From not knowing to doing: An interprofessional approach to clinician training in use of Goal Attainment Scaling (GAS) as a recovery-oriented outcome measure in a rural mental health service

Outcome measurement and feedback are key to quality improvement in healthcare. Goal attainment scaling (GAS) is a tool that could be used to measure outcomes of mental health services delivering recovery-oriented care. The objective of this prospective study was to evaluate the effectiveness of tailored, interprofessional, multilevel and adaptable GAS training on clinician views, learning, competence, performance and confidence in the use of GAS. Thematic analysis of eight clinician participant views was done using the method proposed by Braun and Clarke (Thematic analysis: a practical guide to understanding and doing, 2022). Four main themes were generated: clinicians found that this type of training is useful, GAS influenced the way they thought about their roles in goal setting and recovery-oriented care and COVID-19 pandemic impacts. Furthermore, clinicians' skills to set scalable GAS goals with consumers and clinician confidence in using GAS improved. The results of this study show a positive impact of tailored, interprofessional, multilevel and adaptable training supporting development of clinician skills in the GAS process. The training design had a favourable effect on clinician views, learning, competence, performance and confidence of GAS as a recovery-oriented outcome measure. The approach to GAS training and use of GAS as a recovery-oriented outcome measure should be considered in response to mental health service reform.

What accounts for turnover intention in the Australian public mental health workforce?

High staff turnover is common within the Australian public mental health workforce, contributing to workforce shortages and ultimately impacting the ability to provide stable efficient, effective, and ongoing optimal care to the community. In this study, we aimed to (a) establish the most pertinent factors associated with increased turnover intention in the public mental health workforce in Australia, and (b) establish whether such factors differ between metropolitan and rural services. We used a cross-sectional, correlational design using an online survey method. In total, 235 mental health service staff of various disciplines and levels, from four public hospitals in Victoria, Australia participated in the study. We used three feed-forward multiple regression analyses to assess the study aims. We found that job satisfaction, occupational burnout, and understaffing may be the most pertinent factors to consider regarding turnover intention. Job satisfaction and occupational burnout were factors endorsed across the entire sample, as well as specifically within both the metropolitan and rural services, while understaffing was a pertinent factor regarding turnover intention across the entire sample and for rural services, but not metropolitan services. Our findings regarding the pertinence of job satisfaction, occupational burnout, and understaffing in turnover intention provide key information that may be used to inform interventional targets aimed at reducing attrition from the public mental health workforce in Australia.

Predicting current and future climate suitability for arecanut (Areca catechu L.) in India using ensemble model

Climate change has the potential to influence plant development, physiology, and distribution. Arecanut (Areca catechu L.), with its long life span of 60-70 years, thrives in a tropical habitat remains exposed to various abiotic and biotic factors. It is pertinent to comprehend the adaptation strategies of this crop towards climate change over time. The Biomod2 ensemble platform for species distribution modeling was utilized to predict the potential impact of climate change on the adaptability of the crop. The extracted study region of India was used for prediction, and the final run of 6 models ensemble includes 894 occurrence points and 9 climate variables with 80%-20% of training and validation sets. The model's outputs had area under curve (AUC) values of 0.943 and true skills statistics (TSS) of 0.741, which are regarded as accurate. The research area was categorized into five groups: very high, high, moderate, low, and very low. The examination involved assessing the shift in each category from the present to two prospective scenarios (shared socio-economic pathways; SSP 2-4.5 and SSP 5-8.5) projected for the 2050s and 2070s. A shift in the climate suitability area from 'very high' and 'high' categories to 'moderate' or 'very low' categories was observed suggesting the need for adaptive strategies to sustain the current yield levels. Amongst the regions, Karnataka state, which at present has more than 50% area under cultivation, is highly vulnerable and more area is coming under 'very low' and 'low' categories from eastern side. Meanwhile, in north eastern part of the country a shift in high suitable region from northwest to southwest is observed. Overall, the model prediction suggests that some parts of west and south interior regions of the country warrant immediate consideration in order to adapt to future climate change, whereas some part of north east can be considered for future cultivation.

Impact of radiation therapy on healthy and cancerous cell dynamics: a Mathematical analysis

This study proposes a novel therapeutic model for cancer treatment with radiation therapy by analyzing the interactions among cancer, immune and healthy cells through a system of three ordinary differential equations. In this model, the natural influx rate of mature immune cells is assumed constant and is denoted by, a. The overall effect of radiation therapy on cancer cells is represented by a parameter, s; which is the surviving fraction of cells as determined by the Linear Quadratic (LQ) model. Conditions for the stability of equilibria in the interaction model modified to include the surviving fraction, are systematically established in terms of the dose and model parameters. Numerical simulations are performed in Wolfram MATHEMATICA software, investigating a spectrum of initial cell population values irradiated with 60Co γ -ray Low-LET radiation and High-LET 165 keV / μ m Ni-ion radiation to facilitate improved visualization and in-depth analysis. By analyzing the model, this study identifies threshold values for the absorbed dose D for particular values of the model and radiation parameters for both High Linear Energy Transfer (high-LET) and Low Linear Energy Transfer (low-LET) radiations that ensure either eradication or minimization of cancer cells from a patient's body, providing valuable insights for designing effective cancer treatments.

Investigating Attraction and Retention of Staff Within Public Mental Health Services in Victoria, Australia: Protocol for a Mixed Methods Study

BACKGROUND

A large proportion of Australians are affected by mental illness each year, and treatment gaps are well known. To meet current and future demands and enable access to treatment that is safe, effective, and acceptable, a robust and sustainable mental health workforce is required. Factors reported to attract people to work within the mental health sector include aspiring to help others, having an interest in mental health and human behavior, the desire to make a difference and do something worthwhile, personal lived experience, recognition, and value of discipline-specific roles. However, despite the various reasons people enter the public mental health workforce, recruitment and retention continue to be ongoing challenges. To date, there has been limited investigation into understanding which factors are most relevant to the current Victorian workforce. Furthermore, a comparison to health care workers outside of mental health is also needed to better understand the specific needs of staff within the mental health sector.

OBJECTIVE

This study aims to explore factors related to attraction, recruitment, and retention of the public mental health workforce in Victoria, Australia.

