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Background Transvenous lead extraction (TLE) for implantable cardiac‐devices is traditionally performed under general anesthesia (GA). This can lead to greater risk of exposure to COVID‐19, longer recovery‐times and increased procedural‐costs. We report the feasibility/safety of TLE using conscious‐sedation alone with immediate GA/cardiac‐surgery back‐up if needed. Methods Retrospective case‐series of consecutive TLEs performed using conscious‐sedation alone between March 2016 and December 2019. All were performed in the electrophysiology‐laboratory using intravenous Fentanyl, Midazolam/Diazepam with a stepwise approach using locking‐stylets/cutting‐sheaths, including mechanical‐sheaths. Baseline patient‐characteristics, procedural‐details and TLE outcomes (including procedure‐related complications/death) were recorded. Results A total of 130 leads were targeted in 54 patients, mean age ± SD 74.6 ± 11.8years, 47(87%) males; dual‐chamber pacemakers (n = 26; 48%), cardiac resynchronization therapy‐defibrillators (n = 17; 31%) and defibrillators (n = 8; 15%) were commonest extracted devices. Mean ± SD/median (range) lead‐dwell times were 11.0 ± 8.8/8.3 (0.3‐37) years, respectively. Extraction indications included systemic infection (n = 23; 43%) and lead/pulse‐generator erosion (n = 27; 50%); mean 2.1 ± 2.0 leads were removed per procedure/mean procedure‐time was 100 ± 54 min. Local anesthetic (LA) was used for all (mean‐dose: 33 ± 8 ml 1% lidocaine), IV drug‐doses used (mean ± SD) were: midazolam: 3.95 ± 2.44 mg, diazepam: 4.69 ± 0.89 mg and fentanyl: 57 ± 40 µg. Complete lead‐extraction was achieved in 110 (85%) leads, partial lead‐extraction (, TLE undertaken using LA/conscious‐sedation was safe/feasible in our series and associated with good clinical outcome/low procedural complications. Reduced risk of aerosolisation of Covid‐19 and quicker patient recovery/reduced anesthetic risk are potential benefits that warrant further study.

Mammary hamartoma is uncommon typically non-malignant benign breast lesion, comprising varying amounts of fatty, fibrous connective tissue and glandular elements. The co-existence of hamartomas and malignancy is very rare and it has no special propensity to undergo malignant transformation. We present a case report of a 66-year-old patient diagnosed with Inflammatory Breast Carcinoma within a previously diagnosed mammary hamartoma in the right breast. The comprehensive work-up with mammography, ultrasound, Positron Emission Tomography – Computed Tomography (PET-CT) and ultrasound-guided biopsy confirmed invasive ductal carcinoma within the hamartoma. Although malignancy arising within hamartoma is an extremely rare entity, the radiologist should be aware and prudent of the atypical as well as suspicious features within hamartoma during interpretation of imaging modalities and should thoroughly investigate any architectural distortion or microcalcifications within an otherwise typical hamartoma. No case has been reported for inflammatory breast carcinoma in mammary hamartoma as per our best of knowledge.

Background: oestrogen receptor positive/ human epidermal growth factor receptor positive (ER+/HER2+) breast cancers (BCs) are less responsive to endocrine therapy than ER+/HER2- tumours. Mechanisms underpinning the differential behaviour of ER+HER2+ tumours are poorly characterised. Our aim was to identify biomarkers of response to 2 weeks’ presurgical AI treatment in ER+/HER2+ BCs. Methods: all available ER+/HER2+ BC baseline tumours (n=342) in the POETIC trial were gene expression profiled using BC360™ (NanoString) covering intrinsic subtypes and 46 key biological signatures. Early response to AI was assessed by changes in Ki67 expression and residual Ki67 at 2 weeks (Ki67 2wk). Time-To-Recurrence (TTR) was estimated using Kaplan-Meier methods and Cox models adjusted for standard clinicopathological variables. New molecular subgroups (MS) were identified using consensus clustering. Findings: HER2-enriched (HER2-E) subtype BCs (44.7% of the total) showed poorer Ki67 response and higher Ki67 2wk (p2wk. Five new MS that were associated with differential response to AI were identified. HER2-E had significantly poorer TTR compared to Luminal BCs (HR 2.55, 95% CI 1.14–5.69; p=0.0222). The new MS were independent predictors of TTR, adding significant value beyond intrinsic subtypes. Interpretation: our results show HER2-E as a standardised biomarker associated with poor response to AI and worse outcome in ER+/HER2+. HRD, TP53 mutational score and immune-tumour tolerance are predictive biomarkers for poor response to AI. Lastly, novel MS identify additional non-HER2-E tumours not responding to AI with an increased risk of relapse. Funding: Cancer Research UK (CRUK/07/015).

