Question:
You will be shown the title of a chemistry paper, together with sections excerpted from the body of the paper. The paper sections may include HTML tags like `<p>` and `</p>`; please ignore these. Your task is to write an abstract for the paper. Your response should include the abstract and no other text.

Title:
Gold Catalyzed Decarboxylative Cross-Coupling of Iodoarenes

Paper sections:

Gold was once thought to have few uses in fine chemical synthesis. 1 Advances in homogeneous gold catalysis demonstrated that gold(I) complexes can promote a wide variety of synthetically relevant transformations. [2][3][4][5] Most employ a gold(I) catalyst as a Lewis acid or π-activator, where gold is thought to formally remain at the +1 oxidation state. The apparent redox stability of gold(I) complexes [6][7][8] contrasts with prominent two electron redox events known for palladium, rhodium, platinum, and iridium complexes. The redox stability of gold(I) complexes has limited development of complementary methods utilizing redox gold catalysts. This work describes a gold catalyzed decarboxylative cross-coupling reaction.

Pioneering studies demonstrated that gold(I) complexes could participate in oxidative addition with methyl iodide, 9,10 trifluoromethyl iodide, 11,12 aryl diazonium salts, [13][14][15][16][17][18] iodine(III) reagents, [19][20][21][22][23][24][25][26] and other strong oxidants. [27][28][29] Initially Lloyd-Jones and co-workers demonstrated a catalytic oxidative coupling of aryl silanes in the presence of a strong acid and a stoichiometric iodine(III) oxidant (Scheme 1a). 20,21 A limiting feature of this and subsequent work [22][23][24][25][26]30,31 is that the site selectivity of C-H bond activation is governed by an apparent electrophilic aromatic substitution (EAS) mechanism. Patil and coworkers demonstrated a dual gold/photoredox catalyzed cross-coupling with aryl silanes 17 or aryl stannanes, which is thought to occur via a radical mechanism (Scheme 1b). 18 The direct oxidative addition with more standard and less hazardous aryl halide electrophiles (e.g. Ar-I), which is standard for palladium(0), is relatively rare with gold(I). 6,7,[30][31][32][33][34][35][36][37][38] The barrier for the oxidative addition of gold(I) complexes into aryl halides can be decreased through the use of bidentate ligands with a hemilabile site. 6,33,37 Amgoune, Bourissou, and co-workers recently disclosed a gold catalyzed arylation of electron rich indoles and trimethoxybenzene with aryl halides (Scheme 1c). 30,31 This was recently expanded to amination. 38,39 Attempts at expanding this reactivity to more common organometallic reagents have been problematic. In an elegant study, Bower, Russell, and co-workers demonstrated that all three elementary steps in a putative gold(I/III) cross-coupling are viable. 6,32 However, this reactivity was not incorporated into a catalytic method. Additionally, aryl boron reagents were found to be sub-optimal coupling partners, which may be due to a challenging and potentially endothermic transmetalation. 40,41 An alternative to transmetalation would be to utilize decarboxylation.

Scheme 1. Gold Catalyzed Biaryl Formations

Our lab has focused on decarboxylative cross-coupling. 42,43 Decarboxylative functionalization reactions are recognized as promising alternatives to traditional cross-couplings because expensive or unstable organometallic reagents can be replaced by readily available benzoic acids . [44][45][46][47][48] Inspired by two reports describing stoichiometric gold(I) mediated decarboxylation, 49,50 we surmised that this elementary step could offer an alternate pathway to gold-aryl complexes, obviating traditional transmetalation. 6,40,41 Presented herein is a gold catalyzed decarboxylative cross-coupling reaction between iodoarenes and (hetero)aryl carboxylates (Scheme 1e). This work represents the first site-specific gold catalyzed cross-coupling with standard coupling partners and the first gold catalyzed decarboxylative coupling of (hetero)aryl carboxylates. Initial trials were inspired by Amgoune and Bourissou, who recommended MeDalphos as a ligand. 30,31 The use of sodium carboxylate 1a (M = Na) with NaOTf did not produce any detectible biaryl (Table 1, entry 1). Excitingly, using AgOTf afforded cross-coupled product 3a along with protodecarboxylation product 4 (entry 2). 51 Switching from a sodium carboxylate to a silver carboxylate (entry 3) and decreasing the loading of AgOTf dramatically improved the yield (entry 4). Changing the limiting reagent to iodoarene 2a significantly diminished the yield (entry 5).

