BACKGROUND Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial. METHODS After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol. RESULTS A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005). CONCLUSION In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective. LEVEL OF EVIDENCE Therapeutic Level IV.
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In this paper, we present a novel fuzzy rule extraction approach by employing the Gaussian kernels and fuzzy concept lattices. First we introduce the Gaussian kernel to interval type-2 fuzzy rough sets to model fuzzy similarity relations and introduce a few concepts and theorems to improve the classification performance with fewer attributes accordingly. Based on this idea, we propose a novel attribute reduction algorithm, which can achieve better classification performance of deducing reduction subset of fewer attributes, and this will be used in the subsequent decision rule extraction. Then we justify the necessary and sufficient conditions of our fuzzy rule extraction approach through three implicit rule theorems and present a novel fuzzy decision rule extraction algorithm using fuzzy concept lattices and introduce the concepts of frequent nodes and candidate 2-tuples to our pruning strategy. Also, comparative performance experiments are carried out on the UCI datasets, and the results of both reduction subset size and classification ability show the advantages of our algorithm.
The mobility of gas is greatly reduced when the injected gas is foamed. The reduction in gas mobility is attributed to the reduction in gas relative permeability and the increase in gas effective viscosity. The reduction in the gas relative permeability is a consequence of the larger amount of gas trapped when foam is present while the increase in gas effective viscosity is explicitly a function of foam texture. Therefore, understanding how foam is generated and subsequent trapped foam behavior is of paramount importance to modeling of gas mobility. In this paper, we push the envelope to enlighten our decisions of which descriptions are most physical to foam flow in porous media regarding both the flowing foam fraction and the rate of generation. We use a statistical pore network interwoven with the invasion percolation with memory algorithm to model foam flow as a drainage process and investigate the dependence of the flowing foam fraction on the pressure gradient and to shed light on foam generation mechanisms. A critical snap-off probability is required for strong foam to emerge in our network. The pressure gradient and, hence, the gas mobility reduction are very low below this critical snap-off probability. Above this snap-off probability threshold, we find that the steady-state flowing lamellae fraction scales as \((\nabla \tilde{p})^{0.19}\) in 2D lattices and as \((\nabla \tilde{p})^{0.32}\) in 3D lattices. Results obtained from our network were convolved with percolation network scaling ideas to compare the probabilities of snap-off and lamella division mechanisms in the network during the initial gas displacement at the leading edge of the gas front. At this front, during strong foam flow, lamella division is practically nonexistent in 2D lattices. In 3D lattices, lamella division occurs, but the probability of snap-off is always greater than the probability of lamella division.
Neuronal nicotinic receptors containing α4 and β2 subunits assemble in two pentameric stoichiometries, (α4)3(β2)2 and (α4)2(β2)3, each with distinct pharmacological signatures; (α4)3(β2)2 receptors are strongly potentiated by the drug NS9283, whereas (α4)2(β2)3 receptors are unaffected. Despite this stoichiometry-selective pharmacology, the molecular identity of the target for NS9283 remains elusive. Here, studying (α4)3(β2)2 receptors, we show that mutations at either the principal face of the β2 subunit or the complementary face of the α4 subunit prevent NS9283 potentiation of ACh-elicited single-channel currents, suggesting the drug targets the β2–α4 pseudo-agonist sites, the α4–α4 agonist site, or both sites. To distinguish among these possibilities, we generated concatemeric receptors with mutations at specified subunit interfaces, and monitored the ability of NS9283 to potentiate ACh-elicited single-channel currents. We find that a mutation at the principal face of the β2 subunit at either β2–α4 pseudo-agonist site suppresses potentiation, whereas mutation at the complementary face of the α4 subunit at the α4–α4 agonist site allows a significant potentiation. Thus, monitoring potentiation of single concatemeric receptor channels reveals that the β2–α4 pseudo-agonist sites are required for stoichiometry-selective drug action. Together with the recently determined structure of the (α4)3(β2)2 receptor, the findings have implications for structure-guided drug design.