The coronavirus disease (COVID-19) pandemic has rapidly spread across the globe since its first detection in March 2020. Its widespread manifestations and vascular complications are increasingly being reported even in young and middle-aged patients. Hyperinflammation is a continuum of host’s exaggerated inflammatory response representing cytokine dysregulation/storm which produces coagulopathy and vascular endothelial dysfunction, apart from a prothrombotic state. Cytokine storm or direct viral invasion of the vascular endothelial cells through surface angiotensin-converting enzyme 2 receptors may result in endothelial dysfunction which can potentially result in dissection. Only a few case reports have been published in the literature describing vascular dissection without any inciting factors in COVID-19 patients. Herein, we present the first case report of bilateral renal artery dissection in a 41-year-old male patient who recently recovered from COVID-19 and was managed successfully in stages after many medical hurdles.

Summary SARS‐CoV2 is a novel coronavirus; the seventh of its species to infect humans. The spread of this virus emerged in Wuhan, China in late December, 2019. Since then, this virus has spread to more than 200 countries and has caused a worldwide pandemic. Being a new species of coronaviruses, any cure or vaccines for this virus has not yet been obtained. A large amount of scientific studies and clinical trials are being carried out across the world to find a potential vaccine for this virus. Current work reports a review of potential drugs and vaccines that may be effective against this virus. Different scientific therapies that may potentially be effective against the SARS‐CoV2 virus are also reviewed. The mechanisms of various drugs, their efficiency in various clinical trials and their side effects are also studied.

Aims and Objectives: To study “Honeycomb” pattern of gallbladder wall thickening (GBWT) in dengue fever (DF) and to assess its clinical significance in early diagnosis of severe DF. Materials and Methods: A total 244 patients of DF were studied, 84 patients were classified as severe DF, 61 patients as DF with warning signs, and 99 patients as DF without warning signs. Abdominal ultrasound was performed for assessment of GBWT patterns, hepatomegaly, splenomegaly, pancreatic enlargement, ascites, pleural effusion, and other additional findings were recorded in severe DF cases. Statistical comparison between “Honeycomb” pattern of GBWT and clinically severe DF was done using Pearson correlation test. Results: Out of 244 patients, 145 patients were males and 99 patients were females, belonging to various age groups ranging from 1 to 81 years and 14.34% (35 patients) among them included in pediatric group. In total, 65.57% (160 patients) were non-severe DF cases and 34.42% (84 patients) were severe DF cases. A total of 84 patients of severe DF, 92.85% patients showed GBWT, and out of which, 71.42% patients had “Honeycomb” pattern, whereas a total of 160 patients of non-severe DF patients, 45% patients had GBWT and out of which, only 5.6% patients showed “Honeycomb” pattern.”Honeycomb” pattern of GBWT shows sensitivity of 71.4%, 94.37%, Positive predictive value of 86.95%, and Negative predictive value of 86.28% in severe DF. Conclusion:”Honeycomb” pattern of GBWT is significant finding in severe DF. Its sensitivity and specificity are high in severe DF with significant statistical correlation. It can aid in early diagnosis of severe DF.