Table 1. Optimization for Gold Catalyzed Decarboxylative Cross-Coupling

a Reactions conducted with benzoate 1a (0.1 mmol), iodoarene 2a (0.5-1.0 mmol), in 1,2-dichlorobenzene (0.5 M, DCB), with 5 mol % [Au]. b Yield determined by 19 F NMR analysis. All yields reflect the average of duplicate trials. c Reactions conducted neat in iodoarene 2a. d  A variety of precatalysts were screened and it was discovered that Buchwald style phosphine ligands performed well under neat conditions (entries 6-11). 52 The quantity of iodoarene was decreased from 10 equiv to 5 equiv (entries 12-13). The t BuXPhos ligand outperformed the t BuJohnphos ligand under these conditions. Next, the counterion on the precatalyst was evaluated (entries 14-16). With LAuCl or LAuI complexes, in the absence of silver trifluoromethanesulfonate, significant homocoupling of benzoate 1a was observed. The optimal precatalyst was LAuNTf2 (entry 17). A further reduction in the iodoarene to 3 equiv was tolerated but decreased the selectivity (entry 18). The reaction was conducted in a new vial with a new stir bar to avoid possible contamination, 53 which did not significantly affect the yield (entry 19). In the absence of gold, small amounts of product were observed along with significant protodecarboxylation (entry 20, see SI for additional trials and control experiments).

The substrate scope of the iodoarene was investigated (Table 2). Substrate 3a was isolated in excellent yield (86%). Iodobenzene (3b), 4-iodoanisole (3c), and 4-iodobenzotrifluoride (3d) afforded product, covering the traditional Hammett series (4-OMe, σp = -0.27; 4-CF3, σp = 0.54). Iodoanisole gave an improved yield at 120 °C, while iodobenzotrifluoride required heating to 160 °C. This matches prior observations demonstrating that oxidative addition at gold(I) is faster with electron rich substrates (vide infra). 31,33 Iodoarenes with meta substituents gave acceptable yields (3e-3h). The reaction tolerated ortho groups (3i-3k). Chemoselectivity was observed for oxidative addition in the presence of aryl chlorides (3j) and aryl bromides (3h, 3k). Iodonaphthalene (3l) also worked well.

Table 2. Substrate Scope of Iodoarene

Yield determined by 19 F NMR. Yield in parenthesis is the isolated yield. All values are the average of duplicate reactions. Reaction conducted at a 120 °C, b 160 °C, c in 1,2-dichlorobenzene. See SI.

A competition experiment was conducted between 4-iodoanisole (2c) and 4-iodobenzotrifluoride (2d, Table 2 bottom). The reaction afforded biaryl 3c as the major product with a 3c:3d ratio of 3.3:1. A similar competition experiment with stoichiometric MeDalphosAuSbF6, afforded gold(III) complexes with a ratio of 6.7:1. 31 The inversion of reactivity, relative to oxidative addition at palladium(0), 54 is a potential hallmark of gold oxidative addition. 27,31,33 The substrate scope with respect to the aryl carboxylate was investigated (Table 3). It is well recognized in the area of palladium, copper, and silver decarboxylative cross-coupling that substrates with polarizing ortho substituents are particularly reactive. [44][45][46][47][48] Hoover and co-workers correlated the field effect parameter (Fortho) to reactivity for silver mediated protodecarboxylation. 55 Here, products 3m -3v could be isolated in good to excellent yield and these results qualitatively correlate to the field effect parameter. Less activated substrates required elevated temperatures and/or increased catalyst loading (3v -3y). It is particularly exciting that substrates 3x and 3y can be isolated in any yield given the scope limitations of other decarboxylative cross-coupling reactions. 43,48,56 Substrates with an ortho C-H bond did not afford product with palladium catalyzed reactions 42,43,56 and a chlorine substituent (3y) is not considered to be particularly polarizing. A substrate with an orthomethoxy was not activated enough to provide an acceptable yield (3z, Fortho = 0.29). Activated pyridine carboxylates afforded products 3aa and 3bb. Pyridines are particularly challenging substrates in traditional cross-coupling reactions. [57][58][59] It is conceivable that the observed cross-coupling reaction could proceed via protodecarboxylation 51,55 and subsequent C-H bond activation. 60 This concern is valid because product 4 was observed and since carboxylates facilitate C-H bond activation. 60 A reaction with 1,3-difluorobenzene (4) and excess silver benzoate 1o afforded a negligible quantity of product 3a (Scheme 2a). The majority of compound 4 was detected after the reaction, with the mass loss being attributed to volatility. As such, a protodecarboxylation and C-H bond activation sequence is unlikely.