Live mentoring services are recent novel social media, in which mentees can input expertise requests and wait for accepting some expert mentor who is willing to tackle the requests in a live and one-by-one manner. While mentee's satisfaction of being mentored is determined by the matched mentor, it is crucial to have an effective mentor–mentee matching. This paper aims at recommending mentors based on the requests in Codementor, which is one of the popular live mentoring services. An accurate mentor recommendation will support the mentees' decisions in finding suitable mentors, support the mentors' decisions in filtering out irrelevant requests, and support the mentoring services' decisions in assigning mentors to mentees. We divide the mentor recommendation problem into two tasks, Mentor Willingness Prediction (MWP) and Mentee Acceptance Prediction (MAP). MWP is to predict whether a mentor is willing to tackle a request, while MAP is to predict whether a mentee user will accept a recommended mentor. We propose to simultaneously deal with such two tasks by recommending a ranked list of mentors such that the recommended mentors who are really willing to tackle the request are as many as possible (MWP) and the final mentor who is accepted by the mentee can be ranked as high as possible (MAP). We develop four categories of features, availability, capability, activity, and proximity, to model the willingness of a mentor dealing with the request and the potential of a mentee to accept the recommended mentor. By applying various supervised learning methods, experimental results show the effectiveness of these features and provide extensive analyses to reveal more factors that can affect the quality of mentor recommendation. In addition, we also conduct a user study on Codementor platform to exhibit the practical performance of the proposed method. The innovation of this work includes the formulation of MWP and MAP problem in online mentoring services, feature engineering for mentoring prediction tasks, and data-driven experimental studies in prediction and a practical user study.
Odorant receptors represent the largest family of mammalian G protein-coupled receptors. Phylogenetically, they are split into two classes (I and II). By analyzing the entire subclass I odorant receptors sequences, we identified two class I-specific and highly conserved motifs. These are predicted to face each other at the extra-cellular portion of the transmembrane domain, forming a vestibular site at the entrance to the orthosteric-binding cavity. Molecular dynamics simulation combined with site-directed mutagenesis and in vitro functional assays confirm the functional role of this vestibular site in ligand-driven activation. Mutations at this part of the receptor differentially affect the receptor response to four agonists. Since this vestibular site is involved in ligand recognition, it could serve ligand design that targets specifically this sub-genome of mammalian odorant receptors.
Glutamate is the major excitatory neurotransmitter in the central nervous system. Beyond this function, glutamate also plays a key role in intermediary metabolism in all organs and tissues, linking carbohydrate and amino acid metabolism via the tricarboxylic acid cycle. Under both physiological and pathological conditions, we have recently found that the ability of glutamate to fuel cell metabolism selectively relies on the activity of two main transporters: the sodium–calcium exchanger (NCX) and the sodium-dependent excitatory amino-acid transporters (EAATs). In ischemic settings, when glutamate is administered at the onset of the reoxygenation phase, the coordinate activity of EAAT and NCX allows glutamate to improve cell viability by stimulating ATP production. So far, this phenomenon has been observed in both cardiac and neuronal models. In this review, we focus on the most recent findings exploring the unusual activity of glutamate as a potential survival factor in different settings.
Senescent cells undergo structural and functional changes that affect essentially every aspect of cell physiology. To date, the impact of senescence on the cytoskeleton is poorly understood. This study evaluated the cytoskeleton in two independent cellular models of kidney epithelium senescence. Our work identified multiple senescence-related alterations that impact microtubules and filamentous actin during interphase. Both filamentous systems reorganized profoundly when cells became senescent. As such, microtubule stability increased during senescence, making these filaments more resistant to disassembly in the cold or by nocodazole. Microtubule stabilization was accompanied by enhanced α-tubulin acetylation on lysine 40 and the depletion of HDAC6, the major deacetylase for α-tubulin lysine 40. Rho-associated kinase Rock1 is an upstream regulator that modulates key properties of the cytoplasmic cytoskeleton. Our research shows that Rock1 concentrations were reduced significantly in senescent cells, and we revealed a mechanistic link between microtubule stabilization and Rock1 depletion. Thus, Rock1 overexpression partially restored the cold sensitivity of microtubules in cells undergoing senescence. Additional components relevant to microtubules were affected by senescence. Specifically, we uncovered the senescence-related loss of the microtubule nucleating protein γ-tubulin and aberrant formation of γ-tubulin foci. Concomitant with the alterations of microtubule and actin filaments, senescent cells displayed functional changes. In particular, cell migration was impaired significantly in senescent cells. Taken together, our study identified new senescence-associated deficiencies of the microtubule and actin cytoskeleton, provided insights into the underlying molecular mechanisms and demonstrated functional consequences that are important to the physiology and function of renal epithelial cells.
The ADAM10-mediated cleavage of transmembrane proteins regulates cellular processes such as proliferation or migration. Substrate cleavage by ADAM10 has also been implicated in pathological situations such as cancer or Morbus Alzheimer. Therefore, identifying endogenous molecules, which modulate the amount and consequently the activity of ADAM10, might contribute to a deeper understanding of the enzyme's role in both, physiology and pathology.
Method
To elucidate the underlying cellular mechanism of the TBX2-mediated repression of ADAM10 gene expression, we performed overexpression, RNAi-mediated knockdown and pharmacological inhibition studies in the human neuroblastoma cell line SH-SY5Y. Expression analysis was conducted by e.g. real-time RT-PCR or western blot techniques. To identify the binding region of TBX2 within the ADAM10 promoter, we used luciferase reporter assay on deletion constructs and EMSA/WEMSA experiments. In addition, we analyzed a TBX2 loss-of-function Drosophila model regarding the expression of ADAM10 orthologs by qPCR. Furthermore, we quantified the mRNA level of TBX2 in post-mortem brain tissue of AD patients.