Objectives: Magnetic resonance imaging has proven to be a valuable tool in the assessment of disc abnormalities. Two types of disc extrusion can be described according to the direction of herniated disc material: shoulder type and axillary type. Axillary disc herniation is described when the extruded disc fragment lies in the recess between the lateral border of cauda equina and medial to the nerve roots, while in the shoulder type the disc lies lateral to the nerve roots. It is very important to describe the type of disc herniation, as the surgical approach differs in each type. To the best of the authors' knowledge, no definite signs have been described in literature to date. This study aimed to address the accuracy of the kissing sign on MRI for he diagnosis of axillary disc herniation. Methods: The MRIs of 72 patients undergoing spinal surgery were prospectively evaluated for axillary disc herniation by a senior radiologist and experienced spinal surgeon using the kissing sign on MRI. The kissing sign was considered positive when the herniated disc material was in direct contact with the lamina and/or ligamentum flavum on axial images. Subsequently, all surgeries were performed by two independent surgeons and the actual type of disc herniation was documented. The accuracy of the results was statistically assessed. Results: The kissing sign on MRI was found to be 66.66% sensitive, 92.59% specific, and 76.38% accurate in detecting axillary disc herniation with significant correlation with the surgical findings. Conclusion: The type of disc herniation is an important parameter for patient selection in different surgical approaches. The kissing sign on MRI can be considered as an important tool for diagnosing axillary disc herniation due to its high specificity and accuracy. RESUMO Objetivos: A ressonância magnética provou ser uma ferramenta valiosa na avaliação das anormalidades do disco. Dois tipos de extrusão de disco podem ser descritos de acordo com a direção do disco herniado: lateral e axilar. A hérnia de disco axilar é definida quando o fragmento do disco extruso encontra-se no recesso entre a borda lateral da cauda equina e medial às raízes do nervo, enquanto na hérnia lateral o disco posiciona-se lateralmente às raízes do nervo. A descrição do tipo de hérnia de disco é extremamente importante, pois a abordagem cirúrgica difere em cada tipo. Tanto quanto é do conhecimento dos autores, nenhum sinal definido foi descrito na literatura até o momento. Este estudo teve como objetivo abordar a precisão do sinal do beijo na RM no diagnóstico de herniação de disco axilar. Métodos: As RM de 72 pacientes submetidos à cirurgia da coluna vertebral foram avaliadas prospectivamente em relação à presença de hérnia de disco axilar por um radiologista sênior e cirurgião da coluna experiente com o sinal do beijo na RM. O sinal do beijo foi considerado positivo quando o material do disco herniado estava em contato direto com a lâmina e/ou ligamento amarelo em imagens axiais. Posteriormente, todas as cirurgias foram feitas por dois cirurgiões independentes e o tipo real de hérnia de disco foi documentado. A precisão dos resultados foi avaliada estatisticamente. Resultados: O sinal do beijo na RM apresentou 66,66% de sensibilidade, 92,59% de especificidade e 76,38% de precisão na detecção de hérnia de disco axilar com correlação significativa com os achados cirúrgicos. Conclusão: O tipo de hérnia de disco é um parâmetro importante para a seleção de pacientes em diferentes abordagens cirúrgicas. O sinal do beijo na RM pode ser considerado uma ferramenta importante para o diagnóstico de hérnia de disco axilar devido à sua alta especificidade e precisão.

Resumo Objetivos A ressonância magnetica provou ser uma ferramenta valiosa na avaliacao das anormalidades do disco. Dois tipos de extrusao de disco podem ser descritos de acordo com a direcao do disco herniado: lateral e axilar. A hernia de disco axilar e definida quando o fragmento do disco extruso encontra‐se no recesso entre a borda lateral da cauda equina e medial as raizes do nervo, enquanto na hernia lateral o disco posiciona‐se lateralmente as raizes do nervo. A descricao do tipo de hernia de disco e extremamente importante, pois a abordagem cirurgica difere em cada tipo. Tanto quanto e do conhecimento dos autores, nenhum sinal definido foi descrito na literatura ate o momento. Este estudo teve como objetivo abordar a precisao do sinal do beijo na RM no diagnostico de herniacao de disco axilar. Metodos As RM de 72 pacientes submetidos a cirurgia da coluna vertebral foram avaliadas prospectivamente em relacao a presenca de hernia de disco axilar por um radiologista senior e cirurgiao da coluna experiente com o sinal do beijo na RM. O sinal do beijo foi considerado positivo quando o material do disco herniado estava em contato direto com a lâmina e/ou ligamento amarelo em imagens axiais. Posteriormente, todas as cirurgias foram feitas por dois cirurgioes independentes e o tipo real de hernia de disco foi documentado. A precisao dos resultados foi avaliada estatisticamente. Resultados O sinal do beijo na RM apresentou 66,66% de sensibilidade, 92,59% de especificidade e 76,38% de precisao na deteccao de hernia de disco axilar com correlacao significativa com os achados cirurgicos. Conclusao O tipo de hernia de disco e um parâmetro importante para a selecao de pacientes em diferentes abordagens cirurgicas. O sinal do beijo na RM pode ser considerado uma ferramenta importante para o diagnostico de hernia de disco axilar devido a sua alta especificidade e precisao.