METHODS

The study is a multisite, mixed methods cross-sectional study to be conducted at 4 public hospital services within Victoria, Australia: 2 in metropolitan and 2 in regional or rural locations. Current, previous, and nonmental health workers will be asked to complete a 20-25-minute web-based survey, which is developed based on previous research and offered participation in an optional 30-60-minute semistructured interview to examine personal experiences and perceptions. Both aspects of the project will examine factors related to attraction, recruitment, and retention in the public mental health workforce. Differences between groups (ie, current, past, and nonmental health workers), as well as location, discipline, and health setting will be examined. Regression analyses will be performed to determine the factors most strongly associated with retention (ie, job satisfaction) and turnover intention. Qualitative data will be transcribed verbatim and thematically analyzed to identify common themes.

RESULTS

As of May 2023, we enrolled 539 participants in the web-based survey and 27 participants in the qualitative interview.

CONCLUSIONS

This project seeks to build on current knowledge from within Australia and internationally to understand role and service/system-related issues of attraction, recruitment, and retention specifically within Victoria, Australia. Seeking up-to-date information from across the health workforce may provide factors specific to mental health by illuminating any differences between mental health workers and health care workers outside of mental health. Furthermore, exploring motivators across health care disciplines and locations to enter, stay in, or leave a role in public mental health settings will provide valuable information to support how the sector plans and develops strategies that are fit for purpose.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48855.

A two-galectin network establishes mesenchymal condensation phenotype in limb development

Previous work showed that Gal-1A and Gal-8, two proteins belonging to the galactoside-binding galectin family, are the earliest determinants of the patterning of the skeletal elements of embryonic chicken limbs, and further, that their experimentally determined interactions in the embryonic limb bud can be interpreted via a reaction-diffusion-adhesion (2GL: two galectin plus ligands) model. Here, we use an ordinary differential equation-based approach to analyze the intrinsic switching modality of the 2GL network and characterize the network behavior independent of the diffusive and adhesive arms of the patterning mechanism. We identify two states: where the concentrations of both the galectins are respectively, negligible, and very high. This bistable switch-like system arises via a saddle-node bifurcation from a monostable state. For the case of mass-action production terms, we provide an explicit Lyapunov function for the system, which shows that it has no periodic solutions. Our model therefore predicts that the galectin network may exist in low expression and high expression states separated in space or time, without any intermediate states. We test these predictions in experiments performed with high density cultures of chick limb mesenchymal cells and observe that cells inside precartilage protocondensations express Gal-1A at a much higher rate than those outside, for which it was negligible. The Gal-1A and -8-based patterning network is therefore sufficient to partition the mesenchymal cell population into two discrete cell states with different developmental (chondrogenic vs. non-chondrogenic) fates. When incorporated into an adhesion and diffusion-enabled framework this system can generate a spatially patterned limb skeleton.

Prevalence and factors associated with mental health problems of psychological distress and depression among rural Victorians - analysis of cross-sectional data (Crossroads II)

BACKGROUND

Research suggests that rates of mental illness are similar in rural and urban Australia, although there are significant workforce shortages in rural regions along with higher rates of chronic disease and obesity and lower levels of socioeconomic status. However, there are variations across rural Australia and limited local data on mental health prevalence, risk, service use and protective factors. This study describes the prevalence of self-reported mental health problems of psychological distress and depression, in a rural region in Australia and aims to identify the factors associated with these problems.

METHODS

The Crossroads II study was a large-scale cross-sectional study undertaken in the Goulburn Valley region of Victoria, Australia in 2016-18. Data were collected from randomly selected households across four rural and regional towns and then screening clinics from individuals from these households. The main outcome measures were self-reported mental health problems of psychological distress assessed by the Kessler 10 and depression assessed by Patient Health Questionnaire-9. Unadjusted odd ratios and 95% confidence intervals of factors associated with the two mental health problems were calculated using simple logistic regression with multiple logistic regression using hierarchical modelling to adjust for the potential confounders.

RESULTS

Of the 741 adult participants (55.6% females), 67.4% were aged ≥ 55 years. Based on the questionnaires, 16.2% and 13.6% had threshold-level psychological distress and depression, respectively. Of those with threshold-level K-10 scores, 19.0% and 10.5% had seen a psychologist or a psychiatrist respectively while 24.2% and 9.5% of those experiencing depression had seen a psychologist or a psychiatrist, respectively in the past year. Factors such as being unmarried, current smoker, obesity, were significantly associated with a higher prevalence of mental health problems whereas physical activity, and community participation reduced the risk of mental health problems. Compared to rural towns, the regional town had higher risk of depression which was non-significant after adjusting for community participation and health conditions.

CONCLUSIONS

The high prevalence of psychological distress and depression in this rural population was consistent with other rural studies. Personal and lifestyle factors were more relevant to mental health problems than degree of rurality in Victoria. Targeted lifestyle interventions could assist in reducing mental illness risk and preventing further distress.

The impact of COVID-19 on the mental health workforce: A rapid review

The COVID-19 pandemic led to significant adaptations to healthcare. Provision of mental healthcare in a changing environment presented healthcare workers with unique challenges and demands, including changes in workload and expectations. To inform current and future healthcare service responses, and adaptations, the current review aimed to collate and examine the impact of the pandemic on mental healthcare workers (MHWs). We conducted a rapid systematic review to examine the overall impact of the COVID-19 pandemic on MHWs. Searches were conducted in Ovid Medline and PsycInfo and restricted to articles published from 2020. Inclusion criteria specified articles written in English, published in peer-reviewed journals, and that examined any outcome of the impact of COVID-19 on MHWs; 55 articles fulfilled these criteria. Outcomes were categorized into 'work-related outcomes' and 'personal outcomes'. Mental healthcare workers worldwide experienced a range of work-related and personal adversities during the pandemic. Key work-related outcomes included increased workload, changed roles, burnout, decreased job satisfaction, telehealth challenges, difficulties with work-life balance, altered job performance, vicarious trauma and increased workplace violence. Personal outcomes included decreased well-being, increased psychological distress and psychosocial difficulties. These outcomes differed between inpatient, outpatient and remote settings. The COVID-19 pandemic significantly altered the delivery of mental healthcare and MHWs experienced both work-related and personal adversities during the COVID-19 pandemic. With the continuation of changes introduced to healthcare in the initial stages of the pandemic, it will be important to maintain efforts to monitor negative outcomes and ensure supports for MHWs, going forward.

