcriptional plasticity as well as spatial memory in a mouse model for Alzheimer's disease, when given orally before or after the onset of pathology. At the mechanistic level, we provide evidence that anle138b blocks the activity of conducting Aβ pores without changing the membrane embedded Aβ‐oligomer structure. In conclusion, our data suggest that anle138b is a novel and promising compound to treat AD‐related pathology that should be investigated further.

This paper investigates how the numerosity bias influences individuals’ allocation of resources between themselves and others, using the backdrop of the traditional dictator game. Across four studies including both hypothetical and real exchanges of money, we show that the form of the numerical value representing the quantity of the resource (e.g., $20 vs 2000 cents) systematically biases the decision-maker to perceive the quantity s/he is thinking of allocating as being “less than adequate” or “more than adequate”. Essentially, such a biased perception of adequacy with respect to the quantity of the resource consequently influences the decision-maker’s final allocation decision. We attribute this systematic bias to the “numerosity” of the resource. We find that bigger numerical values representing quantity (e.g., 2000 cents) bias decision-makers to over-infer the quantity, thus inducing them to allocate less to the entities they are focusing on.

Kmt2a and Kmt2b are H3K4 methyltransferases of the Set1/Trithorax class. We have recently shown the importance of Kmt2b for learning and memory. Here, we report that Kmt2a is also important in memory formation. We compare the decrease in H3K4 methylation and de-regulation of gene expression in hippocampal neurons of mice with knockdown of either Kmt2a or Kmt2b. Kmt2a and Kmt2b control largely distinct genomic regions and different molecular pathways linked to neuronal plasticity. Finally, we show that the decrease in H3K4 methylation resulting from Kmt2a knockdown partially recapitulates the pattern previously reported in CK-p25 mice, a model for neurodegeneration and memory impairment. Our findings point to the distinct functions of even closely related histone-modifying enzymes and provide essential insight for the development of more efficient and specific epigenetic therapies against brain diseases.

Background: Kv7 neuronal channels are recognized as a potential drug target for anxiolytic effects. We hypothesize that flupirtine as a potassium channel opener would effectively reduce the preoperative anxiety of patients undergoing craniotomy procedure. Methods: In prospective-double-blinded fashion, 124 counseled patients were randomized to receive 5 sequential doses of capsule flupirtine 100 mg (F Group) or physically similar starch capsules (C Group), at 12 h intervals during preoperative hospitalization. Primary outcome included various aspects of patient anxiety measured by visual analog scale (VAS) just before preoperative counseling and 2 h after the completion of drug regimen under trial. Statistical tool included Mann–Whitney U-test and Wilcoxon signed rank test. Results: Baseline VAS scores were higher for fear of surgical harm, being at the mercy of medical staff, and not awakening after surgery. A significant decline in VAS scores was observed after the completion of drug regime, but to a higher extent in flupirtine-treated patients; it achieved statistical significance in comparison to Group C. No side effects were observed in any patient. Conclusion: Flupirtine is a useful premedication in conjunction with behavioral therapy to alleviate patient anxiety during the preoperative period.

The formation of the sea urchin spicule skeleton requires the participation of hydrogel-forming protein families that regulate mineral nucleation and nanoparticle assembly processes that give rise to the spicule. However, the structure and molecular behavior of these proteins is not well established, and thus our ability to understand this process is hampered. We embarked on a study of sea urchin spicule proteins using a combination of biophysical and bioinformatics techniques. Our biophysical findings indicate that recombinant variants of the two most studied spicule matrix proteins, SpSM50 and SpSM30B/C (S. purpuratus) have a conformational landscape that include a C-terminal random coil/intrinsically disordered MAPQG sequence coupled to a conserved, folded N-terminal C-type lectin-like (CTLL) domain, with SpSM50 > SpSM30B/C with regard to intrinsic disorder. Both proteins possess solvent-accessible unfolded MAQPG sequence regions where Asn, Gln, and Arg residues may be accessible for protein hydrogel interactions with water molecules. Our bioinformatics study included seven other spicule matrix proteins where we note similarities between these proteins and rare, unusual proteins that possess folded and unfolded traits. Moreover, spicule matrix proteins possess three types of sequences: intrinsically disordered, amyloid-like, and folded protein-protein interactive. Collectively these reactive domains would be capable of driving protein assembly and hydrogel formation. Interestingly, three types of global conformations are predicted for the nine member protein set, wherein we note variations in the arrangement of intrinsically disordered and interactive globular domains. These variations may reflect species-specific requirements for spiculogenesis. We conclude that the molecular landscape of spicule matrix protein families enables them to function as hydrogelators, nucleators, and assemblers of mineral nanoparticles.