Introduction: Mycobacterium chimaera ( M. chimaera) is a recently characterised bacterium that can cause life-threatening infections in small numbers of patients who undergo cardiopulmonary bypass during cardiac surgery. The likely mode of transmission is thought to occur through aerosolisation from contaminated water reservoirs. The airborne bacteria then contaminate the surgical field, leading to an infection months or even years later. The preferred practical solution to disrupt the transmission of these airborne bacteria to the patient is to remove the heater-cooler units (HCUs) from the operating room (OR). We describe a process of achieving this in order to provide information to guide other institutions who wish to do a similar thing. Methods: A multidisciplinary team was assembled to work on the project. The planning phase involved trialling different OR layouts and simulating the alterations in the HCU circuit function. The changes to the OR were made over a weekend to minimise disruption to the operating schedule. Results: The HCU was moved to the dirty utility room adjacent to the OR. Standard operating procedures (SOP) and risk assessments were made to enable this to be used for a dual purpose. One of the ORs was reconfigured to allow the cardiopulmonary bypass machine to be located close to the HCU in the dirty utility room. The total cost of the alterations was £6,158. Although we have provided a physical barrier to interrupt patient exposure to aerosolised M. chimaera from HCUs, we continue to perform cultures and decontamination as per the national recommendations. The SOP was designed to be auditable to ensure compliance with the protocols. Conclusions: We show a method by which the HCU can be removed from the OR in a relatively low-cost, straightforward and practical manner.

This paper presented Design and modelling of controller for PMSG based wind energy conversion system. A main objective of this paper is by using PMSG based wind turbine improve fault ride through capability and analyse controller performance at different initial condition. The PMSG based WECS connected with back to back converter with dc- link. The performance of the WECS with the fuzzy based controller is established for fault ride through capability, output voltage regulation at grid side and analyse the performance of controller in various case study. Simulation results shows the possibility of accomplishing stable operation at load variation and output voltage regulation for DC link simultaneously with fuzzy based PI controller. The results shown response and strength of the control scheme suggested.

This paper presented Design and modelling of controller for PMSGbased wind energy conversion system. A main objective of this paper is by using PMSG based wind turbine improve fault ride through capability and analyse controller performance at different initial condition. The PMSG based WECS connected with back to back converter with dc-link. The performance of the WECS with the proposed controller is established for fault ride through capability, output voltage regulation at grid side and analyse the performance of controller in various case study. Simulation results shows the possibility of accomplishing stable operation atload variation and output voltage regulation for DC link simultaneously with controller. The results shown response and strength of the control scheme suggested.

Dengue fever is a major public health problem with an increased incidence in recent years. Gall bladder wall thickening has been reported as one of the most common findings in dengue fever. There is a paucity of literature regarding the various patterns of gall bladder wall thickening in dengue fever and their significance in predicting the severity of disease.Out of 93 seropositive patients included in the study, 54 patients with dengue fever had gall bladder wall thickening. 4 patterns of gall bladder wall thickening are demonstrated in this study. A uniform echogenic pattern in 20 patients, striated or tram track pattern in 11 patients, an asymmetric pattern in 2 patients and a honeycombing pattern in 21 patients. The range of patterns of wall thickening included normal wall thickening or uniform echogenic wall thickening in DF without warning signs, a striated or tram track pattern, and a honeycomb pattern in severe DF. Serial ultrasound done on consecutive alternate days revealed a change in the pattern of gall bladder wall thickening according to the severity of disease.The present study revealed 4 distinct patterns of gall bladder wall thickening. The uniform echogenic pattern was found to be more prevalent in dengue fever without warning signs, while the honeycomb pattern was found to be more prevalent in severe dengue fever. A change in the pattern of gall bladder wall thickening on subsequent serial ultrasound can predict the severity of the disease.