Improving maternal update rates within the first hour of NICU admission

BACKGROUND

Timely communication is essential in attaining maternal satisfaction, developing an excellent physician-patient rapport, and increasing trust. This study reports a significant improvement in maternal communication rates through the quality improvement method.

METHODS

An educational module was developed, and NICU staff was presented with the slides, followed by a performance questionnaire to demonstrate understanding. The first phase was completed by obtaining feedback from mothers through a questionnaire. The first plan-do-study-act (PDSA) cycle, carried out for eight weeks looking at the rates of the maternal update provided within an hour of admission of their neonates to the NICU, was followed by the second PDSA cycle, carried out for ten weeks. The improvement was calculated using conventional statistics and a statistical process control chart.

RESULTS

During the first phase of the study, thirty-six percent of the mothers were updated within an hour of admission of their neonates to the NICU. During the first PDSA cycle, we did not notice a special cause variation or process change. A significant shift, eight consecutive points above the mean, was noted on the control chart during PDSA cycle 2. The mean±SD of the weekly update rate increased significantly during PDSA cycle 2 (76.8±11) compared to PDSA cycle 1 (47.5±14), p-value = 0.0002.

CONCLUSION

We improved the maternal update rates through the educational module following the QI improvement model using the PDSA cycles.

TB disease patterns by HIV and diabetes status

BACKGROUND: TB is commonly categorised as pulmonary (PTB) or extrapulmonary TB (EPTB). Knowledge of TB disease patterns (PTB and/or EPTB) and determining risk factors remains limited.METHODS: This was a prospective cohort study using point-of-care ultrasound (POCUS) in Indian patients with presumed TB. Clinical and imaging data were used to develop refined case definitions for PTB, concurrent PTB and EPTB (PTB + EPTB) and EPTB without PTB (EPTB). These groups were analysed by HIV (HIV+/-) and diabetes mellitus (DM+/-) status.RESULTS: Of 172 HIV-/DM- patients with TB, 48% had PTB, 23% PTB + EPTB and 29% had EPTB, totalling 52% with any EPTB (PTB + EPTB or EPTB). In HIV+/DM- patients with TB (n = 35), 6% had PTB, 40% had PTB + EPTB and 54% had EPTB, accounting for 94% with EPTB. In HIV-/DM+ patients with TB (n = 61), 61% had PTB, 28% had PTB + EPTB and 11% had EPTB, representing 39% with EPTB.CONCLUSION: Refined case definitions revealed high proportions of EPTB even without HIV or DM. HIV further altered the TB disease pattern towards EPTB and DM towards PTB. Therefore, the dichotomy between PTB or EPTB does not represent the actual spectrum of TB disease. EPTB should receive higher priority in research and clinical practice.

ONCOLYTIC ACTIVITY OF HUMAN ORTHOPNEUMOVIRUS IN CANCER CELL LINES

Oncolytic virotherapy is an emerging biotherapeutic platform for selectively infecting cancer cells and triggering apoptosis in a number of malignant cells due to robust viral replication. Studies related to the oncolytic activity of human orthopneumovirus (hOPV) are conflicting.

AIM

This study was designed to elucidate the possible role of hOPV in the modulation of cell growth and apoptosis in cancer cell lines including human epidermoid carcinoma (HEp-2), lung epithelial cell line (A549), and breast cancer cell line (MCF-7).

MATERIALS AND METHODS

The oncolytic activity of hOPV on cancer cells was studied in vitro. The virus titers were determined by tissue culture infectious dose (TCID50/mL) in A549 cell. The cytotoxic effect of the virus on HEp-2, A549, and MCF-7 was determined using MTT and trypan blue dye exclusion test assays. hOPV in the infected cells was detected using real-time reverse transcription polymerase chain reaction (rRT-PCR) and indirect immunofluorescence (IIF) assays. The relative expression of apoptosis-related genes (CASP-3, -8, -9, Bax, Bcl-2, Bcl-XL, TP53, P21) during virus infection was estimated using rRT-PCR assay in comparison with the house-keeping gene (GAPDH).

RESULTS

hOPV infection inhibited the growth of HEp-2, A549, and MCF-7 cells in a dose-and time-dependent manner. At a multiplicity of infection (MOI) of 5, hOPV reduced the viability of A549 cells to about 16%, HEp-2 to 22%, and MCF-7 to 28% (p = 0.001), while no significant inhibitory effect was observed when cells were infected at MOI of 1 and 2. hOPV mRNA and antigens were detected in infected HEp-2, A549, and MCF-7 cells by RT-PCR and IIF. Upon hOPV infection, expression of CASP-3, -8, -9, as well as Bax, TP53, and p21 mRNA increased while expression of Bcl-2, Bcl-xL anti-apoptotic genes decreased. In hOPV-infected A549 cells, the fold increase of CASP-8 and CASP-9, Bax, TP53, and P21 expression exceeded significantly compared to that in HEp-2 or MCF-7 cells.

CONCLUSIONS

Our results provide evidence that hOPV could be a potential candidate for oncolytic virotherapy.

Levosulpiride and Ramosetron for the Prevention of Postoperative Nausea and Vomiting in Laparoscopic Surgery: A Prospective Randomized Double-blind Study

Background

Postoperative nausea and vomiting (PONV) continues to be common complication of anesthesia and surgery in spite of availability of so many antiemetic drugs and regimens for prevention. This study compared Ramosetron and Levosulpiride in terms of efficacy for PONV prevention after laparoscopic surgery.

Aim

To compare the efficacy of intravenous (i.v.) Levosulpiride 25 mg with i.v. Ramosetron 0.3 mg in preventing PONV.

Setting

S. D. M. College of Medical Sciences and Hospital, Sattur, Dharwad from November 2018 to June 2020.

Design

It is a prospective randomized double-blind study.

Statistical Analysis

All the data were collected, tabulated, and expressed as mean ± standard deviation. Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS 22.0 Evaluation version). Unpaired sample t-test and Chi-square test have been used for the quantitative and qualitative data, respectively. A P value of 0.05 was considered statistically insignificant.

