The need for creation of new learning outcomes in core curricula publications on differences in sex development and transgender anatomy

Despite recognition that sex is a spectrum there are no learning outcomes in the Anatomical Society's Core Curricula that effectively deal with the anatomy of differences in sex development or the anatomy of transgender individuals who have undergone gender affirming surgery. We believe this is a gap that needs to be plugged urgently. Particularly in relation to healthcare students the consequence of perpetuating the stereotype of sexual dimorphism as a norm could marginalise these communities of patients even further. We believe that action in the form of a Delphi process to create new outcomes can be a first step in creating change that will lead to a more inclusive anatomy education.

Neurologic Manifestations of Long COVID Differ Based on Acute COVID-19 Severity

OBJECTIVE

To characterize neurologic manifestations in post-hospitalization Neuro-PASC (PNP) and non-hospitalized Neuro-PASC (NNP) patients.

METHODS

Prospective study of the first 100 consecutive PNP and 500 NNP patients evaluated at a Neuro-COVID-19 clinic between 5/2020 and 8/2021.

RESULTS

PNP were older than NNP patients (mean 53.9 vs 44.9 y; p < 0.0001) with a higher prevalence of pre-existing comorbidities. An average 6.8 months from onset, the main neurologic symptoms were "brain fog" (81.2%), headache (70.3%), and dizziness (49.5%) with only anosmia, dysgeusia and myalgias being more frequent in the NNP compared to the PNP group (59 vs 39%, 57.6 vs 39% and 50.4 vs 33%, all p < 0.003). Moreover, 85.8% of patients experienced fatigue. PNP more frequently had an abnormal neurologic exam than NNP patients (62.2 vs 37%, p < 0.0001). Both groups had impaired quality of life in cognitive, fatigue, sleep, anxiety, and depression domains. PNP patients performed worse on processing speed, attention, and working memory tasks than NNP patients (T-score 41.5 vs 55, 42.5 vs 47 and 45.5 vs 49, all p < 0.001) and a US normative population. NNP patients had lower results in attention task only. Subjective impression of cognitive ability correlated with cognitive test results in NNP but not in PNP patients.

INTERPRETATION

PNP and NNP patients both experience persistent neurologic symptoms affecting their quality of life. However, they harbor significant differences in demographics, comorbidities, neurologic symptoms and findings, as well as pattern of cognitive dysfunction. Such differences suggest distinct etiologies of Neuro-PASC in these populations warranting targeted interventions. ANN NEUROL 2023;94:146-159.

Imaging Recommendations for Diagnosis, Staging and Management of Larynx and Hypopharynx Cancer

We discussed the imaging recommendations for diagnosis, staging, and management of larynx and hypopharynx cancer. Carcinoma of the larynx is a common cancer, with males being affected more. Hypopharyngeal carcinoma is less common than laryngeal malignancies. Squamous cell carcinoma is the most common histological type. Nonsquamous cell malignant lesions are rare and mostly submucosal lesions. Clinical examination and endoscopy play an integral role in its detection and staging. Imaging also plays a major role in its staging, including local disease extent, nodal and distant metastatic status, as well as to assess response to therapy. Follow-up of treated cases and differentiation of recurrence from post treatment changes can be done on imaging. Early stage disease is treated with single modalities such as radiotherapy or surgery. Advanced disease is treated with multimodality of either chemoradiotherapy or surgery followed by adjuvant radiotherapy with or without concurrent chemotherapy.

1294 ASSESSMENT AND MANAGEMENT OF FRAILTY: A SURVEY OF HEALTHCARE PROFESSIONALS

Introduction

By 2030, it is estimated that 25% of Europeans will be aged over 65. [Dugarova; UN Development Programme; 2017] Frailty in this group is a key contributor to poorer outcomes. [Eamer; BMC Anesthesiology; 2017; 17:99] The term is common in healthcare but research into the issues faced by staff around assessment and management of frailty has been limited. We undertook a survey to identify challenges faced in providing care to those living with frailty and considered potential interventions.

Method

The survey was across three hospitals in our health board (which serves a population of around 390,000 with a range of services). [SBUHB;2022] It was developed iteratively through consultation in a multidisciplinary group and adapted questions from other similar validated surveys. [Eamer; BMC Anesthesiology; 2017; 17:99][Taylor; Future Healthcare Journal; 2017; 4(3):207-212].