Background Dengue fever is a major public health problem with an increased incidence in recent years. Gall bladder wall thickening has been reported as one of the most common findings in dengue fever. There is a paucity of literature regarding the various patterns of gall bladder wall thickening in dengue fever and their significance in predicting the severity of disease. Methodology and Significant Findings Out of 93 seropositive patients included in the study, 54 patients with dengue fever had gall bladder wall thickening. 4 patterns of gall bladder wall thickening are demonstrated in this study. A uniform echogenic pattern in 20 patients, striated or tram track pattern in 11 patients, an asymmetric pattern in 2 patients and a honeycombing pattern in 21 patients. The range of patterns of wall thickening included normal wall thickening or uniform echogenic wall thickening in DF without warning signs, a striated or tram track pattern, and a honeycomb pattern in severe DF. Serial ultrasound done on consecutive alternate days revealed a change in the pattern of gall bladder wall thickening according to the severity of disease. Conclusion The present study revealed 4 distinct patterns of gall bladder wall thickening. The uniform echogenic pattern was found to be more prevalent in dengue fever without warning signs, while the honeycomb pattern was found to be more prevalent in severe dengue fever. A change in the pattern of gall bladder wall thickening on subsequent serial ultrasound can predict the severity of the disease.

We present a case report of recurrent disseminated peritoneal leiomyomatosis in a 30-year-old female with a past history of laparoscopic myomectomy by a technique of morcellation for a large fibroid in 2014. After one year she presented in 2015 with a well-defined oval shaped fibroid along the anterior abdominal wall, which was supplied by the 10th intercostal artery and a branch of right internal mammary artery. She was again presented after 1 year in 2016 with a large pelvic-abdominal fibroid with blood supply from the omental artery, a branch from the right gastroepiploic artery, and sigmoid branches of inferior mesenteric artery.

Summary Background Dengue fever is a tropical disease that is transmitted by female Aedes Aegypti mosquitos. Early diagnosis is necessary to reduce the mortality and morbidity associated with the disease. A combination of clinical, laboratory, and sonography findings can be potentially helpful in making an early diagnosis of dengue fever. There is paucity of literature on the use of ultrasound for dengue fever screening; hence, the primary objective of the study was to evaluate the utility of ultrasound as a screening tool in dengue fever. Material/Methods A total of 160 patients of suspected dengue fever were included in the study. They underwent ultrasound examinations in order to search for thickening of the gallbladder wall, pleural effusion, and ascites. On the basis of ultrasound findings, 65 cases were positive and 95 cases were negative for dengue fever. Serological tests were also used for diagnosing dengue fever, 93 cases were seropositive and 67 cases were seronegative. The ultrasonically diagnosed cases were compared with serologically diagnosed cases, and appropriate descriptive statistical analyses were applied. Results The ultrasound findings included gall bladder wall thickening in 66 patients (41.2%). The sensitivity, specificity, and positive predictive value of ultrasound in diagnosing dengue fever were 58%, 84%, and 83%, respectively. The negative predictive value and accuracy were 59% and 68.8%, respectively. Conclusions The present study suggests that increased gall bladder wall thickness, pleural effusion, ascites, hepatomegaly, and splenomegaly are highly suggestive of dengue fever in clinically suspected cases. However, ultrasound should not be used as a screening tool, as negative ultrasound findings cannot rule out dengue fever due to the low sensitivity of this examination.