Materials and Methods

This prospective randomized, double-blind study was conducted in 200 patients undergoing laparoscopic surgery falling under the inclusion criteria are numbered and every nth patient selected by systemic random sampling procedure and allocated into two groups of 100 each, group Levosulpiride (Group L) and group Ramosetron (group R) study drugs givenwithin 30 min induction of anesthesia. Group L will receive LEVOSULPIRIDE 25 mg i.v. Group R will receive RAMOSETRON 0.3 mg i.v.

Results

The incidence of vomiting in the Levosulpiride group and in the Ramosetron groupduring 0-4 h (20% vs. 30%, P = 0.1110), 4-8 h (4% vs. 5%, P = 0.7450), 8-12 h (5% vs. 4% P = 0.7210) and 12-24 h (0% vs. 0%). The incidence of nausea and overall PONV and the use of rescue antiemetic was not significantly different during all time intervals. The severity of nausea was not different between the two groups. Difference in the efficacy of Levosulpiride and Ramosetron was statistically insignificant (P > 0.05) in the prevention of PONV.

Conclusion

Levosulpiride 25 mg or Ramosetron 0.3 mg given intravenously to prevent PONV inpatients undergoing elective laparoscopic surgery under general anesthesia are equally effective in controlling PONV.

Online KidClot education for patients and families initiating warfarin therapy: The eKITE study

Anticoagulation with Vitamin K antagonists (VKA) has always posed challenges in terms of monitoring requirements. These challenges were further exacerbated in the setting of the COVID-19 pandemic, with limited access to and/or avoidance of laboratory testing. The importance of utilizing point of care (POC) health technology for individualized patient management is salient. The foundation of effective home INR monitoring is establishing patient knowledge about their therapy and INR testing proficiency. The eKITE series was developed to support patients in establishing foundational knowledge required for VKA (warfarin) management and INR monitoring. The primary objectives were to evaluate eKITE, a patient-oriented innovative online education program for warfarin therapy, participant learning stress, and patient preference for online learning. This multi-center prospective study provided patients access to warfarin online education. Participants were required to complete written quizzes assessing warfarin knowledge of key concepts proficiency and identifying knowledge deficits. Patient preference, evaluating calm (lack of anxiety) while learning, and an INR on a home meter was completed. Participants performed INR tests at home and reported INRs by telephone. The analysis included 144 children and caregivers enrolled at five US and CDN sites. Most indications for anticoagulation were cardiac (congenital or acquired heart disease) with varied INR target ranges. Mean knowledge scores for warfarin and INR self-testing modules were 97%, with low anxiety with TTR of 84%. Patient preferred online learning. eKITE is an effective teaching modality for warfarin/home INR monitoring with safe INR testing and warfarin management that is appropriate for pediatrics and adults alike. PROLOGUE: The whir in the hallways is deafening. Lights bright, alarms are ringing in a chorus of unsynchronized beeps and screeches. It has been more than a week since I have slept. Snuggled beside me is my precious child, whining and equally irritated with the asynchronous symphony, further compounded by anxiety, procedures, and pain. The sun has broken. The staff smiles are welcoming and incessant, as one after one, they approach hurried, urgent, assiduous, their need to coach me for our upcoming departure to the warmth of home. Each provides essential information that I will require to keep my child, my treasure, safe and healthy. Yet, my eyes are heavy, blurred, and my brain foggy, trapped in a dark heavy cloud. How am I to follow? Comprehend? and retain anything? As they instruct, my precious child yearns for loving arms, compassion and love, whining, crying in disquiet. Overwhelmed does not adequately describe my ineffable exhaustion. Amidst this, how am I to learn about warfarin? Such a challenging medication, with so much to know. Concentrate, I tell myself, focus; now is my only opportunity to learn. I must be alert. It seems to be nonsensical.

Data of 16S rRNA gene amplicon-based metagenomic signatures of arecanut rhizosphere soils in Yellow Leaf Disease (YLD) endemic region of India

Arecanut (Areca catechu L.) is an important plantation crop cultivated predominantly in the Indian states of Karnataka, Kerala, Assam, West Bengal, and Maharashtra in an area of 5.19 lakh ha, with Karnataka State alone accounting for about 68.41% of the area and 79.97% of production. Arecanut production has recently been hampered due to environmental and disease pressures, especially the escalating incidence of Yellow Leaf Disease (YLD). The involvement of phytoplasma as the etiological agent of YLD has been reported. Symptoms include yellowing at the tip of leaflets of two or three fronds of the outer most whorl which gradually spreads to the inner whorl of leaves. As the disease progresses, the entire crown becomes yellow leaving only the spear leaf green. In severe cases, the affected leaves often show necrosis from their tips. In advanced stages, the leaves are reduced in size and become stiff and pointed and the crown ultimately falls off. Degeneration of cortex is commonly observed in the diseased roots. The kernel of affected nuts shows discolouration and later turns blackish. The reduction in yield over a period of three years, immediately after the incidence of the disease, has been estimated to be around 50%. Harnessing the arecanut–microbiome interactions to address the biotic and abiotic stresses of the host plant offers immense opportunity to increase arecanut production sustainably. Here, we report a comprehensive analysis of the structural composition of the arecanut rhizosphere bacterial diversity utilizing next-generation sequencing (NGS) technology. We have used amplicon sequencing (V3-V4 regions of the 16S rRNA gene) of bulk soil and rhizosphere samples collected from YLD endemic regions of Aranthodu, Sullia Taluk, Dakshina Kannada District, Karnataka State, India, to assess the microbial diversity. The results revealed that while there is a great diversity of bacterial communities, relatively few bacterial phyla predominate with higher relative abundance. The phyla viz., Proteobacteria, Bacteroidetes, Firmicutes, Acidobacteria, Planctomycetes, Patescibacteria, Chloroflexi, Actinobacteria, Fusobacteria, and Verrucomicrobia were found to be dominant in the rhizosphere of the arecanut.

Steroids use in non-oxygen requiring COVID-19 patients: a systematic review and meta-analysis

BACKGROUND

Corticosteroids have become the mainstay treatment in severe COVID-19. However, its role is mild disease is controversial due to lack of robust scientific evidence. This systematic review and meta-analysis were conducted to assess effect of steroids in mild COVID-19 patients.