Table 3. Substrate Scope of (hetero)aryl carboxylates

Yield determined by 19 F NMR. Yield in parenthesis is the isolated yield. All values are the average of duplicate reactions. Reaction conducted a in 1,2-dichlorobenzene at 0.1 M, b in 1,2-dichlorobenzene at 0.17 M, c at 180 °C, d at 180 °C using 10 mol % [Au]. See SI. Fortho = field effect parameter.

A tentative mechanism was supported by monitoring various elementary steps with isolated complexes (Scheme 2). Benzoate 1a' underwent salt metathesis, yielding complex Au1 (Scheme 2b). Gold(I)-aryl complex Au2 could be isolated via thermolysis of complex Au1 (Au2 crustal structure shown, Scheme 2b), indicating that gold mediated decarboxylation is viable. 49,50 Heating complex Au2 in neat iodoarene provided some biaryl (Scheme 2c). The majority of complex Au2 remained unreacted, even after 24 h. However, when AgOTf was used with complex Au2, product 3a was observed in high yield (Scheme 2c). This suggests that silver is needed to either promote oxidative addition or reductive elimination en route to product 3a. Tetracoordinate gold(III) complexes can be stable and halide abstraction can trigger reductive elimination. 12,27 While minimal product 3a was formed from complex Au2 (Scheme 2c) in the absence of silver, using stoichiometric t BuXPhosAuNTf2 with carboxylate 1a' did produce product 3a (21%) as well as complex Au2 (36%, Scheme 2d). Potentially, t BuXPhosAuNTf2 can abstract iodide from a putative gold(III) complex, while complex Au2 does not. To test this hypothesis, complex Au2 was subjected to the reaction conditions with added t BuXPhosAuNTf2 (Scheme 2e) and product 3a was observed. These results demonstrate that silver is not required and the most likely role for AgOTf is to promote halogen abstraction prior to reductive elimination from an Au(III) complex. 12,27 A reversible and endothermic oxidative addition is also possible and would complicate the isolation of Au(III) complex.  In conclusion, we report the first gold catalyzed decarboxylative cross-coupling. This work expands on recent progress regarding gold(I) oxidative addition. Decarboxylation overcomes site selectivity limitations associated with prior gold catalyzed arylations. The scope of the aryl carboxylate correlates qualitatively with the field effect parameter and preliminary studies indicate that all steps in a catalytic cycle can occur at gold. A more comprehensive mechanistic study will be reported in due course.

Answer: This report details a decarboxylative cross-coupling of (hetero)aryl carboxylates with iodoarenes in the presence of a gold catalyst (>25 examples, up to 96% yield). Generating an aryl nucleophile via decarboxylation obviates problems associated with transmetalation at a putative gold(III) complex. This reaction is site specific, which overcomes prior limitations associated with gold catalyzed oxidative coupling reactions. The reactivity of the (hetero)aryl carboxylate correlates qualitatively to the field effect parameter (Fortho). Furthermore, each step in a proposed mechanism was observed from isolated gold complexes, supporting a gold catalyzed mechanism.