Renal ectopia is a rare congenital anomaly. Thoracic ectopic kidney was being considered as rarest, however no case of bilateral subdiaphragmatic kidneys in omphalocele patients presented with ventral hernia has been reported yet, as per our best of knowledge. This is a report of a 5-year-old male patient who presented with ventral hernia after omphalocele. A thorough examination, laboratory, and radiological investigations including ultrasonography, plain abdominal x-ray, intravenous urogram, and computerized tomography revealed bilateral subdiaphragmatic ectopic kidneys with azygos continuation of inferior vena cava, retro-aortic left renal vein and spina bifida.

Summary Background Urethral valves are infravesical congenital anomalies, with the posterior urethral valve (PUV) being the most prevalent one. Anterior urethral valve (AUV) is a rare but a well-known congenital anomaly. AUV and diverticula can cause severe obstruction, whose repercussions on the proximal urinary system can be important. Few cases have been described; both separately and in association with urethral diverticulum. The presentation of such a rare but important case led us to a report with highlighting its classic imaging features. Case Report We present a case report of AUV with lower urinary tract symptoms in a 6-year-old boy with complaints of a poor stream of urine and strain to void. Unique findings were seen on Retrograde Urethrography (RGU) and Voiding Cysto-Urethrography (VCUG), i.e. linear incomplete filling defect in the penile urethra and associated mild dilatation of the anterior urethra ending in a smooth bulge. On cysto-urethroscopy the anterior urethral valve was confirmed and fulguration was done. Conclusions Congenital anterior urethral valve is an uncommon but important cause of infravesical lower urinary tract obstruction that is more common in male urethra. It can occur as an isolated AUV or in association with diverticulum and VATER anomalies. Early diagnosis and management of this rare condition is very important to prevent further damage, infection and vesicoureteral reflux. AUV may be associated with other congenital anomalies of the urinary system; therefore a full evaluation of the urinary system is essential.

Tuberculosis is one of the microbial diseases having a long history of its occurrence and yet to be eradicated from the world. Due to the development of bacterial resistance, treatment has changed from monotherapy to combotherapy to fixed dose combinations (FDCs). Rifampicin has been found one of the most important anti-tubercular drugs, however variable bioavailability of rifampicin in some FDCs as well as separate formulations has been reported in the literature, and led to the development of WHO model protocol for evaluation of FDCs for bioequivalence trials. In present investigation, role of physiological variability in rifampicin bioequivalence was studied. Influence of subject's body weight, inter/intra-individual variability of elimination rate and impact of outliers on the decision of bioequivalence were investigated. Normalization of pharmacokinetic measures for bioequivalence (AUC and C(max)) were carried out as per body weights and elimination rate constants of subjects, then different statistical tests like two-way ANOVA, hauschke analysis, normal and log-transformed confidence interval were applied to check for the change in bioequivalence decision. It was found that normalization as per body weights did not play a significant role in the outcome of bioequivalence endpoint. Similarly, elimination rate variability and outliers have been found insignificant regarding final outcome of bioequivalence study. Hence, it has been concluded that physiological variability did not play a significant role in bioequivalence of rifampicin in FDCs.

s / International Journal of Surgery 12 (2014) S13eS117 S76 0313: ADVANCES IN TRAINING: A HIGH FIDELITY PRACTICAL COURSE ON CADAVERS FOR COMPLEX CARDIAC PROCEDURES John Massey, Jasmine Winter-Beatty , Nigel Drury, Jitendra Parmar. University Hospital Coventry and Warwickshire, Coventry, UK. Introduction: Surgical education is changing owing to implementation of European Working time Directive. Cadaveric-based educational programs have had positive feedback from surgical trainees. Our training centre allows trainees to gain experience in complex cardiac procedures in a safe, non-time pressurised environment.We look at how trainees benefit from a high fidelity course-training surgeons to perform two complex cardiac procedures. Methods: Cadavers had been prepared through a midline sternotomy, pericardium opened with heart and great vessels exposed. Trainees performed a stentless aortic valve replacement and an aortic root replacement. Faculty surgeons facilitated learning as required. Results: There was a 100% response for a post course feedback form. Knowledge survey revealed an increase in perception of knowledge. There was an increase in trainees' confidence to assist these procedures in future. 100% of attendees would recommend it to their peers. Trainees stated that they felt more comfortable assisting and performing the procedures having practiced on cadavers. Conclusions: Simulated training using fresh frozen human cadavers can be incorporated into surgical training of cardiothoracic trainees. Such a course can have high face validity and significantly improve trainees' perception of technical knowledge as well as increasing confidence to assist and perform complex cardiac procedures. 0320: THE LESSER-SPOTTED MEDICAL STUDENT: UNDERSTANDING AND FACILITATING STUDENT PRESENCE ON WARDS Ian Henderson, Jessika Voll , Damian Bragg. Queen's Medical Centre (NUH)