METHODS

PubMed, EMBASE, Web of Science and medRxiv were searched from 31 December 2019 to 14 May 2021 for studies that reported effectiveness of steroids in non-oxygen requiring COVID-19 patients in terms of progressing to severe disease, mortality, duration of fever, duration of viral clearance and length of hospital stay (LOHS). Studies on inhalational steroids, case reports and reviews were excluded. Risk of bias (ROB) was assessed by the Cochrane's ROB tool and ROBANS tool. Quantitative data synthesis was done using the generic inverse variance method.

RESULTS

A total of 6411 studies were identified, 2990 articles were screened after exclusion. Seven studies which fit the criteria (involving 2214 non-oxygen requiring COVID-19 patients) were included and analysed. Overall odds of progression to severe disease among the non-oxygen requiring COVID-19 patients receiving steroids was 5.97 [95% confidence interval (CI): 1.27-27.99, I2 = 0%] and odds of death (OR: 1.35, 95% CI: 1.01-1.79; I2 = 0%) as compared to the patients not receiving steroids. Mean duration of fever (7.4 days), duration to viral clearance (18.9 days) and LOHS (20.8 days) were significantly higher in the steroid arm, as compared to that in no-steroid arm (6.7, 16.5 and 15.2 days, respectively).

CONCLUSION

Steroids in non-oxygen requiring COVID-19 patients can be more detrimental than beneficial.

PROTOCOL REGISTRATION

The study was prospectively registered in PROSPERO (CRD 42021254951).

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

BACKGROUND

Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

AIM

Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

DESIGN

This was a retrospective, single-centre, observational study.

METHODS

We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

RESULTS

Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

CONCLUSION

COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Mid-term follow-up of percutaneous access for standard and complex EVAR using the ProGlide device

OBJECTIVES

Endovascular Aneurysm Repair is an established treatment for abdominal aortic aneurysm which requires arterial access via the groin. Most centres perform percutaneous ultrasound-guided access into the common femoral artery for delivery of the stent graft. The profile of endovascular devices necessitates large sheath sizes, therefore formal closure of the arterial puncture site is required. Various percutaneous devices are available, with data lacking on efficacy and mid-term safety profile. We present outcomes from a single centre with the Perclose ProGlide™ (Abbott Vascular Devices, CA, USA) suture-mediated system, using the well described "pre-close" technique.

MATERIALS & METHODS

Data were collected from operative records and electronic medical records. Patients undergoing standard (EVAR) or complex (F/B-EVAR) aneurysm repair between March 2015 and September 2019 were included. Complications were recorded per-patient and per-groin procedure.

RESULTS

266 patients were included; 182 (68.4%) standard infrarenal EVAR, 84 (31.6%) F/B-EVAR. There were a total of 484 groin procedures performed. Intraoperative Perclose ProGlide™ success was 98.1% (per patient) or 99.0% (per groin procedure). 30-day groin complication rate was 6.1% (per patient) or 3.1% (per groin procedure). There were no pre- or peri-operative factors which predicted the occurrence of groin complications. The rate of groin complications was not related to sheath size.

CONCLUSIONS

Our data support the use of percutaneous access with a pre-close technique for a variety of endovascular aneurysm repair procedures with both large- and small-bore access. The Perclose ProGlide™ system provides excellent mid-term complication-free and reintervention-free outcomes for groin procedures.

Matrix adhesion and remodeling diversifies modes of cancer invasion across spatial scales

The metastasis of malignant epithelial tumors begins with the egress of transformed cells from the confines of their basement membrane (BM) to their surrounding collagen-rich stroma. Invasion can be morphologically diverse: when breast cancer cells are separately cultured within BM-like matrix, collagen I (Coll I), or a combination of both, they exhibit collective-, dispersed mesenchymal-, and a mixed collective-dispersed (multimodal)- invasion, respectively. In this paper, we asked how distinct these invasive modes are with respect to the cellular and microenvironmental cues that drive them. A rigorous computational exploration of invasion was performed within an experimentally motivated Cellular Potts-based modeling environment. The model comprised of adhesive interactions between cancer cells, BM- and Coll I-like extracellular matrix (ECM), and reaction-diffusion-based remodeling of ECM. The model outputs were parameters cognate to dispersed- and collective- invasion. A clustering analysis of the output distribution curated through a careful examination of subsumed phenotypes suggested at least four distinct invasive states: dispersed, papillary-collective, bulk-collective, and multimodal, in addition to an indolent/non-invasive state. Mapping input values to specific output clusters suggested that each of these invasive states are specified by distinct input signatures of proliferation, adhesion and ECM remodeling. In addition, specific input perturbations allowed transitions between the clusters and revealed the variation in the robustness between the invasive states. Our systems-level approach proffers quantitative insights into how the diversity in ECM microenvironments may steer invasion into diverse phenotypic modes during early dissemination of breast cancer and contributes to tumor heterogeneity.

Practical approach for safe anesthesia in a COVID-19 patient scheduled for emergency laparotomy

COVID-19 patients presenting for emergency laparotomy require evaluation of surgical illness and viral disease. As these patients are likely to have a wide spectrum of deranged physiology and organ dysfunction, optimization should start preoperatively and continue through intraoperative and postoperative recovery periods along with appropriate antimicrobial cover. The goal should be not to delay damage control surgery in favor of evaluation and optimization. When a COVID-19 positive or suspected patient is to be operated for laparotomy, the situation often demands general anesthesia with invasive monitoring and analgesia complemented by regional anesthesia to minimize postoperative opioid requirements to facilitate early recovery. This particular article addresses the issues related to emergency laparotomy management in relation to COVID-19 patient. Healthcare workers should diligently use effective PPE and practice disinfection to prevent spread. Video-communication is an effective means of evaluation. Information expected from investigations should be weighed against risk of exposure to healthcare workers/laypersons. Simulation and memory aids should be used to familiarize team members with roles and techniques of management while in PPE. Step-wise detailed planning for patient transfer, anesthesia induction, maintenance and emergence, aid in enhancing HCW safety without compromising patient care.