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
for many patients with multivessel disease , pci is a definitive alternative to coronary artery by - pass graft ( cabg ) [ 1 , 2 ] .
complete revascularization remains a desirable goal , and a satisfactory outcome may be obtained with complete revascularization with ptca   or cabg [ 4 , 5 ] .
however , complete revascularization may not be possible in many patients , either because of the operator inability to treat all diseased coronary arteries such as chronic total occlusions and adverse stenosis morphology or simply being not easy to plan in the presence of coronary narrowing less than severe ( > 50% but < 70% ) .
alternatively , the operator might decide to selectively revascularize only large areas of myocardium at risk .
indeed , clinical reasons for this decision include , among others , unstable angina , recent myocardial infarction , severe left ventricular dysfunction , urgent / emergent pci , preexisting renal failure for which the amount of angiographic contrast media should be limited , and   premature termination of the procedure for unexpected problems , such as in those elderly or frail patients who can not lay flat for prolonged periods .
thus , revascularization of the culprit lesion may be part of an incomplete revascularization strategy which may be of value other than a common clinical practice in many selected cases , when wisely chosen because of its easier achievement and lower immediate risk .
in the bari trial comparing cabg with multivessel pci , the 10-year survival did not differ between the two treatments despite the fact that 91% of significant lesions were bypassed in the cabg patients compared to 54% of significant lesions in the pci patients . in the same trial , cardiac death ,
myocardial infarction and angina at 10-year follow - up were similar in patients in whom a pci was performed as a planned incomplete revascularization , as compared to those with a planned complete revascularization .
furthermore , even in patients for whom complete revascularization with angioplasty was planned , only 50% of lesions were both attempted and dilated .
similar results were obtained by vandormael et al . who found an important symptomatic relief achieved with partial revascularization in patients with multivessel disease .
in these patients , 1-year cardiac event rate was not significantly higher than the rate in the group with complete revascularization . at followup ,
66% of patients with complete revascularization were asymptomatic and 84% had clinical improvement ; this was similar to 58% and 85% , respectively , for patients with incomplete revascularization .
thus , incomplete revascularization seems to be a valuable solution when a culprit lesion can be identified , particularly when this vessel is a favourable lesion which serves a large noninfarct territory , or in case of an acute coronary syndrome where there is the need to stabilize patient 's condition [ 11 , 12 ] .
moreover , in the arterial revascularization therapies studies ( arts ) ,   randomization of stenting in patients with incomplete revascularization including diabetics did not influence late mortality .
however , in multivessel disease , complete revascularization is often an achievable goal not often pursued both by pci and cabg , despite the fact that the latter is generally more complete . indeed , even when complete revascularization is planned such as in the chronic total occlusion subgroup of the syntax trial , complete revascularization is obtained in only 49.4% of pci treated patients while in only 68.1% of cabg treated patients .
more recently , in the five - year outcome of the arts ii study , there was no significant difference in survival rates between patients with complete and incomplete revascularization treated by pci or cabg .
conversely , this study showed a significantly lower free - from - mace survival in patients with higher syntax tertiles compared to the lower and intermediate ones .