Information is the most valuable asset for organizations. Web database is combination of database and web technology. In Past few decades database user increasing very rapidly and the secrecy and the integrity are two important demands of security system. Data security is a major issue in any web-based application. Real world web databases have information that needs to be securely stored and accessed. Here we conclude various methods of anomaly detection, intrusion detection and access policy creation that are useful to solve security threats we also discuss various results and there merits and demerits.

Database is an important asset of any leading and emerging industry and this database needs to improved security features from various threats in the network and database repository. Most of an organization's sensitive and proprietary data resides in a Database Management System (DBMS). Data security is a major issue in any web-based application and database repository. Although there are various model implemented in the network for the security of these databases. Real world web databases have information that needs to be securely stored and accessed. In this paper we discussed proposed work classification based approach to create database policy dynamically and using these policy find intrusion in user request and response the request accordingly. The focus of our work is to develop advanced security solutions for protecting the data residing in a DBMS. Our approach is to develop an Intrusion Detection and Response (IDR) system. We introduce a policy-driven intrusion response mechanism that is capable of issuing an appropriate response based on the details of the anomalous request and discuss the implementation details on the same and report experimental results that show that our techniques are feasible and efficient.

Database is an important part for any organization and this database needs to make secure from various attacks in the network. Although there are various techniques implemented in the network for the security of these databases. Hare we proposed detection of intrusion is detected that are possible in the databases and various authentication techniques are implemented to made this databases secure. Database security and authentication such as 3 factor authentication, intrusion response system, timestamp, triggers such factors provides more security to the database. The proposed methodology implemented here provides security, authentication, and database policies.

A 23-year-old man with polytrauma was admitted to the intensive care unit for level 3 postoperative support. His medical history included VATER syndrome [1] with corrective surgery for the tracheoesophageal fistula (TEF). Ventilatory support according to ARDSNet criteria in the acute phase was complicated by a persistent air leak and significant gastric distension, raising the possibility of a residual TEF. An initial gastroscopy failed to show a fistulous opening. A Ryle’s tube for gastric air drainage and nasojejunal tube for enteral feeding were left in situ. Flexible bronchoscopy through the endotracheal tube showed a flap with access to the esophagus from the bronchial tree just above the carina, confirming the clinical suspicion of a TEF. At repeat endoscopy, the site of the communication was not immediately apparent but a mucosal flap was noted in the upper esophagus ([Fig. 1 a]). We performed a rendezvous bronchoscopy and identified a 1-cm fistulous opening in the esophagus at 26 cm from incisors ([Fig. 1 b]). This was successfully closed using an over-the-scope clip (OTSC; Ovesco, Tubingen, Germany) ([Fig. 1 c]). The feeding nasojejunal tube was replaced endoscopically ([Fig. 1 d]). Successful closure of the fistula was confirmed by the complete absence of air drainage from the Ryle’s tube, improvement in the ventilatory mechanics, and by a Gastrografin swallow. The patient was subsequently weaned off the ventilator and extubated. OTSCs are widely used for closure of perforations and fistulas [2] [3]. Nonsurgical closure of a TEF by rendezvous bronchoscopy and gastroscopy performed simultaneously has not been reported previously. The fistulous opening of a TEF can usually be identified during gastroscopy; however, in cases where the fistula is small and covered by a mucosal flap, as described here, a combined procedure can facilitate identification of the opening and direction of the fistula to aid accurate clip placement. This technique has the potential for use in closure of similar defects where a definitive surgical procedure would carry a high risk. In our case, the immediate requirement to enable adequate ventilation in a patient with an acute head injury was successfully achieved.