We focus on the everyday decision making challenges faced by high functioning adults across the Autism Spectrum using both between- and within-group comparisons. We used Mturk, backed by a combination of recruiting and screening procedures, to recruit large samples using an online survey. The main differences between groups were: greater relationship problems at home, school and work for the ASD group compared to the control group; greater difficulty in a variety of everyday decisions and the negative consequences of their decisions; greater aversion to social risks; lower levels of Rational Ability; and greater personal endorsement of socially undesirable acts. Poorer decision outcomes within the ASD group were predicted by lower levels of Rational Ability and higher personal endorsement of socially undesirable acts. Some of the same predictor-outcome relations were found within the Control group. These results illustrate how the study of unique groups can increase our overall understanding of individual differences in decision making within the general population, and the need to include both between-group and within-group analyses.

Background and Aims: Poorly managed acute postoperative pain may result in prolonged morbidity. Various pharmacotherapies have targeted this, but research on an ideal preemptive analgesic continues, taking into account drug-related side effects. Considering the better tolerability profile of tapentadol, we assessed its role as a preemptive analgesic in the reduction of postoperative analgesic requirements, after laparoscopic cholecystectomy. Material and Methods: In a prospective-double-blinded fashion, sixty patients posted for above surgery, were randomized to receive tablet tapentadol 75 mg (Group A) or starch tablets (Group B) orally, an hour before induction of general anesthesia. Perioperative analgesic requirement, time to first analgesia, pain, and sedation score were compared for first 24 h during the postoperative period and analyzed by one-way analysis of variance test. A P< 0.05 was considered significant. Results: Sixty patients were analyzed. The perioperative analgesic requirement was significantly lower in Group A. Verbal numerical score was significantly lower in Group A at the time point, immediately after shifting the patient to the postanesthesia care unit. Ramsay sedation scores were similar between the groups. No major side effects were observed except for nausea and vomiting in 26 cases (10 in Group A, 16 in Group B). Conclusion: Single preemptive oral dose of tapentadol (75 mg) is effective in reducing perioperative analgesic requirements and acute postoperative pain, without added side effects. It could be an appropriate preemptive analgesic, subjected to future trials concentrating upon its dose-response effects.

A multi-section active photonic integrated circuit (PIC) is characterized in detail to gauge its suitability as a transmitter for short reach applications. The PIC is 1.5 mm long and consists of two lasers integrated in a master-slave configuration, which enables optical injection locking (OIL) of the slave laser. The beneficial impact of the injection is characterized by static and dynamic measurements. The results show a reduction of the optical linewidth from 8 MHz to 2 MHz, a relative intensity noise (RIN) value as low as −154.3 dB/Hz and a 45% improvement of the slave laser modulation bandwidth from 9.5 GHz to 14 GHz. This frequency response enhancement allows the direct modulation of the slave gain section at a data rate of 10.7 Gb/s and an error-free transmission over 25 km of standard single-mode fiber (SSMF). Transmission performance of the injected case shows a 2 dB improvement in the minimum optical power required to achieve a bit error rate of 3.8×10−3 (hard decision forward error correction limit). These results demonstrate that the multi-section PIC can serve as an attractive cost-efficient transmitter in a wide variety of low-cost short-reach data communication applications.

Abstract Background and Importance: Hydatid cyst is endemic in India, with different clinical presentations according to the site of involvement in the body. However, its occurrence in the brain without the involvement of other body parts is rare. Case Presentation: An eight-year-old female child presented with right-sided limb weakness and slurring of speech. The diagnosis of primary brain hydatid cyst was made with Magnetic Resonance Imaging (MRI) of the brain. The cyst was removed in toto, resulting in improved post-operative slurring of speech and limb weakness. Conclusion: In countries with endemic hydatid disease, it should be kept as one of the possible differential diagnoses and managed as per hydatid protocol until another definitive diagnosis of brain cystic mass can be made, in order to prevent rupture and dissemination.