Results
Here, we report TBX2 as a transcriptional repressor of ADAM10 gene expression: both, the DNA-binding domain and the repression domain of TBX2 were necessary to effect transcriptional repression of ADAM10 in neuronal SH-SY5Y cells. This regulatory mechanism required HDAC1 as a co-factor of TBX2. Transcriptional repression was mediated by two functional TBX2 binding sites within the core promoter sequence (− 315 to − 286 bp). Analysis of a TBX2 loss-of-function Drosophila model revealed that kuzbanian and kuzbanian-like, orthologs of ADAM10, were derepressed compared to wild type. Vice versa, analysis of cortical brain samples of AD-patients, which showed reduced ADAM10 mRNA levels, revealed a 2.5-fold elevation of TBX2, while TBX3 and TBX21 levels were not affected.
Conclusion
Our results characterize TBX2 as a repressor of ADAM10 gene expression and suggest that this regulatory interaction is conserved across tissues and species.
The endocannabinoid (eCB) system is widely expressed in many central and peripheral tissues, and is involved in a plethora of physiological processes. Among these, activity of the eCB system promotes energy intake and storage, which, however, under pathophysiological conditions, can favour the development of obesity and obesity-related disorders. It is proposed that eCB signalling is evolutionary beneficial for survival under periods of scarce food resources. Remarkably, eCB signalling is increased both in hunger and in overnutrition conditions, such as obesity and type-2 diabetes. This apparent paradox suggests a role of the eCB system both at initiation and at clinical endpoint of obesity. This review will focus on recent findings about the role of the eCB system controlling whole-body metabolism in mice that are genetically modified selectively in different cell types. The current data in fact support the notion that eCB signalling is not only engaged in the development but also in the maintenance of obesity, whereby specific cell types in central and peripheral tissues are key sites in regulating the entire body's energy homeostasis.
Mutations in the gene encoding the CFTR chloride channel produce cystic fibrosis (CF). CF patients are more susceptible to bacterial infections in lungs. The most accepted hypothesis sustains that a reduction in the airway surface liquid (ASL) volume favor infections. Alternatively, it was postulated that a reduced HCO3− transport through CFTR leads to a decreased ASL pH, favoring bacterial colonization. The issue is controversial, since recent data from cultured primary cells and CF children showed normal pH values in the ASL. We have reported previously a decreased mitochondrial Complex I (mCx-I) activity in cultured cells with impaired CFTR activity. Thus, we hypothesized that the reduced mCx-I activity could lead to increased lactic acid production (Warburg-like effect) and reduced extracellular pH (pHe). In agreement with this idea, we report here that cells with impaired CFTR function (intestinal Caco-2/pRS26, transfected with an shRNA-CFTR, and lung IB3-1 CF cells) have a decreased pHe. These cells showed increased lactate dehydrogenase (LDH) activity, LDH-A expression, and lactate secretion. Similar effects were reproduced in control cells stimulated with recombinant IL-1β. The c-Src and JNK inhibitors PP2 and SP600125 were able to increase the pHe, although the differences between control and CFTR-impaired cells were not fully compensated. Noteworthy, the LDH inhibitor oxamate completely restored the pHe of the intestinal Caco-2/pRS26 cells and have a significant effect in lung IB3-1 cells; therefore, an increased lactic acid secretion seems to be the key factor that determine a reduced pHe in these epithelial cells.
The popularity of e-business and preference learning techniques have contributed a huge amount of product and user preference data. Analyzing the influence of an existing or new product among the users is critical to unlock the great scientific and social–economic value of these data. In this paper, we advocate the problem of influence-based cost optimization for the user preference and product data, which is fundamental in many real applications such as marketing and advertising. Generally, we aim to find a cost optimal position for a new product such that it can attract at least k or a particular percentage of users for the given user preference functions and competitors' products. Although we show the solution space of our problem can be reduced to a finite number of possible positions (points) by utilizing the classical k-level computation techniques, the computation cost is still very expensive due to the nature of the high combinatorial complexity of the k-level problem. To alleviate this issue, we develop efficient pruning and query processing techniques to significantly improve the performance. In particular, our traverse-based 2-dimensional algorithm is very efficient with time complexity O(n) where n is the number of user preference functions. For general multi-dimensional spaces, we develop space partition-based algorithm to significantly improve the performance by utilizing cost-based, influence-based and local dominance-based pruning techniques. Then, we show that the performance of the partition-based algorithm can be further enhanced by utilizing sampling approach, where the problem can be reduced to the classical half-space intersection problem. Based on the problem of influence-based cost optimization, two naturally extended problems are proposed, which are Batch-Query and the most cost-effective influence query. We demonstrate the efficiency of our techniques with extensive experiments over real and synthetic datasets.