Results

218 responses were received covering a variety of medical and surgical specialties. Participants showed a strong (80%) self-reported understanding of frailty as a clinical concept, but only 46% felt confident in their ability to assess patients for frailty. 74% stated they would benefit from more education on frailty. Other barriers included systemic challenges such as staffing and social care, but also a lack of understanding of frailty by patients and relatives which impacted shared decision-making.

Conclusions

The survey showed a significant demand for more education, especially awareness of pathways and assessment methods. It also highlighted the issue of patients’ (and relatives’) lack of understanding of frailty. In response, we are planning a targeted multi-disciplinary educational programme on frailty across the health board, as well as introducing patient information leaflets.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

1017 EVALUATION OF FRAILTY DOCUMENTATION PRE AND DURING THE COVID-19 PANDEMIC IN A LARGE REGIONAL CENTRE

Background

Identifying frailty can lead to improvements in patient outcomes through interventions such as CGA and prompt discussions around resuscitation and ACP. [Welsh; International Journal of Clinical Practice; 2014; 290– 293] Frailty is associated with a higher risk of postoperative mortality and morbidity, and mortality due to COVID-19.[Parmar; Annals of Surgery; 2021; 709–718, Dumitrascu; Journal of the American Geriatrics Society; 2021; 2, 419– 2, 429] Our audit considers whether the pandemic had any effect on documentation of frailty, and identifies interventions to improve this process.

Method

We retrospectively reviewed notes to look for elements of social history which identify frailty including mobility, ADLs, and CFS. We conducted a series of spot audits in February 2020 (pre-pandemic), April 2021 (Wave 2), and November 2021 (Wave 3) across surgical and medical wards.

Interventions and Results

February 2020 This cohort consisted of 62 patients and showed poor documentation across both medicine and surgery with an average of only 21% relevant social history recorded and 0% CFS scoring. Interventions that followed included an educational series by geriatricians and introduction of triaging tools based on CFS in response to the pandemic e.g. Swansea Hip interrogation Fracture Tool (SHiFT). [Cronin; British Orthopaedic Association; 2020] April 2021 The relevant documentation improved to an average of 31% in this cohort of 37 patients. Interventions that followed included further educational sessions on frailty, a surgical liaison service, and the appointment of an orthogeriatrician. November 2021 This cohort consisted of 149 patients, average relevant social history continued to improve to 49%. Subgroup analysis showed 76% of orthopaedics patients had a CFS score, including 100% of NOF patients.

Conclusion

Frailty is important as it is linked to an increased risk of mortality and morbidity. In the pre-pandemic cohort, the results were poor. Improvements were seen after interventions such as educational sessions, pandemic triaging tools, and the surgical liaison service. However, there are still inconsistencies between teams. Future interventions include a CFS app, expansion of the surgical liaison service, and improved proformas.

1028 OLDER PERSON’S ASSESSMENT SERVICE (OPAS): DELIVERING COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) IN THE EMERGENCY DEPARTMENT (ED)

Introduction

Innovative models of service delivery are required to provide Comprehensive Geriatric Assessment for older patients presenting to the Emergency Department with frailty syndromes.

Method

In 2018, the Older Person’s Assessment Service began a liaison service to the ED, taking referrals from the medical and ED teams for patients who presented with frailty syndromes (falls, cognitive impairment, care dependence, polypharmacy). The service saw 437 patients April–August 2018. 76% of the patients assessed were discharged by utilising available community services, rapid access outpatient follow up and inpatient reablement off the acute site. The service was estimated to avoid 50–80 admissions per month to medicine (saving 17–23 beds a year) and was commissioned as a permanent service. Phase 2 In 2020, a dedicated unit within ED was allocated to OPAS, enabling the acceptance of patients directly from triage and from the Ambulance Service by direct referral. This provided rapid access to specialist assessment, continued access to Elderly Care services, avoided exposure to coronavirus related admissions and the risks of nosocomial infection associated with admission. The service operates from 8 am-4 pm on weekdays.

Results

Between June 2020 and October 2021, the service saw 1,173 new patients. 988 patients (84.5%) were discharged off the acute site on the day of assessment. 68 (5.79%) patients were admitted to other facilities run by the Health Board (e.g Inpatient Reablement). The average age of an OPAS patient was 83 yrs and had a CFS > 5. Readmission rate at 14 days was 4% (47).Of the 253 patients who were admitted to an inpatient setting, 13.5% (35) contracted nosocomial covid-19.

Conclusion

The service has been supported and funded to expand into extended weekday hours as a result of this success and there are plans for future 7 day working.