 exercise testing is a widely used method particularly valuable in assessing cardiovascular status after the occurrence of a cardiac event or therapeutic interventions such as pci .
when it is performed after discharge it is helpful for activity counseling and/or exercise training as part of the cardiac rehabilitation program .
however , data obtained from two meta - analyses demonstrate that exercise testing , even if information from the electrocardiogram and symptomatic data   is   synthesized , is poor diagnostic for myocardial ischemia with a sensitivity of 46% and a specificity of 77% [ 6 , 7 ] .
the use of stress nuclear imaging increases significantly the sensitivity to 87% and the specificity to 78% , while that of stress echocardiography imaging increases the sensitivity to 63% and the specificity to 87% .
the lower sensitivity of the exercise ecg compared to imaging techniques in clinical practice is worsened further by inadequate stress yielding low exercise heart rates , the use of drugs that are known to influence test results , and the extent of disease in vessels other than those dilated .
furthermore , the exercise electrocardiogram does not permit the determination of location of the ischemia , nor does it accurately assess the extent of ischemia ; these factors are often crucial in the clinical decision making after - pci .
although exercise testing has the advantage of widespread availability and relatively low cost , the higher test accuracy obtained by stress imaging provides greater advantages for clinical assessment of these patients .
an additional advantage is that pharmacological imaging stress testing may be performed in patients who are unable to exercise or who have an uninterpretable electrocardiogram .
several studies [ 6 , 7 , 1623 ] employing spect myocardial perfusion imaging ( mpi ) at different times from pci have shown high level of sensitivity and specificity of nuclear imaging when compared to those of coronary angiography ( figures 1 and 2 ) .
the overall performance of spect - mpi for the detection of myocardial ischemia was 79% for both sensitivity and specificity .
the decreased specificity observed when mpi is performed prematurely after pci was initially noted following ptca [ 2426 ] and after coronary stenting    [ 27 , 28 ] .
indeed , mpi may be altered as a consequence of impaired flow reserve due to an epicardial coronary stenosis or , in the absence of coronary obstruction , as a consequence of an endothelial dysfunction and medial injury at the treated site or abnormal microvascular and resistive vessel function distal to the pci site as shown by various authors [ 29 , 30 ] and by us in two editorials [ 31 , 32 ] .
similar to mpi , echocardiography in conjunction with exercise provides useful functional assessment of coronary lesions and has a high concordance with myocardial scintigraphy .
mertes and colleagues found that exercise echocardiography may predict the development of recurrent ischemia after ptca , with a sensitivity of 83% and specificity of 85% .
the functional significance of a lesion may also be determined with the use of pharmacological stress .
for the detection of coronary restenosis , exercise , dipyridamole , and dobutamine echocardiography   have shown a diagnostic accuracy similar to that seen with mpi although a lower sensitivity ( 75% to 87% ) and a slight higher specificity ( 84% to 95% ) were found in the direct comparison with the nuclear data [ 36 , 37 ] .
a limitation of stress echocardiography is the inability to get acceptable quality images of left ventricle walls in about 15% of patients .
indeed , if this exam is performed at institutions and interpreted by physicians with adequate experience and training , it is considered of major importance for coronary artery disease detection and , along with gadolinium , for viability detection to predict left ventricular function recovery .
both mpi and stress echocardiography have a clear superiority with regard to specificity and predictive value for postrevascularization events [ 4044 ] .
indeed , for mpi , these findings have been shown regardless of the method selected and include the use of 201tl or 99mtc radiopharmaceuticals or after the use of different modes of stress imaging [ 4548 ] . in the angioplasty
compared to medicine study , 328 patients were randomized to ptca or to medical therapy . at six months after randomization
, 82% of patients underwent stress mpi and were followed for more than five years .
mortality in the ptca group was 20% for those with a reversible defect versus 7% for those without such a defect ( p = 0.03 ) . by multivariate analysis , the strongest predictors of mortality were diabetes , smoking , and a reversible perfusion defect at mpi .