The problem of time series prediction has been well explored in the community of data mining. However, little research attention has been paid to the case of predicting the movement of a collection of related time series data. In this work, we study the problem of simultaneously predicting multiple time series data using joint predictive models. We observe that in real-world applications, strong relationships between different time-sensitive variables are often held, either explicitly predefined or implicitly covered in nature of the application. Such relationships indicate that the prediction on the trajectory of one given time series could be improved by incorporating the properties of other related time series data into predictive models. The key challenge is to capture the temporal dynamics of these relationships to jointly predict multiple time series. In this research, we propose a predictive model for multiple time series forecasting and apply it to the domain of inventory management. The relationships among multiple time series are modeled as a class of constraints, and in turn, refine the predictions on the corresponding time series. Experimental results on real-world data reveal that the proposed algorithms outperform well-established methods of time series forecasting.
Data Ecosystems are socio-technical complex networks in which actors interact and collaborate with each other to find, archive, publish, consume, or reuse data as well as to foster innovation, create value, and support new businesses. While the Data Ecosystem field is thus arguably gaining in importance, research on this subject is still in its early stages of development. Up until now, not many academic papers related to Data Ecosystems have been published. Furthermore, to the best of our knowledge, there has been no systematic review of the literature on Data Ecosystems. In this study, we provide an overview of the current literature on Data Ecosystems by conducting a systematic mapping study. This study is intended to function as a snapshot of the research in the field and by doing so identifies the different definitions of Data Ecosystem and analyzes the evolution of Data Ecosystem research. The studies selected have been classified into categories related to the study method, contribution, research topic, and ecosystem domains. Finally, we analyze how Data Ecosystems are structured and organized, and what benefits can be expected from Data Ecosystems and what their limitations are.
To describe a quality assurance issue, producing non-diagnostic high contrast radiographs, when imaging teeth restored with all zirconia crowns on bitewing radiographs.
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To analyze the immunohistochemical expression of fatty acid synthase (FASN) and cyclooxygenase-2 (COX‑2) in tooth germ (TG), ameloblastoma (AM), ameloblastic carcinoma (AC), ameloblastic fibroma (AF) and ameloblastic fibrosarcoma (AFS).
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Our previous study of patients with unilateral TMJ osteoarthritis (OA) showed that the affected joints had greater horizontal condylar angle (HCA) than contralateral unaffected joints. However, it was unclear whether the HCA changes preceded or were the result of OA changes. The aim of this study was to investigate the relationship between HCA and OA progression in a longitudinal study.
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This study analyzed and compared the immunoexpression of Regγ, Wnt-1 and β-catenin in ameloblastomas, adenomatoid odontogenic tumors (AOTs), and odontogenic keratocysts (OKCs).
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Epithelioid osteoblastoma is a clinically aggressive subtype of osteoblastoma that favors the mandible and maxilla. Its histological features lie on a spectrum between conventional osteoblastoma and low grade osteosarcoma, thus making it difficult at times to confirm the diagnosis. It is known to have a high risk of recurrence after surgical resection but it is a benign entity and lacks the propensity to metastasize. To our knowledge, there is no published literature on findings of epithelioid osteoblastoma on positron emission tomography/computed tomography (PET/CT).
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A 33-year-old Hispanic woman presented to the allergy and immunology clinic for recurrent angioedema. She was previously healthy until she began to experience intermittent, infrequent episodes of angioedema at age 25. Prior to evaluation, she had experienced seven episodes of angioedema affecting the extremities with no oropharyngeal or abdominal involvement. The angioedema was non-pruritic and was not associated with urticaria, trauma, foods, medication, infections, or menstruation. She did not take any medications, including angiotensin-converting enzyme inhibitors or hormonal therapies.
Increasing evidence suggests that aberrant expression of miR-495 is associated with the progression of various cancers. The aim of this study was to investigate the function and underlying mechanism of miR-495 in oral squamous cell carcinoma (OSCC).
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The orbito-zygomatic complex (OZC) includes several key structures, and its destruction leads to the impairment of functional activities such as nutrition, communication, nasal support, and vision. Management of benign tumors of the OZC is therefore a surgical challenge due to the necessity of reconstruction of these elements. Autogenous bone is considered to be the gold standard for reconstruction. Nevertheless, the difficulty is related to the complex anatomy and distorted skeletal anatomical landmarks, which require precise work in the case of bone grafts.
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Mandibular asymmetry due to Condylar Hyperactivity (CH) depicts a complex set of morphological features that pose challenges for its correction. Using state-of-the-art morphometric techniques, we provide a detailed and hierarchical description of the features present in CH-asymmetric mandibles, offering new knowledge for its surgical treatment.