Peri-operative management of percutaneous fetoscopic spina-bifida repair: a descriptive review of five cases from the United Kingdom, with focus on anaesthetic implications

We present a case-based review of the first five percutaneous fetoscopic in-utero spina bifida repair procedures undertaken in the UK. Our focus is on implications of anaesthesia and analgesia for the mother and fetus, provision of uterine relaxation and fetal immobilisation while providing conditions conducive to surgical access. Minimising risks for fetal acidosis, placental and fetal hypoperfusion, maternal and fetal sepsis and maternal fluid overload were the foremost priorities. We discuss optimisation strategies undertaken to ensure fetal and maternal well-being under anaesthesia, shortcomings in the current approach, and possible directions for improvement.

IMRiS phase II study of IMRT in limb sarcomas: Results of the pre-trial QA facility questionnaire and workshop

INTRODUCTION

Soft tissue sarcomas of the extremities (STSE) are rare malignancies. We report current UK practice for immobilisation of soft tissue sarcoma of STSE, as part of the initial study set-up within the IMRiS trial, a phase II study of intensity modulated radiotherapy (IMRT) in primary bone and soft tissue sarcoma.

METHODS

A facility questionnaire (FQ) was circulated to 29 IMRiS centres investigating the variation in immobilisation devices, planning techniques, and imaging protocols. A workshop was held to address concerns raised by centres. It focused on STSE immobilisation and patient set-up. Robustness of patient set-up at each centre was evaluated based on the following criteria: evidence of local set-up audit, calculation of margins based on set-up audit results, imaging frequency, and number of patients treated per centre per annum.

RESULTS

Twenty-seven (93%) questionnaires were returned. 30% (8/27) of responders routinely treated STSE with IMRT. The remaining 70% (19/27) had little or no experience with IMRT for STSE. Vacuum bags were the most frequent immobilisation device (9/27), followed by thermoplastic shells (7/27). Nine centres had audited their local set-up; however, only 4 had calculated margins in response to the results. Ten centres were classified as having high level of robustness.

CONCLUSIONS

Immobilisation devices and planning techniques for STSE are inconsistent across centres. Robustness of set-up is an important tool to ensure quality of results in a multicentre trial setting with such different levels of experience. The IMRiS trial Quality Assurance programme encourages centres to assess robustness of set-up through local audit and subsequent calculation of treatment margins.

IMPLICATIONS FOR PRACTICE

This is the first study that used robustness criteria to tailor QA support to individual centres.

Abstract P6-20-10: Role of GPR110 in breast cancer

Our long-term goal is to discover adhesion GPCR targets in breast cancer. Our previous studies have found GPR110 to be overexpressed in tumorigenic cell population as well as in anti-HER2 drug-resistant derivatives of HER2+ breast cancer cells. In subsequent studies, we found that GPR110 knockdown inhibited anchorage-independent cell growth, mammosphere formation, and invasion/migration of HER2+ breast cancer cells. Conversely, overexpression of GPR110 by lentiviral delivery of cDNA enhanced anchorage-independent cell growth, mammosphere formation, and invasion/migration in HER2+ breast cancer cells. In addition, GPR110 overexpression led to increase in the % of Aldefluor-positive tumorigenic cell population, further emphasizing the role of GPR110 as a mediator of tumorigenesis in addition to the metastatic processes in HER2+ breast cancer. Among various subtypes of breast cancer, GPR110 expression was higher in HER2+ and basal subtypes, most of which are triple-negative (negative for ER, PR, and HER2), compared to luminal A and B subtypes. GPR110 was either gene amplified or upregulated in 4% of all breast cancers based on the publicly available TCGA dataset. GPR110 overexpression predicted poorer recurrence-free survival in triple-negative breast cancer. Furthermore, GPR110 was overexpressed in brain metastatic lesions compared to mammary tumors in patient-derived xenograft models of triple-negative breast cancer (WHIM2 and WHIM30). Knocking down GPR110 reduced anchorage-dependent and -independent cell growth, mammosphere formation, and invasion/migration of triple-negative breast cancer cells. Overall, our results suggest that GPR110 may be a potential drug target in HER2+ and triple-negative breast cancer. Drug discovery efforts to identify GPR110 antagonists will provide useful pharmacological tools for validating GPR110 as a drug target in breast cancer. Since GPR110 is also overexpressed in various other types of cancer, understanding the mechanism of GPR110 upregulation and signaling in cancer is an important future direction.

This work was supported by the Department of Defense Grants W81XWH-14-1-0340 and W81XWH-14-1-0341 to Drs. Trivedi and Schiff, respectively.

Citation Format: Bhat R, Qin L, De Angelis C, Sahay D, Bhargava D, Creighton C, Yadav P, Yazdanfard S, Alrawi A, Yadav V, Vasaikar S, Nanda S, Sethunath V, Fu X, Zhang B, Narkar V, Schiff R, Trivedi M. Role of GPR110 in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-20-10.

Longitudinal study of health, disease and access to care in rural Victoria: the Crossroads-II study: methods

Background

High quality, contemporary data regarding patterns of chronic disease is essential for planning by health services, policy makers and local governments, but surprisingly scarce, including in rural Australia. This dearth of data occurs despite the recognition that rural Australians live with high rates of ill health, poor health behaviours and restricted access to health services. Crossroads-II is set in the Goulburn Valley, a rural region of Victoria, Australia 100–300 km north of metropolitan Melbourne. It is primarily an irrigated agricultural area.

The aim of the study is to identify changes in the prevalence of key chronic health conditions including the extent of undiagnosed and undermanaged disease, and association with access to care, over a 15 year period.

Methods/design

This study is a 15 year follow up from the 2000–2003 Crossroads-I study (2376 households participated). Crossroads-II includes a similar face to face household survey of 3600 randomly selected households across four towns of sizes 6300 to 49,800 (50% sampled in the larger town with the remainder sampled equally from the three smaller towns). Self-reported health, health behaviour and health service usage information is verified and supplemented in a nested sub-study of 900 randomly selected adult participants in ‘clinics’ involving a range of additional questionnaires and biophysical measurements. The study is expected to run from October 2016 to December 2018.

Discussion

Besides providing epidemiological and health service utilisation information relating to different diseases and their risk factors in towns of different sizes, the results will be used to develop a composite measure of health service access. The importance of access to health services will be investigated by assessing the correlation of this measure with rates of undiagnosed and undermanaged disease at the mesh block level. Results will be shared with partner organisations to inform service planning and interventions to improve health outcomes for local people.