similarly , the relative prognostic information derived from mpi at 1 year after revascularization for patients with multivessel coronary artery disease included in the prospective east trial reveals a strong correlation between detected ischemia on thallium scintigraphy and subsequent events [ 45 , 47 ] .
more recently , in patients with incomplete revascularization procedures , we demonstrated that exercise spect mpi provides significant independent information concerning the subsequent risk of both hard and soft cardiac events , with a composite annualized event rate < 2% for patients with a normal scan ( figure 3 ) .
mpi is able to provide incremental prognostic information after adjusting for clinical , angiographic , and exercise variables and is able to predict the occurrence of cardiac hard and soft events when separating patients according to the presence of myocardial ischemia and necrosis ( figures 4 and 5 ) .
the results of this study suggest that certain high - risk patients , such as those with multivessel coronary artery disease , treated by incomplete revascularization may benefit from routine mpi ; this is especially true for low - risk patients as shown by ho and colleagues who studied 211 patients between 1 and 3 years after pci and monitored them for 7.3 years .          despite a low overall annual event rate of 1% per year ,
an abnormal mpi was significantly predictive of cardiac death or mi , whereas a normal mpi was associated with low risk .
to date , the major evidence that supports revascularization in patients with an abnormal mpi is based on the following three studies .
examined a prospective database from a single center and classified patients on the basis of the severity of ischemia on stress mpi and examined the effect of revascularization versus medical therapy on subsequent mortality after an average followup of two years .
there was no difference in mortality between medical therapy and revascularization in patients with ischemia < 10% of myocardium , while patients with an ischemia > 10% had lower mortality with revascularization .
these results were also confirmed in the nuclear substudy of the courage trial , in which patients with stable angina had paired mpi studies performed at baseline and 618 months after randomization of optimal medical therapy versus optimal medical therapy and pci .
a reduction of ischemia > 5% on mpi was associated with a 13.4% rate of the death / myocardial infarction composite event rate , whereas in those with no reduction of ischemia the composite event rate was 27.4% ( more than two - fold ) . indeed , pci was more effective in achieving an ischemia reduction of > 5% compared to medical therapy ( 33% versus 19.8% , p = 0.004 ) .
these two studies suggest that the benefits of revascularization over medical therapy are related rather than to a more complete anatomical revascularization , to a significant reduction of   ischemia , revascularization driven .
similarly , in a recent study by our group in patients with a residual cto in a main coronary artery left untreated after pci who underwent follow - up stress mpi , myocardial perfusion imaging provided significant independent information concerning the subsequent risk of cardiac events .
indeed , patients with severe ischemia had significantly higher rates of death and myocardial infarction than those with either mild ischemia or no ischemia .
furthermore , by characterizing the type of defect in terms of presence of scar , ischemia only , or scar and ischemia , we observed that patients with ischemia had the worst outcomes .
this study emphasizes the prognostic significance of ischemia on stress mpi even in patients with chronically occluded coronary vessels , so refocusing the attention on the difference between anatomic and functional revascularization .
this study , with all others from literature , underlines that it is not the anatomic severity of coronary disease which determines prognosis , rather the achievement of a  functionally  complete revascularization , in other words revascularization of all coronary arteries which serve only ischemic and viable myocardial segments [ 9 , 13 , 52 , 53 ] ( figure 6 ) .
this is   why many studies evaluating the impact of completeness of revascularization strategy based only on anatomic criteria ( coronary stenosis 50% ) have failed to demonstrate improvements in survival rates .
although complete revascularization remains a desirable goal in multivessel disease patients , incomplete revascularization strategy may be a preferred treatment strategy and a common clinical practice in many selected cases , when wisely chosen , because of its easier achievement and lower immediate risk . among these incompletely revascularized patients , mpi is able to identify those patients with ischemic and viable myocardial regions , in which a  functionally complete revascularization  is needed to improve their outcome ( figure 7 ) .