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The extraction of third molars is the most common surgical procedure performed in the oral cavity. Coronectomy is a surgical protocol to reduce the risk of neurologic lesions to the inferior alveolar nerve (IAN). The authors look for early (up to 1 month) and late (from 2 to 60 months) postoperative complications.
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Dental rehabilitation in patients receiving free-flap reconstructive surgery to the mandible or maxilla is an important part of bringing patients back to normality both in a physical and a psychological way. It is therefore important to be able to do this in the fastest way possible.Virtual pre-planned reconstructions of jaws with implants placed simultaneously are a good way to expedite this process and has the advantage of allowing true backward planning to get the bone where it prosthetically needs to be.
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Reconstruction of mandibular substance loss by free flap is a widely used technique. This technique suffers from several disadvantages; these include the presence of a second intervention site and a significant frequency of complications. We have undertaken a custom-made three-dimensional reconstruction (using CAD/CAM) with prosthetic dental rehabilitation and esthetic improvement by lipomodelling of the face. A fifty-year-old woman presented with a massive recurrence of an ameloblastoma of the right hemimandible.
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Smartphone addiction has become a crucial social issue. Past studies have indicated that phone use such as talking or texting while walking constitutes a dual task that may cause pedestrians inattentional blin...
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Musculoskeletal models permit the determination of internal forces acting during dynamic movement, which is clinically useful, but traditional methods may suffer from slowness and a need for extensive input data. Recently, there has been interest in the use of supervised learning to build approximate models for computationally demanding processes, with benefits in speed and flexibility. Here, we use a deep neural network to learn the mapping from movement space to muscle space. Trained on a set of kinematic, kinetic and electromyographic measurements from 156 subjects during gait, the network's predictions of internal force magnitudes show good concordance with those derived by musculoskeletal modelling. In a separate set of experiments, training on data from the most widely known benchmarks of modelling performance, the international Grand Challenge competitions, generates predictions that better those of the winning submissions in four of the six competitions. Computational speedup facilitates incorporation into a lab-based system permitting real-time estimation of forces, and interrogation of the trained neural networks provides novel insights into population-level relationships between kinematic and kinetic factors.
The minimal clinically important difference (MCID) of the 22‐item Sino‐Nasal Outcome Test (SNOT‐22) is specific but not sensitive for identifying patients experiencing noticeable improvement in symptoms of chronic rhinosinusitis (CRS). It is unclear why some patients with less than 1 MCID change in SNOT‐22 score nevertheless report noticeable improvement in their CRS symptoms.
Methods
This investigation was a retrospective study of 247 CRS patients undergoing medical management who completed SNOT‐22 surveys in 2 consecutive visits 2‐12 months apart. The validated nasal, sleep, ear/facial discomfort, and emotional SNOT‐22 subdomain scores were calculated. At the second visit, patients reported their global change in CRS symptoms on a 5‐item transition rating scale as: "Much worse"; "A little worse"; "About the same"; "A little better"; or "Much better." Patient‐reported improvement in symptoms (at least "A little better") was tested for association with changes in SNOT‐22 subdomain scores.
Results
In the entire cohort, patient‐reported improvement in CRS symptoms was associated with improvement in all SNOT‐22 subdomain scores (p < 0.001). In patients with less than 1 MCID (12 points) of change in the SNOT‐22, only the nasal subdomain (adjusted odds ratio, 0.89; 95% confidence interval [CI], 0.79‐0.99; p = 0.042) was associated with patient‐reported improvement in CRS symptoms. Changes in none of the other SNOT‐22 subdomain scores were associated with patient‐reported improvement in CRS symptoms.
Conclusions
Among patients with less than 1 MCID change in the SNOT‐22, improvement in only nasal symptoms—but not extranasal symptoms—of CRS is associated with those who nevertheless report improvement of their CRS symptoms.
Objective: In this study, we have described the technique to overcome difficulty faced during trans-foraminal endoscopic discectomy for the treatment of lumbar radiculopathy in patients who have herniated discs at the upper lumbar level & thoracolumbar junction. Method: After institutional review board approval, A retrospective analysis of 27 patients operated between March 2013- September 2017, by a single specialist for disc herniation at upper lumbar levels D12-L1, L1-2, L2-3 with or without high canal compromise by outside in technique (using rigid endoscope, sequential reamers) along with detailed description of our technique is the focus of this study. Results: Out of 27 patients there were 11 cases for L1-2 & 16 cases of L2-3 disc herniation respectively. There were 21 cases of broad-based, high canal compromised disc herniation with significant neurological deficit & only 6 cases were of focal herniation type. The average preoperative VAS score of 8.5 (range 6-10) reduced to 4 (range 2-7) immediate postoperatively & it further reduced to 2 (range 0-4) at one month follow up. The average preoperative ODI score of 65 (range 28- 88) reduced to 27 (range 12-40) immediate postoperatively & it further reduced to 10 (range 3- 18) at one month follow up. Post-operative MRI showed that the ruptured disc had been successfully removed. Conclusion: An anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation. Foraminotomy is recommended for all intra-canalicular herniation. Transforaminal endoscopic discectomy and foraminotomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of an upper lumbar disc herniation.