Stent Graft Exclusion of Pseudo-Aneurysm Arising from PTFE Hemodialysis Graft after Recurrence following Ultrasound Guided Thrombin Injection

There are various non-invasive or minimally invasive techniques for management of pseudoaneurysms including ultrasound guided compression, ultrasound guided thrombin injection and covered stent placement. We report a case where a covered stent graft was successfully used for the treatment of a pseudoaneurysm directly arising from a PTFE graft which recurred 3 months following treatment with ultrasound guided thrombin injection.

Lectin-gated and glycan functionalized mesoporous silica nanocontainers for targeting cancer cells overexpressing Lewis X antigen

Gated mesoporous silica nanoparticles can deliver payload upon the application of a predefined stimulus, and therefore are promising drug delivery systems. Despite their important role, relatively low emphasis has been placed on the design of gating systems that actively target carbohydrate tumor cell membrane receptors. We describe herein a new Lewis X (Le^x) antigen-targeted delivery system comprising mesoporous silica nanoparticles (MSNs) loaded with ATTO 430LS dye, functionalized with a Le^x derivative (1) and capped with a fucose-specific carbohydrate-binding protein (Aleuria aurantia lectin (AAL)). This design takes advantage of the affinity of AAL for Le^x overexpressed receptors in certain cancer cells. In the proximity of the cells, AAL is detached from MSNs to bind Le^x, and selectins in the cells bind Le^x in the gated MSNs, thereby inducing cargo delivery. Gated MSNs are nontoxic to colon cancer DLD-1 cells, and ATTO 430LS dye delivered correlated with the amount of Le^x antigen overexpressed at the DLD-1 cell surface. This is one of the few examples of MSNs using biologically relevant glycans for both capping (via interaction with AAL) and targeting (via interaction with overexpressed Le^x at the cell membrane).

Detection of Free Radicals in Electron Beam-Irradiated Mucuna pruriens (L. DC.) Seeds by Electron Spin Resonance

Electron spin resonance (ESR) spectroscopy was employed to detect free radicals in raw Mucuna pruriens (velvet bean) seeds after electron beam irradiation (Microtron source: 0, 2.5, 5, 7.5, 10, 15 and 30 kGy) and conventional processing (roasting, powdering and cooking). The ESR signal of irradiated seeds (g=2.0055±0.0001) was more prominent in the seed coat than cotyledon. Seed coat of irradiated samples showed dose-dependent linear increase of this signal (g = 2.0055) accompanied by a weak triplet (satellite peak; aH = 3 mT) produced exclusively by radiolysis and could be used as an indication of successful irradiation. Irradiated cotyledon portion devoid of satellite peak (triplet) showed a linear increase in signal intensity up to 10 kGy with a sharp decline at higher doses (15 and 30kGy). Stability of radiation-induced ESR signals after 6 months of storage (25 ± 1°C) revealed the presence of a weak triplet with a substantial loss of signal intensity. Thermal effects such as roasting and powdering of seeds increased the signal intensity (g = 2.0055) similar to or in greater proportion than irradiation. Phenolics in seeds, which contribute significantly to detect free radicals in vegetative parts of a plant showed a waning trend in seed coat, while it was vice versa in cotyledon. Textural studies revealed significant loss in firmness after irradiation (p<0.05), which might favour in minimising the cooking time. Results of the present study might help to divulge the beneficial effects of application of electron beam irradiation technology as a better alternative to fumigants in seed preservation for safety and quarantine purposes.

A Cross Cultural Study of Communication Strategies for Building Business Relationships

This study aims to explore communication strategies for relationship building across cultures from a linguistic as well as a culture-specific perspective. Specifically, it sees business relationships as part of social capital and compares communication strategies used to build relationships in sales firms. The research method is based on a discourse analysis of interviews with business managers, which also incorporates their success stories. In the analysis, relationship building is divided into two stages: the initiating stage and the maintaining stage. It has been found that more interpersonal strategies have been employed by Chinese and Indian business managers when initiating a business relationship. In contrast, the New Zealand and South African managers tend to use more impersonal communication strategies to promote public relations. Similar interpersonal communication strategies are employed in all the target cultures for maintaining relationships. However, a stronger orientation for long-term relationships in the Chinese and Indian cultures has been identified. Furthermore, the communication strategies are dynamic in all the countries investigated since they are becoming more and more multicultural and increasingly globalized in international business and management.

Disorders of the lymphatic system of the abdomen

The lymphatic system of the abdomen comprises of the cisterna chyli, its major and minor lymphatic tributaries, and lymph nodes. Disorders of the lymphatic system of the abdomen are rarely encountered and consist of primary and secondary types. Abdominal lymphangiomas constitute the majority and have characteristic imaging features. Complicated lymphangiomas may pose a diagnostic dilemma. Generalised systemic lymphangiomatosis is a rare condition and affects major organs with a poor prognosis. Retroperitoneal lymphangiectasia in the appropriate setting might predict underlying infection, such as filariasis. Other acquired conditions include iatrogenic or treatment-induced chylocoele. Chylous ascites can be secondary to multiple causes and can be confirmed by biochemical testing and lymphangiogram in appropriate settings.

Suicide rates in five-year age-bands after the age of 60 years: the international landscape

BACKGROUND

There is paucity of studies examining suicide rates in narrow five-year age-bands after the age of 60 years. This study examined suicide rates in eight five-year age-bands between the age of 60 and 99 years because this will allow more precise comparison between the young old (60-79 years) and the oldest old (80+ years) age groups.

METHODS

Data on the number of suicides (International Classification of Diseases - ICD-10 codes, X60-84) in each of the eight five-year age-bands between the age-bands 60-64 years and 95-99 years in both gender for as many years as possible from 2000 were ascertained from three sources: colleagues with access to national data, national statisics office websites and email contact with the national statistics offices. The population size for the corresponding years and age-bands was estimated for each country using data provided by the United Nations website.

RESULTS

In men, suicide rates continued to increase for each of the seven five-year age-bands from 60-64 years to 90-94 years age-band, and then declined slightly for the 95-99 year age-band. In women, suicide rates continued to increase for each of the six five-year age-bands from 60-64 years to 85-89 years age-bands, and then declined slightly for the 90-94 years and 95-99 years age-bands.