Answer:
percutaneous coronary intervention ( pci ) is actually the most used method of revascularization .
 although complete revascularization remains a desirable goal , it may not be possible or not easy to plan in many patients .
 thus , incomplete revascularization might be a preferred treatment strategy in selected patient categories .
 stress myocardial scintigraphy , because of its high diagnostic accuracy and prognostic value and its ability to assess location and extent of myocardial ischemia regardless of symptoms as well as to evaluate patients who are unable to exercise or who have uninterpretable electrocardiogram , is of paramount importance for clinical decision making in patients with multivessel disease and incomplete revascularization .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
approximately 225,000 primary total hip arthroplasties ( thas ) are performed in the united states per year , and projections indicate that more than 4 million thas will be performed annually by 2030.1 neurologic injury after tha is reported to occur in 0.09 to 3.7% of primary thas and 0 to 7.4% of revision thas.2 noted causes of neurologic injury include direct intraoperative nerve injury , leg lengthening , excess retraction , cement extravasation , cement - related thermal damage , patient positioning , and postoperative hematoma.2 the majority of these injuries are symptomatic within the early postoperative period and can be managed conservatively with close follow - up . delayed onset of neurologic injury
we report a case of neuropathy caused by malposition of an acetabular cup screw causing direct injury to the sciatic nerve .
the patient developed progressively worsening loss of ankle dorsiflexion , resulting in complete footdrop 2 years after initial tha .
the presentation , intervention , and outcome of other cases of delayed neuropathy are reviewed in the present report .
delayed neuropathies are most often caused by irritation from hardware , component failure , or wear - related pseudotumors .
the patient was a 52-year - old woman with end - stage arthritis of her bilateral hips with previous uncomplicated right tha that underwent an elective left tha .
no intraoperative complications , abnormal anatomic landmarks , or events were noted at the time of surgery .
the patient 's initial orthopedic postoperative course was complicated by paresthesias of the right lower extremity , severe hypesthetic pain primarily in the lateral and anterior aspect of the right calf , and severe sciatica . during her hospital
stay , the patient 's sensation and pain improved ; however , less than 1  year after her tha she noted gradual onset of weakness in her right lower extremity .
, she had developed a complete footdrop with loss of ankle dorsiflexion and required the use of an ankle - foot orthosis ( afo ) to ambulate .
she underwent an emg at an outside facility , had a neurologic evaluation , and was undergoing physical therapy .
the patient had 0/5 dorsiflexion strength with 3/5 eversion and 5/5 inversion and plantarflexion strength .
decreased sensation was noted in the lateral aspect of the leg and the dorsum of the foot .
she had no gross deformity of the lower extremity and had normal quadriceps and hamstring strength at the knee and the hip .
emg showed severely reduced amplitude of the peroneal compound muscle action potentials and unrecordable superficial peroneal sensory response .
fibrillation potentials were seen in the peroneal division of the sciatic nerve with minimal evidence of reinnervation changes to the muscle units .
this localized the lesion to proximal to the short head of the bicep femoris muscle .
this led to obtaining advanced imaging consisting of a computed tomography ( ct ) of the pelvis , which demonstrated a malpositioned acetabular cup screw within the soft tissues adjacent to the sciatic nerve ( fig .
the sciatic nerve was dissected via internal neurolysis into peroneal and tibial divisions at the level of the buttock .
the division of the sciatic complex was dissected proximally to the exit of the sciatic from the pelvis .
the peroneal portion of the nerve was found to be compromised by the malpositioned screw .
there was no neuroma identified at the site of nerve compression , although there was evidence of nerve displacement by the protruding screw .
the nerve was stimulated locally and nerve action potentials were recorded proximal and distal to the site of injury .
both peroneal and tibial portions of the nerve were tested separately to avoid false - positive conduction from the tibial division .
the intraoperative recordings showed preservation of conduction across the site of nerve impingement ( fig .
the nerve was reflected off the head of the screw and gently moved proximally toward the sciatic notch .
when the nerve was free of the screw and protected , a titanium cutting drill bit was used to shorten the screw so that it was flush with the bony interface . repeated
stimulation of the nerve confirmed that action potentials were still able to propagate past the site of injury .
the patient is now 2 years out of surgery and has demonstrated some recovery of peroneal nerve function , supporting the decision to pursue external neurolysis . the patient 's improvement has not been complete and the patient requires an external orthosis .
the patient was a 52-year - old woman with end - stage arthritis of her bilateral hips with previous uncomplicated right tha that underwent an elective left tha .
no intraoperative complications , abnormal anatomic landmarks , or events were noted at the time of surgery .
the patient 's initial orthopedic postoperative course was complicated by paresthesias of the right lower extremity , severe hypesthetic pain primarily in the lateral and anterior aspect of the right calf , and severe sciatica . during her hospital
stay , the patient 's sensation and pain improved ; however , less than 1  year after her tha she noted gradual onset of weakness in her right lower extremity .
, she had developed a complete footdrop with loss of ankle dorsiflexion and required the use of an ankle - foot orthosis ( afo ) to ambulate .