Neuropathic pain (NeP) constitutes a major pain-related disorder, which is often underdiagnosed and undertreated. Adverse physical, psychological, and economic consequences associated with NeP lead to poor quality of life. Burden of NeP in developing countries like India is colossal. Various international guidelines provide effective approaches to diagnose and manage NeP. However, differences in the genetic makeup of Indian population can result in subtle differences in clinical response, considering their low body weight, drug metabolism ability, and pain perception. Similarly, treatment-related adverse effects may also vary. Practice of Indian physicians may also differ for choice of drugs based on their availability and affordability. In the absence of country-specific guidelines, this document could serve as a guiding tool for health-care providers, ensuring uniformity in the treatment of NeP. Thus, applicability of all recommendations from any of these guidelines in Indian setting demands careful evaluation. Clinical experience of Indian physicians suggests that there are lot many challenges (e.g., busy outpatient departments, nonavailability of screening questionnaires in regional languages, and availability and affordability of medications) faced by them when managing NeP. In addition, in India, there are no country-specific guidelines that would help them to address these challenges. The objective for this consensus was to develop an expert opinion guideline to harmonize the management of NeP in India. The expert panel consisted of experts from various specialties such as pain medicine, anesthesiology, diabetology, neurology, and orthopedics. The panel critically reviewed the existing literature evidence and guideline recommendations to provide India-specific consensus on the management of NeP. The final consensus document was reviewed and approved by all the experts. This expert opinion consensus will help health-care professionals as a guiding tool for effective management of NeP in India. Use of Douleur Neuropathique 4 (DN4) questionnaire for NeP screening should be routine in day-to-day clinical practice. For effective utilization of DN4 questionnaire, it should be converted to regional language. If DN4 questionnaire screening fails to identify NeP, it should not be disregarded and should not replace the sound clinical judgment from the treating physician. Diagnostic tests may be considered as a supplement to clinical judgment. Cost-effective treatment should be the initial choice. Dosing should be individualized based on efficacy and tolerability. Tricyclic antidepressants (TCAs), gabapentinoids, and serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered among initial choices. Tramadol can be considered as a second-line add-on treatment for NeP if there is partial response to the first-line agent either alone or in combination. Fixed-dose combination (FDC) of gabapentinoids such as pregabalin (75 mg) with TCA such as nortriptyline (10 mg) is synergistic and improves treatment adherence. Among other treatments, Vitamin B12 (methylcobalamin) can be used either alone or in combination for the management of NeP. Use of Vitamin D and steroids should be limited to specific NeP in individual cases. Referral to pain specialists can be considered if two drugs fail to provide relief in NeP.
Is tactile acuity altered in individuals with acute mechanical neck pain?
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Shobhalakshmi S Holla, Turiya Vats, Pratima Nagpal DOI:10.4103/ijpn.ijpn_20_18
Background: Tactile acuity measured by point discrimination (TPD) refers to the precision by which we can sense touch.An increase in TPD threshold (loss of tactile acuity) is considered suggestive of disruptions to S1 cortical maps of that specific body part. In some chronically painful conditions, reduced tactile acuity is a manifestation of Central sensitization (CS).The other symptoms include hyperalgesia and allodynia due to repeated activation of spinal nociceptors. A recent study has shown that tactile acuity is affected in individuals with chronic neck pain. While there seems to be adequate evidence stating that tactile acuity is reduced in individuals with chronic pain, CS may not be limited to chronic pain states. There is a paucity of literature with respect to the tactile acuity of a person with acute neck pain. A measurement of tactile acuity of the affected body area in acute pain, may suggest the extent of the altered threshold of sensory discriminative aspect of pain experience. Objectives: To compare the two-point discrimination over C7 spinous process between the symptomatic individuals with mechanical neck pain and age matched healthy controls. Methods: 30 individuals with mechanical neck pain & 30 age matched normals were assessed for two point discrimination using mechanical calipers, The two sharp points of the caliper were vertically placed against the skin surface over C7 spinous process, commencing with 5mm, which was stretched out till the subject appreciated the two points. Values were noted down in millimeters. Results: An independent t – test showed a significant difference in the two point discrimination between the 2 groups (P < 0.000). Conclusion: It can be concluded that individuals with acute mechanical neck pain demonstrated a change in tactile acuity.