Occurrence of mammalian small carnivores in Kalakad-Mundanthurai Tiger Reserve, Western Ghats, India

The small mammalian carnivores are important for maintaining healthy ecosystems.  The present documentation is based on the camera trap survey in Kalakad-Mundanthurai Tiger Reserve, Tamil Nadu.  Paired camera-traps were set in a grid of 1.413 × 1.413 km area of 180km² within an altitudinal range of 80–1,866 m.  A total of 11 species were recorded in different habitat types.  Brown Palm Civet Paradoxurus jerdoni and Leopard Cat Prionailurus bengalensis had the highest capture rates and the lowest was Rusty Spotted Cat Prionailurus rubiginosus.

Prevalence of mandibular fractures

Aim

The aim of this study was to determine the etiology, dissemination of mandibular fractures among different age, gender, and to determine the frequency of anatomic distribution in patients who reported to our institution from February 2015 to September 2015.

Materials and Methods

All patients who fulfilled the selection criteria and had mandible fracture were selected for the study. The values were subjected to Z and Chi-square tests.

Results

Out of 50 patients, 44 were male patients (88%) and 6 were female patients (12%). We found a peak occurrence of fractures in young adults, with mean age of 36 years. In case of etiology of fracture, road traffic accident was the most common (72%) and parasymphysis was most frequently involved site (n = 13.26%).

Conclusion

In this study, the prevalence of mandibular fracture was more prevalent in male patients, especially during the third decade of life. The most common cause was road traffic accident and the more frequently affected region was parasymphysis of the mandible.

Evaluating the expression of GLUT-1 in oral leukoplakia

Aim:

The aim of the present study is to analyze the role of GLUT-1 in detection of early alterations occurring in oral leukoplakia. This study was to evaluate the expression of GLUT-1 in normal oral epithelium, the expression of GLUT-1 levels in the tissue samples of oral leukoplakia and to statistically compare the expression of GLUT-1 in normal epithelium and oral leukoplakia.

Materials and Methods:

The study sample comprised formalin-fixed and paraffin-embedded tissue specimens from 23 cases of histopathologically diagnosed oral leukoplakia and formalin-fixed paraffin-embedded tissue specimens from 10 cases of normal oral mucosa. Sections were mounted on glass slide coated with Aminopropyltriethoxysilane (APES; Sigma chemical co., USA) and processed for subsequent immunohistochemical study to demonstrate GLUT-1.

Results:

GLUT-1 expression in normal oral mucosa revealed weak positivity in all 10 cases (100%). The oral leukoplakia cases showed immunopositivity in all 23 cases (100%) of which 10 cases (39.14%) demonstrated focal positivity and 13 cases (60.86%) of diffuse positivity. The results were compared statistically using ANOVA test was significant at P = 0.002.

Conclusion:

The present study shows expression of GLUT-1 in leukoplakia may be used as a reliable marker to identify the high risk group for malignant transformation.

Seasonal abundance & role of predominant Japanese encephalitis vectors Culex tritaeniorhynchus & Cx. gelidus Theobald in Cuddalore district, Tamil Nadu

Background & objectives:

Japanese encephalitis (JE) is the leading cause of viral encephalitis in Asia. The first major JE outbreak occurred in 1978 and since 1981 several outbreaks had been reported in the Cuddalore district (erstwhile South Arcot), Tamil Nadu, India. Entomological monitoring was carried out during January 2010 - March 2013, to determine the seasonal abundance and transmission dynamics of the vectors of JE virus, with emphasis on the role of Culex tritaeniorhynchus and Cx. gelidus.

Methods:

Mosquito collections were carried out fortnightly during dusk hours in three villages viz. Soundara Solapuram, Pennadam, Erappavur of Cuddalore district. Mosquitoes were collected during dusk for a period of one hour in and around the cattle sheds using oral aspirator and torch light. The collected mosquitoes were later identified and pooled to detect JE virus (JEV) infection by enzyme linked immunosorbent assay (ELISA).

Results:

A total of 46,343 mosquitoes comprising of 25 species and six genera were collected. Species composition included viz, Cx. tritaeniorhynchus (46.26%), Cx. gelidus (43.12%) and other species (10.62%). A total of 17,678 specimens (403 pools) of Cx. gelidus and 14,358 specimens (309 pools) of Cx. tritaeniorhynchus were tested, of which 12 pools of Cx. gelidus and 14 pools of Cx. tritaeniorhynchus were positive for JE virus antigen. The climatic factors were negatively correlated with minimum infection rate (MIR) for both the species, except mean temperature (P<0.05) for Cx. gelidus.

