Contemporary intraoperative visualization for GBM with use of exoscope, 5-ALA fluorescence-guided surgery and tractography

Maximal safe resection is the primary goal of glioma surgery. By incorporating improved intraoperative visualization with the 3D exoscope combined with 5-ALA fluorescence, in addition to neuronavigation and diffusion tensor imaging (DTI) fiber tracking, the safety of resection of tumors in eloquent brain regions can be maximized. This video highlights some of the various intraoperative adjuncts used in brain tumor surgery for high-grade glioma. In this case, the authors highlight the resection of a left posterior temporal lobe high-grade glioma in a 33-year-old patient, who initially presented with seizures, word-finding difficulty, and right-sided weakness. They demonstrate the multiple surgical adjuncts used both before and during surgical resection, and how multiple adjuncts can be effectively orchestrated to make surgery in eloquent brain areas safer for patients. Patient consent was obtained for publication. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21174

INFORMATION AND LEGAL COMPONENTS OF LABOR PROTECTION IN THE CONTEXT OF THE COVID-19 PANDEMIC

The article summarizes the state of legal regulation and judicial and law enforcement practice in the field of labor relations, which arise against the background of the COVID-19 pandemic. The normative legal acts referred to by the Ukrainian authorities when making decisions on compulsory vaccination, and which serve as a normative basis for the removal of certain employees from work, are analyzed. At the same time, an analytical review of the decisions of the Supreme Court of Ukraine and the decisions of the European Court of Human Rights on appeals concerning coercion by the authorities and administrative institutions to vaccinate was carried out. Analytical materials of public associations of lawyers and the practice of the Verkhovna Rada Commissioner for Human Rights were also used for analysis. Attention is drawn to gaps in legislation and regulations on the issue of informed patient consent. Certain options for amending the relevant acts are proposed. Conclusions on the instrumental impact of information and legal aspects on the general state of labor protection in a pandemic. The author, in particular, draws attention to the fact that the state, having established the rule that without vaccinations certain categories of workers can not be admitted to work, fulfills its obligation to ensure labor protection. That is, by creating safety and health conditions at work, public authorities and employers protect not only all workers and those who receive their services, but also the person who has not received preventive vaccinations, through the mechanism of offering such an employee, for example, conditions for remote work. At the same time, the article emphasizes the fact that medical institutions and doctors are largely ignoring the provisions of current legislation on the objective information of patients undergoing vaccination. It is about informing patients about the features of different vaccines and the possible consequences of their use. And this, in turn, should lead to the informed consent of the patients themselves. Thus, informed consent in the described legal relations is a specific indicator and, at the same time, an instrument of labor protection. This, in this case, applies not only to subjects who are vaccinated, because then they receive "admission" to the place of work and the work itself, but also, separately, it is a criterion of quality working conditions of health workers, quality of medical services as an independent species. labor. And reaching the level of collective immunity, thanks to mass vaccination, creates a more global protection of the population, and thus, for its working part, and a tool to protect all types of work.

Intraoperative Evaluation of Effects of Different Gas Mixtures (Oxygen 100%, O2 50%:N2O 50%, Air on Cuff Pressure of PLMA (Proseal LMA)

Introduction:- we study the intra operative evaluation of different gas mixture(oxygen 100%, O2 50%:N2O 50%, AIR on cuff pressure of PLMA. Aims and Objectives:- To study intracuff pressure changes and the change in final volume of gas mixture during inflation and deflation during intraoperative period and postoperative complications. Material and Methods:- This double blind, prospective Study was conducted in Department of Anaesthesiology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala following approval from institutional ethical committee and written informed patient consent. The sample size of 120 patient aged 18 to 60 years, belonging to ASA physical status 1 and 2 undergoing surgery in general anesthesia with PLMA as airway device divided into three group on the basis of PMLA cuff gas mixture:-Group O - oxygen 100%, Group ON - Nitrous 50%: Oxygen 50%, Group A – Air. Results and Conclusion:- Combination of N2O and O2 resulted in decreased intracuff pressure and air lead to a slight increase in intracuff pressure with O2 providing relatively stable cuff pressures. Keywords: PLMA,100% Oxygen, Air, Oxygen 50% N2O 50%, Air.