CONCLUSIONS

The overall global suicide rates for each of the eight five-year age-bands are sufficiently large for them to constitute a public health concern. This is especially important given the ongoing rise in the elderly population size and the paucity of data on risk and protective factors for suicide in the five-year age-bands after the age of 60 years.

Comparison of intranasal dexmedetomidine and dexmedetomidine-ketamine for premedication in pediatrics patients: A randomized double-blind study

BACKGROUND

Goal of premedication in pediatric anesthesia are relieving pre and postoperative anxiety, good parental separation, and smooth induction of anesthesia. Anxiety can produce aggressive reactions, increased distress, increased postoperative pain and postoperative agitation. The benzodiazepine, midazolam, is the most frequently used premedication in pediatric anesthesia. Midazolam has a number of beneficial effects when used as premedication in children: Sedation, fast onset, and limited duration of action. Though midazolam has a number of beneficial effects, it is far from an ideal premedicant having untoward side effects such as paradoxical reaction, respiratory depression, cognitive impairment, amnesia, and restlessness. Dexmedetomidine is a newer α-2-agonist, which can be used as premedicant.

AIMS

To compare the level of sedation, parental separation, mask acceptance, postoperative recovery of intranasal premedication with dexmedetomidine and dexmedetomidine-ketamine combination in pediatric patients.

SETTINGS AND DESIGN

Prospective randomized double-blind study.

SUBJECTS AND METHODS

After written informed consent from the patient's parents or legal guardian, 54 children of American Society of Anesthesiologists physical status I or II, aged between 1 and 6 years, scheduled to undergo elective minor surgery were enrolled. In group D patient received 1 μg/kg dexmedetomidine intranasally and in group DK received 1 μg/kg dexmedetomidine and 2 mg/kg ketamine intranasally. Patients were assessed every 10 min for the level of sedation, parenteral separation, heart rate, and oxygen saturation by an independent observer. Mask acceptance and postoperative agitation were noted using an appropriate scale.

STATISTICAL ANALYSIS USED

Pearson Chi-square analysis to determine differences between two groups with respect to separation anxiety and acceptance of the anesthesia mask. Percentages used to represent frequencies. The level of significance was set at P< 0.05.

RESULTS

Acceptable parenteral separation was achieved in 90% of patients 30 min after premedication. Sedation was acceptable in 80% of patients at induction. Good mask acceptance was seen in 60% of patients. The incidence of emergence agitation (EA) was 2%. None of the above parameters was statistically significant between the two groups.

CONCLUSIONS

Dexmedetomidine, as premedicant in children provides acceptable parenteral separation. However, mask acceptance in operation room is poor. Combination of dexmedetomidine and ketamine does not increase the success of premedication. Use of dexmedetomidine is associated with decreased EA.

Comparison of Macintosh laryngoscope and C-MAC video laryngoscope for intubation in lateral position

Background and Aims:

Endotracheal intubation is conventionally performed when the patient is in supine position. It may be required to secure airway in laterally positioned patient. Tracheal intubation in lateral position seems to be difficult because the laryngeal view is compromised. Hence, C-MAC video laryngoscope (Karl Storz, Germany), a newer device using a modified macintosh blade may be useful for intubation in lateral position.

Material and Methods:

A total of 100 American Society of Anesthesiologists Grade I and II patients, randomly allotted to C-MAC or direct laryngoscopy group. Patients with difficult airway were excluded. After induction of anesthesia, patient was put in right-lateral position and intubation was carried out by consultant who is well-versed in using C-MAC laryngoscope. Time for intubation, number of attempts, Modified Cormack – Lehane grade, mucosal injury, and external laryngeal manipulation applied were noted.

Statistical Analysis:

Demographics and baseline airway assessments were analyzed using summary statistics. Unpaired t-test was used to assess intubation time. Number of attempts, esophageal intubation, dental injury, mucosal injury, use of stylet, and application of external laryngeal manipulation were analyzed using Chi-square test.

Results:

Overall intubation success rate was 100%. The time taken in C-MAC group was 24.8 ± 8.5 s and in direct group was 33.8 ± 9.12 s. The number of intubation attempts was not significant. Cormack – Lehane grade was better with C-MAC laryngoscope. Mucosal injury and use of external laryngeal manipulation was more in direct group.

Conclusion:

C-MAC is better than Macintosh laryngoscope for intubation in lateral position.

Thermoresponsive block copolymer micelles with tunable pyrrolidone-based polymer cores: structure/property correlations and application as drug carriers

Residue structure affects the physicochemical properties, drug loading efficiency, and thermoresponsive drug release profiles of block copolymer micelles with pyrrolidone-based polymer cores.

Effect of residue structure on the thermal and thermoresponsive properties of γ-substituted poly(N-acryloyl-2-pyrrolidones)

We discuss the results of an investigation into the structure/property correlations of γ-substituted poly(N-acryloyl-2-pyrrolidone)s, a recently reported class of pyrrolidone-based polymers prepared from pyroglutamic acid, a bio-derived resource.

Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome

The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity (wherein the scapulae ride high on the back), synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA). After intubation, we used second smaller endotracheal tube (ETT) to stabilize and elongate the first ETT while removing the LMA.

The use of cinacalcet in pregnancy to treat a complex case of parathyroid carcinoma

We present the case of a patient with metastatic parathyroid carcinoma whose hypercalcaemia was medically managed through two pregnancies. The diagnosis was made when the patient presented with chronic knee pain and radiological findings consistent with a brown tumour, at the age of 30. Her corrected calcium and parathyroid hormone (PTH) levels were significantly elevated. Following localisation studies, a right parathyroidectomy was performed with histology revealing parathyroid carcinoma, adherent to thyroid tissue. Aged 33, following biochemical recurrence of disease, the patient underwent a second operation. A subsequent CT and FDG–PET revealed bibasal pulmonary metastases. Aged 35, the patient was referred to our unit for treatment of persistent hypercalcaemia. The focus of treatment at this time was debulking metastatic disease using radiofrequency ablation. Despite advice to the contrary, the patient conceived twice while taking cinacalcet. Even though there are limited available data regarding the use of cinacalcet in pregnancy, both pregnancies continued to term with the delivery of healthy infants, using intensive medical management for persistent hypercalcaemia.