Interpretation & conclusions:

High abundance of Cx. tritaeniorhynchus and Cx. gelidus was observed compared to other mosquito species in the study area. Detection of JEV antigen in the two species confirmed the maintenance of virus. Appropriate vector control measures need to be taken to reduce the vector abundance.

Formulation and Evaluation of Oral Elementary Osmotic Pump Tablets of Sumatriptan Succinate

Aim: In the present study, Sumatriptan succinate was formulated as oral elementary osmotic pump with a zero-order drug release profile. Methodology: The effect of different formulation variables i.e. different types of osmogens, concentrations of osmogen and concentration of coating solution were studied. The in vitro evaluation was carried out in different release media. Result: Highest percentage of drug release was observed at high concentration of mannitol i.e., 1:3 (drug: mannitol). Osmogen with low osmotic pressure (38 atm) showed 71.01% zero-order drug release for 12 hours when compared to that of the osmogen with high osmotic pressure (356 atm) which showed 67.38% of release by zero order. Conclusion: Elementary osmotic pump tablets of Sumatriptan succinate were able to deliver zero-order release up to 12 hours independent of pH of dissolution media and have overcome the problem of chronotherapeutic effect.

Comparison of the anaesthetic efficacy of different volumes of 4% articaine (1.8 and 3.6 mL) as supplemental buccal infiltration after failed inferior alveolar nerve block

AIM

To compare the anaesthetic efficacy of different volumes (1.8 mL vs. 3.6 mL) of 4% articaine with 1 : 100 000 epinephrine injected as buccal infiltrations after a failed inferior alveolar nerve block (IANB) in patients with symptomatic irreversible pulpitis.

METHODOLOGY

Two hundred and thirty-four adult patients, diagnosed with irreversible pulpitis in a mandibular tooth, participated in this multicentre, randomized double-blinded trial. Patients received IANB with 1.8 mL of 4% articaine with 1 : 100 000 epinephrine. Pain during treatment was recorded using the Heft-Parker visual analogue scale (HP VAS). The primary outcome measure, and the definition of 'success', was the ability to undertake pulp chamber access and canal instrumentation with no or mild pain (HP VAS score <55 mm). Patients who experienced 'moderate-to-severe' pain (HP VAS score ≥ 55 mm) were randomly allocated into two groups and received buccal infiltrations with either 1.8 mL or 3.6 mL of 4% articaine with 1 : 100 000 epinephrine. Root canal treatment was re-initiated after 10 min. Success was again defined as no pain or weak/mild pain during endodontic access preparation and instrumentation. Statistical analysis was performed using Mann-Whitney U and chi-square tests.

RESULTS

The initial IANB of 4% articaine gave an overall success rate of 37%. The success rate of supplementary buccal infiltration with 1.8 and 3.6 mL volumes was 62% and 64%, respectively. The difference between the success rates of the two volumes was not statistically significant.

CONCLUSIONS

Increasing the volume of 4% articaine with 1 : 100 000 epinephrine from 1.8 to 3.6 mL, given as supplementary buccal infiltrations after a failed primary IANB with 1.8 mL of 4% articaine with 1 : 100 000, did not improve the anaesthetic success rates in patients with symptomatic irreversible pulpitis.

An unusual occurrence of bilaterally geminated mandibular second premolars resulting in premolar molarization: A case report

Gemination refers to an attempt by a single tooth bud to divide, with a resultant formation of either a large tooth with a bifid crown or two completely divided teeth throughout the crown and root. This report describes a rare case of bilateral gemination of permanent mandibular second premolar tooth giving rise to molarization of premolars. The mesiodistal width of these teeth is similar to mandibular molars, but the cervicoocclusal width is lesser than that of the molar tooth. This paper also discusses the potential orthodontic, periodontal, and endodontic complications of premolar molarization.

Description of a new species, Toxorhynchites (Toxorhynchites) tyagii (Diptera: Culicidae), from Nilgiri hills, Western Ghats, southern India

Specimens of Toxorhynchites (Toxorhynchites) tyagii, sp. n., were collected from the fringe areas of Gudaloor town, Ooty in the Nilgiri hills at an altitude of 1000 m above sea level in Western Ghats ranges in southern India during October 2011 and from Darjeeling ranges in the northern hilly region of Raymatang TG in Jalpaiguri district, West Bengal, in eastern India during February 2012. The adults, pupa and fourth-instar larva of this species are described and illustrated to distinguish it from Toxorhynchites (Tox.) splendens and Toxorhynchites (Tox.) edwardsi, which are the closest allies of Tx. (Tox.) tyagii. Besides possessing remarkable distinguishing male genital characteristics, Tx. tyagii differs from Tx. splendens also by the presence of conspicuous yellow scale-patches over the wing root that extend to the scutellum, and differs from Tx. edwardsi by having midtarsomeres 3-5 all dark whereas in Tx. edwardsi tarsomeres 3 and 4 and a larger part of 5 are white.