Utilization of Generic Cardiovascular Drugs in Medicare’s Part D Program

Background: Generic medications cost less than brand-name medications and are similarly effective, but brand-name medications are still prescribed. We evaluated patterns in generic cardiovascular medication fills and estimated the potential cost savings with increased substitution of generic for brand-name medications. Methods: This was a cross-sectional study of cardiovascular therapies using the Medicare Part D database of prescription medications in 2017. We evaluated drug fill patterns for therapies with available brand-name and generic options. We determined the generic substitution ratio and estimated the potential savings with increased generic substitution at the national, state, and clinician level. We compared states with laws related to mandatory pharmacist generic substitution and patient consent for substitution. Results: Of ≈$22.9 billion spent on cardiovascular drugs in Medicare Part D prescription programs in 2017, ≈$11.0 billion was spent on medications with both brand-name and generic options. Although only 2.4% of medication fills were for the brand-name choice, they made up 21.2% of total spending. Accounting for estimated brand-name rebates, generic substitution for these medications would save $641 million, including $135 million in costs shouldered by patients. Furthermore, the minority of clinicians with the lowest generic utilization was responsible for a large proportion of the potential cost savings. Conclusions: There are substantial potential cost savings from substituting brand-name medications with generic medications. These savings would be primarily driven by lower use of brand-name therapies by the minority of clinicians who prescribe them at increased rates.

Brief Consent Methods Enable Rapid Enrollment in Acute Stroke Trial: Results From the TICH-2 Randomized Controlled Trial

Background and Purpose: Seeking consent rapidly in acute stroke trials is crucial as interventions are time sensitive. We explored the association between consent pathways and time to enrollment in the TICH-2 (Tranexamic Acid in Intracerebral Haemorrhage-2) randomized controlled trial. Methods: Consent was provided by patients or by a relative or an independent doctor in incapacitated patients, using a 1-stage (full written consent) or 2-stage (initial brief consent followed by full written consent post-randomization) approach. The computed tomography-to-randomization time according to consent pathways was compared using the Kruskal-Wallis test. Multivariable logistic regression was performed to identify variables associated with onset-to-randomization time of ≤3 hours. Results: Of 2325 patients, 817 (35%) gave self-consent using 1-stage (557; 68%) or 2-stage consent (260; 32%). For 1507 (65%), consent was provided by a relative (1 stage, 996 [66%]; 2 stage, 323 [21%]) or a doctor (all 2-stage, 188 [12%]). One patient did not record prerandomization consent, with written consent obtained subsequently. The median (interquartile range) computed tomography-to-randomization time was 55 (38–93) minutes for doctor consent, 55 (37–95) minutes for 2-stage patient, 69 (43–110) minutes for 2-stage relative, 75 (48–124) minutes for 1-stage patient, and 90 (56–155) minutes for 1-stage relative consents ( P <0.001). Two-stage consent was associated with onset-to-randomization time of ≤3 hours compared with 1-stage consent (adjusted odds ratio, 1.9 [95% CI, 1.5–2.4]). Doctor consent increased the odds (adjusted odds ratio, 2.3 [1.5–3.5]) while relative consent reduced the odds of randomization ≤3 hours (adjusted odds ratio, 0.10 [0.03–0.34]) compared with patient consent. Only 2 of 771 patients (0.3%) in the 2-stage pathways withdrew consent when full consent was sought later. Two-stage consent process did not result in higher withdrawal rates or loss to follow-up. Conclusions: The use of initial brief consent was associated with shorter times to enrollment, while maintaining good participant retention. Seeking written consent from relatives was associated with significant delays. Registration: URL: https://www.isrctn.com ; Unique identifier: ISRCTN93732214.

The ethical and medico-legal challenges of telemedicine in the coronavirus disease 2019 era: A comparison between Egypt and India

Background In the coronavirus disease 2019 era, doctors have tried to decrease hospital visits and admissions. To this end, telemedicine was implemented in a non-systematic manner according. The objective of this study was to assess the current knowledge and attitudes of physicians in Alexandria, Egypt, and Punjab, India, toward telemedicine and its ethical and medico-legal issues. Method A cross-sectional study was implemented using an anonymous self-administered questionnaire carried out over two months (July and August 2020). A four-point Likert scale was used to collect data about background knowledge, training in telemedicine and ethical and medico-legal issues in telemedicine practice. Results The questionnaire was completed by 175 Egyptian and 51 Indian physicians from different specialties. A significantly higher percentage of Indian physicians practiced telemedicine than Egyptian physicians during the coronavirus disease 2019 era. Although most physicians had no specific training or licensing to practice telemedicine, most of them practiced telemedicine through their social media accounts. Ethical violations involving waiving patient consent were detected. Significant ethical violations to doctors, for example, blackmail, defamation, hate speech, accusations in a court and violations of privacy, were observed. Indian physicians (39.2%) and Egyptian physicians (24%) thought the penalties should be lower in telemedicine than in traditional practice. Finally, most participants would like to continue using telemedicine after the coronavirus disease 2019 era but with improvements. Conclusions Coronavirus disease 2019 changed the acceptance of telemedicine by physicians. Many ethical and legal issues need to be addressed and clarified using formal training before implementation and standardization of telemedicine services.