A comparative study of ultrasound-guided femoral nerve block versus fascia iliaca compartment block in patients with fracture femur for reducing pain associated with positioning for subarachnoid block
Context: Lower extremity peripheral nerve blocks are increasingly being recommended for pain control in patients with fracture femur as it reduces pain and shortens the duration of hospital stay. Aims: To compare analgesic efficacy of ultrasound guided femoral nerve block (FNB) and fascia iliaca compartment block (FICB) in patients with fracture femur for reducing pain associated with positioning for subarachnoid block. Settings and Design: It was a prospective, randomized, double blind study. Methods and Material: Group A (n = 25) received ultrasound guided FNB and Group B (n = 25) received ultrasound guided FICB using 0.5% ropivacaine. Primary objective was to observe reduction in pain associated with positioning (sitting) for subarachnoid block. Statistical Analysis used: For data analysis t test, Mann Whitney test and Chi-square test were applied. Results: Visual analog scale (VAS) score for pain before giving peripheral nerve block between Group A (7.60 ± 0.57) and Group B (7.44 ± 0.50) was comparable (P = 0.302). VAS score for pain in sitting position before giving subarachnoid block was lesser in Group A (1.88 ± 0.83) than in Group B (2.40 ± 0.57) (P = 0.013). Mean reduction in VAS score for pain was more in Group A (5.72 ± 0.73) compared to Group B (5.04 ± 0.73) (P = 0.002). Conclusion: Ultrasound guided FNB is more efficacious in reducing pain associated with positioning (sitting) for subarachnoid block in patients undergoing surgery for fracture femur compared to ultrasound guided FICB.
Aims: 1. Study the change in pain and function in patient with lumbosacral disc disease on MRI using visual analogue scale (VAS) and the revised Oswestry disability index (ODI) for back pain after administration of fluoroscopically guided transforaminal epidural injection. 2. Correlate the response of the patient with the spread of contrast in epidural space. Method: 100 patients with history of low back ache and imaging findings of disc herniation were enrolled based on inclusion criteria. Patients scored their pain on the VAS and functional disability on revised ODI. The patient was evaluated for distribution of pain and was administered a combination of anaesthetic and steroid after confirming the position of the tip of needle using iodinated contrast. Follow up for response to pain and improvement in disability in immediate post procedure done at 3 and 6 months. Result: 102 injections were administered for 100 patients which comprised of n=69 {67.6%} male and 33{32.4%} female and age distribution was 21-79 years. The distribution of indication was disc bulge n=29 (28.4%), extrusion n=12 (11.8%), post operative n=19 (18.6%), protrusion n=42 (41.2%). No significant difference between the VAS scores (p=0.20) of the individual indication pre procedure. After 3 & 6 months there was statistically significant difference between the mean rank value of population indicating maximum benefit for disc bulge population and least for post operative population at three months follow up. Conclusion: There is statistically proven good results in all cases for 6 months, after which repeat injections may be tried.
Perception, knowledge, and attitudes of first-year postgraduates toward postoperative pain management: A questionnaire-based study
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Pritam B Adsule, Pradnya M Bhalerao, Prakash R Dhumal DOI:10.4103/ijpn.ijpn_31_18
Context: Inadequately controlled postoperative pain has undesirable physiological and psychological consequences. It increases postoperative morbidity, delays recovery, and hence causes a delayed return to normal daily living. Furthermore, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. Aim: To evaluate the knowledge and attitudes of first-year postgraduate students toward postoperative pain. Study Design: This questionnaire-based cross-sectional study was conducted on 42 first-year postgraduate students. Materials and Methods: A 20-point questionnaire was prepared based on the various aspects of postoperative pain services. The students were asked to provide their answers on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The responses were kept anonymous, and the results were expressed in terms of percentage. Results:Almost 70% of students had a good knowledge of opioids, 52% strongly felt the need for a structured pain curriculum, 76% were well aware of nonpharmacological methods of pain relief, 48% agreed on the need for a pain physician, and 52% were aware of the advantage of postoperative analgesia. Conclusion: This pilot study helped us to evaluate the current understanding of our first-year postgraduate students and further created awareness on the importance of pain relief postoperatively.
Executive function and its clinical correlates among migraineurs
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Ashitha Sreedhar, Suresh M Kumar, Anjali N Shobha DOI:10.4103/ijpn.ijpn_38_18
Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients.