Molecular identification of mosquito vectors using genomic DNA isolated from eggshells, larval and pupal exuvium

Correct and precise identification of mosquito vectors is important in many respects including development of vector control strategies. Conventional identification methods have limitations for sibling and closely related species of mosquitoes, stage and quality of the specimen used and this could be overcome by DNA-based identification methods using molecular markers such as nuclear ribosomal internal transcribed spacer (ITS) which do not demand intact or undamaged specimen. Genomic DNA is usually isolated from whole mosquito, legs, wings etc. Alternate sources for genomic DNA isolation such as eggshells, larval and pupal exuviae were explored in this study by amplifying the ITS markers. Standardization of genomic DNA extraction and ITS amplification were carried out with laboratory specimens. The same was applied to specimens collected from the field. The results show that PCR amenable genomic DNA could be isolated from fresh exuviae collected in the laboratory and not from older and/or field specimens. But exuviae of larvae and/or pupae collected in the field reared to adulthood in the laboratory yielded PCR amenable genomic DNA. The results also revealed that the ITS2 marker could very well differentiate Aedes aegypti and Aedes albopictus by producing amplicons of ~330 bp and ~520 bp, respectively. The genomic DNA from these alternate sources also supported the species-specific PCR to distinguish the Culex vishnui subgroup mosquitoes.

A short, stereoselective, and common approach for the synthesis of 4,5-disubstituted delta-lactones simplactone B and its C-5 analogue

A short, stereoselective, and a common approach for the synthesis of 4,5-disubstituted delta-lactones simplactone B and its analogue using Evans protocol is described.

Hemodynamic monitoring in the neurological intensive care unit

The neurointensivist needs to have a thorough understanding of hemodynamic issues and the interaction of the brain and the cardiovascular system. Before one decides to intervene and try to correct an apparent "abnormal hemodynamic parameter" one needs to think whether such an intervention is indeed warranted and what effect the intervention would have on the cerebral circulation. The neurointensivist thus needs to approach these issues differently from the approach an internist or general intensivist would take.

Acinetobacter sepsis in neonates

Twenty-six neonates were diagnosed to have acinetobacter sepsis during 1986-90, representing 6.5% of all cases of bacteriologically proven sepsis. Of these 19 neonates were low birth weight (LBW) 12 were small for gestational age (SGA). Nineteen neonates had early-onset sepsis. The male to female ratio was 9:17. The hematological profile was suggestive of sepsis in 17 cases. All infants had clinical evidence of multi system infection. Eleven babies died; the cases-fatality rate was 42.3%. Only 15/25 culture isolates were sensitive to gentamicin and resistance to other antibiotics was even more frequent. Acinetobacter was cultured from other sites: eye swabs, skin pustules and umbilical catheter tips. Environmental nursery surveillance cultures done during the study period yielded Acinetobacter once from a crib, but no cases of sepsis occurred around that time. The epidemiological features of this organism illustrate the value of vigilance and precautionary measures.

Prognosis of single unprovoked seizure

201 patients (131 males and 70 females) with mean age of 18 years (range 5-55 years) who presented at median of 6 days after the onset of first unprovoked seizure were studied. They were followed for a mean period of 60 months (range 12-84 months). One hundred and fifty four (76%) patients were treated with anticonvulsant medication (group A) on a non-randomized basis and the remaining 47 patients (24%) were not treated (group B). Both the groups were comparable for age, sex, type of seizure and interval between onset of seizure and consultation. The cumulative risk of recurrence for entire study group was 24% at 1 month, 32% at 6 months, 34% at 12 months, 35% at 24 months and 36% at 36 months. The cumulative risk of recurrence in group A was 23%, 30%, 32%, 33% and 33% as compared to 28%, 36%, 40%, 43% and 45% at 1, 6, 12, 24 and 36 months respectively (p > 0.05). Maximum number of recurrences (67%) occurred within 1 month. No recurrence occurred after 36 months after the onset of first seizure. Age at onset, sex, seizure type, family history of seizure, EEG abnormalities and nature of antiepileptic drugs did not influence the risk of recurrence.