Peritoneal Modulators of Endometriosis-Associated Ovarian Cancer

Ovarian cancer is the 4th largest cause of cancer death in women. Approximately 10–15% of women of childbearing age suffer from endometriosis. Endometriosis is defined by the growth and presence of endometrial tissue (lesions) outside of the uterus. The women with endometriosis also have an increased presence of peritoneal fluid (PF) that comprises of inflammatory cells, growth factors, cytokines/chemokines, etc. Epidemiological studies have shown that &gt;3% of women with endometriosis develop ovarian cancer (low-grade serous or endometrioid types). Our hypothesis is that the PF from women with endometriosis induces transformative changes in the ovarian cells, leading to ovarian cancer development. PF from women with and without endometriosis was collected after IRB approval and patient consent. IOSE (human normal ovarian epithelial cells) and TOV-21G cells (human ovarian clear cell carcinoma cell line) were treated with various volumes of PF (no endometriosis or endometriosis) for 48 or 96 h and proliferation measured. Expression levels of epigenetic regulators and FoxP3, an inflammatory tumor suppressor, were determined. A Human Cancer Inflammation and Immunity Crosstalk RT2 Profiler PCR array was used to measure changes in cancer related genes in treated cells. Results showed increased growth of TOV-21G cells treated with PF from women with endometriosis versus without endometriosis and compared to IOSE cells. Endo PF treatment induced EZH2, H3K27me3, and FoxP3. The RT2 PCR array of TOV-21G cells treated with endo PF showed upregulation of various inflammatory genes (TLRs, Myd88, etc.). These studies indicate that PF from women with endometriosis can both proliferate and transform ovarian cells and hence this microenvironment plays a major mechanistic role in the progression of endometriosis to ovarian cancer.

Observational Study to Evaluate the Lipid Profile Abnormalities among Newly Diagnosed Hypertensive Patients

Objective and Aim: Variations from the norm of lipid profile and hypertension frequently coincide. The present study was conducted to evaluate the lipid profile abnormalities among hypertensive patients. Material and Method: This is a retrospective observational study conducted at a primary diabetes and cardiology clinic OPD among 200 patients whose clinical records are well maintained or fully available at the clinics registry. After getting individual patient consent the data collected and analysed to draw a study conclusion. Result: 48.4 ± 6.9 years was the mean average age of study group whereas for the control group it was 49.3± 5.9 years. In the age group 40-49 years occurrence of hypertension was seen in extreme as compare to other age group. In study groups total cholesterol, triglyceride, HDL Cholesterol and LDL Cholesterol were significantly higher as compared to control group (p<0.05). Among the hypertensive subjects most frequently occurring abnormality was elevated TC (78%), followed by elevated LDL (66%). Conclusion: Among newly diagnosed hypertensives lipid variations are highly prevalent as documented in this study. Hypertension is the one of the major risk factor for coronary artery disease and for this biologic interrelations between serum lipids and blood pressure further worsen the condition. Hence to prevent complications early detection and aggressive treatment of dyslipidemia in hypertensive patients should be carried out. Keywords: Hypertension, Lipid profile, Cardiovascular Diseases.

Absence of Consent

Consent has come to be the guardian and gatekeeper of significant elements of our personal integrity. Yet there remains uncertainty as to exactly what consent means. This paper argues that consent marks the divide between the active and the passive. We tend to assume that in our engagements with others, active and passive, there are only two possibilities, consent and non-consent, when in fact there are three. When an agent engages with a patient consent is vital, because the alternative is non-consent. When two people interact, however, consent has nothing to contribute. The law, for excellent reasons, ignores this nuance, so as to treat every absence of consent as non-consent. It does so in order to arm potential victims with a weapon for their protection. To grasp the full significance of that weapon, and to secure proper scrutiny of interaction in other settings, we need to be alive to the reality that the law dispenses with.