Translation and validation of Marathi version of Fear-Avoidance and Belief Questionnaire in patients with chronic low back pain
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Vrushali P Panhale, Reshma S Gurav, Kartiki Suradkar DOI:10.4103/ijpn.ijpn_41_18
Background: Fear-Avoidance Beliefs Questionnaire (FABQ) is widely used to assess the fear-avoidance beliefs in patients with low back pain (LBP). However, English serves as a barrier to the population of the state where Marathi is the prime language. Hence, the FABQ needs to be translated into Marathi for the ease of its use. Materials and Methods: FABQ was successfully translated in Marathi using forward-backward translation using recommended guidelines. The final version of FABQ-Marathi version (FABQ-M) was used on 100 patients with chronic nonspecific LBP to assess its reliability and validity. Reliability was assessed by measuring the internal consistency of FABQ-M and its subscales and by checking the test-retest reliability on day 1 and day 2. For the determination of construct validity, convergent and divergent validity was assessed. The floor and ceiling effects were studied. Results: Reliability-internal consistency-Cronbach's alpha for FABQ-M was 0.860 and test–retest: correlation between FABQ-M on day 1 and day 2 were highly significant. The intraclass coefficient was 0.976. There was a high internal consistency between the FABQ-M and its subscales. On assessing convergent validity, there was moderate correlation found between FABQ-M and TSK (r = 0.52, P = 0.00). Divergent validity showed moderate correlation between FABQ-M and NRS (r = 0.48, P = 0.00) and between FABQ-M and RMDQ (r = 0.59, P = 0.00). Conclusion: The translated FABQ-M proved to be acceptable. The results suggest it is a validated, an easy to comprehend, reliable, and valid instrument for the measurement of the fear and avoidance beliefs caused by back disorders in the Marathi-speaking population.
Cancer is a life changing diagnosis and chronic pain in these terminally ill patients is extremely debilitating. In the present case series, the feasibility of continuous infusion of low dose local anaesthetics and opioids through the intrathecal route has been discussed pertaining to patient selection, technique, drugs used and trouble shooting. The intrathecal catheters were connected through a subcutaneous port to an external ambulatory infusion device (CADD pump) and used on a home care basis.
Quadratus lumborum is one of the common sources of pain and that can be missed or ignored easily. Quadratus lumborum pain syndrome is a myofascial pain syndrome. The pain is due to spasm and stiffness of the muscle. Many a times, weak back muscles are compensated by quadratus lumborum leading to painful spasm. It is diffi cult to differentiate between quadratus lumborum and iliopsoas pain syndrome. Diagnostic quadratus lumborum injection helps differentiate between these two. In this report, we reported a case of quadratus lumborum pain syndrome as a primary diagnosis and iliopsoas pain syndrome as a secondary diagnosis. The diagnosis was confi rmed by fl uoroscopically guided quadratus lumborum injection.
A 50-year-old female presented with severe pain at the cholecystectomy scar site of 4 months' duration. She had an open cholecystectomy done followed by continuous pain from the time of discharge. She was diagnosed as a case of chronic postsurgical pain (CPSP) syndrome. We administered right-sided erector spinae (ES) block by ultrasound guidance depositing 15 ml of 0.25% bupivacaine and 40 mg of methylprednisolone at site of incision. The visual analog score showed significant improvement from 7/10 to 2/10 for the next 2 months of follow-up. We conclude that ultrasonography-guided ES block combined with intralesional steroid is a viable treatment option in cases of CPSP. This is possibly the first case report of postcholecystectomy chronic pain managed with ES block.
Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects.
BACKGROUND Recent investigations noted noninferiority in short-course antimicrobial treatments following source control in abdominal infections. We set out to investigate noninferiority of a short and fixed (24 hours) antibiotic administration compared to extended treatment after source control in complicated appendicitis in a prospective single-center open-label randomized controlled trial. METHODS After Institutional Review Board (IRB) approval, all consecutive adult patients (age, ≥ 18 years) with complicated appendicitis including gangrenous appendicitis, perforated appendicitis, and appendicitis with periappendicular abscess between May 2016 and February 2018 were randomly allocated to antibacterial therapy limited to 24 hours (short) vs. >24 hours (extended) administration after appendectomy. Primary outcomes included composite postoperative complications and Comprehensive Complication Index (CCI). Secondary outcome was hospital length of stay (HLOS). Follow-up analysis at 1 month was conducted per intention and per protocol. RESULTS A total of 80 patients were enrolled with 39 and 41 cases allocated to the short and the extended therapy group, respectively. Demographic profile and disease severity was similar between the study groups. Overall rate of complications was 17.9% and 29.3% in the short and extended group, respectively (p = 0.23). Mean CCI did not differ between the study groups (p = 0.29). Hospital length of stay was significantly reduced in the short therapy group (61 ± 34 hours vs. 81 ± 40 hours, p = 0.005). CONCLUSION In the current prospective randomized investigation, the short (24 hours) antibiotic administration following appendectomy did not result in a worse primary outcome in complicated appendicitis. The short interval administration resulted in a significant reduction in HLOS with a major cost-saving and antibacterial stewardship perspective. LEVEL OF EVIDENCE Therapeutic Level IV.