she underwent an emg at an outside facility , had a neurologic evaluation , and was undergoing physical therapy .
the patient had 0/5 dorsiflexion strength with 3/5 eversion and 5/5 inversion and plantarflexion strength .
decreased sensation was noted in the lateral aspect of the leg and the dorsum of the foot .
she had no gross deformity of the lower extremity and had normal quadriceps and hamstring strength at the knee and the hip .
emg showed severely reduced amplitude of the peroneal compound muscle action potentials and unrecordable superficial peroneal sensory response .
fibrillation potentials were seen in the peroneal division of the sciatic nerve with minimal evidence of reinnervation changes to the muscle units .
this localized the lesion to proximal to the short head of the bicep femoris muscle .
this led to obtaining advanced imaging consisting of a computed tomography ( ct ) of the pelvis , which demonstrated a malpositioned acetabular cup screw within the soft tissues adjacent to the sciatic nerve ( fig .
the sciatic nerve was dissected via internal neurolysis into peroneal and tibial divisions at the level of the buttock .
the division of the sciatic complex was dissected proximally to the exit of the sciatic from the pelvis .
the peroneal portion of the nerve was found to be compromised by the malpositioned screw .
there was no neuroma identified at the site of nerve compression , although there was evidence of nerve displacement by the protruding screw .
the nerve was stimulated locally and nerve action potentials were recorded proximal and distal to the site of injury .
both peroneal and tibial portions of the nerve were tested separately to avoid false - positive conduction from the tibial division .
the intraoperative recordings showed preservation of conduction across the site of nerve impingement ( fig .
the nerve was reflected off the head of the screw and gently moved proximally toward the sciatic notch .
when the nerve was free of the screw and protected , a titanium cutting drill bit was used to shorten the screw so that it was flush with the bony interface . repeated
stimulation of the nerve confirmed that action potentials were still able to propagate past the site of injury .
the patient is now 2 years out of surgery and has demonstrated some recovery of peroneal nerve function , supporting the decision to pursue external neurolysis .
the patient 's improvement has not been complete and the patient requires an external orthosis .
tha is a widely used procedure for the treatment of end - stage hip arthritis that is able to restore functional ability to hundreds of thousands of patients a year in the united states .
there is a known risk of immediate neuropathy from mechanisms such as intraoperative compression from retractors , hematoma , limb lengthening , and inappropriate patient positioning .
however , there is also a rarer risk of delayed neuropathy after tha that has different causative pathologies .
our findings from the literature suggest that late complications from tha may be more likely due to migration of hardware over time with subsequent nerve compression or reactive mass or fluid collection . in our case , a long , malpositioned screw was found in the soft tissue compressing the peroneal branch of the sciatic nerve .
a search of the pubmed database was conducted using the search term  delayed neuropathy after total hip arthroplasty  covering the years 1950 through 2015 .
fifteen case reports on 16 patients were selected based on involvement of a neuropathy that appeared after tha.3
 4
 5
 6
 7
 8
 9
 10
 11
 12
  patients presenting prior to 1  month included those that developed postoperative hematomas , had poor patient positioning , had previously undiagnosed hereditary neuropathy with liability to pressure palsies ( hnpps ) , or had anesthetic - induced inflammatory neuropathy and were felt to qualify as early postoperative complications .
delayed onset was defined as those with neuropathies developing over 1  month from surgery .
abbreviations : afo , ankle - foot orthosis ; ct , computed tomography ; emg , electromyography ; ir , interventional radiology ; mri , magnetic resonance imaging ; tha , total hip arthroplasty .
date of presentation ranged from 4 months to 9 years postoperatively . presenting symptoms included eight patients with pain , nine with sensory deficits , eight with motor deficits , and four with loss of reflexes .
regarding patient workup , three received hip radiographs , four had cts , two had magnetic resonance imaging ( mris ) , and nine underwent emgs .
ten patients received operative intervention , whereas one was treated conservatively with a brace and one with no intervention . mechanisms of injury include three patients with mass formation adjacent to the construct , one patient with limb - lengthening injury , and seven patients with hardware migration and compression .
of those with mass formation next to the construct , one was felt to be inflammatory pseudotumor whereas two were felt to be wear - related cysts caused by metal debris . after intervention
, four patients made a full recovery of function , whereas six out of eight patients with preintervention motor deficits had persistent motor deficits and one without preintervention motor deficits developed a foot drop postoperatively .
out of the nine patients with sensory deficits , four had persistent sensory loss after intervention .
patients with delayed neuropathy varied in presentation with pain , sensory , and motor symptoms .
most patients were evaluated with an emg that can objectively quantify degree of motor compromise and aid in lesion localization . as the causes of delayed nerve injury are largely local anatomical changes , ct and mri can be helpful in identifying the cause of neuropathy .
emg localization of the level of deficit , combined with screw malposition , suggested that it was the cause of the patient 's sensory and motor loss .
delayed neuropathy is a rare complication after primary tha that can be caused by hardware irritation as in the present case .
patients can present with pain , sensory loss , motor loss , and decreased reflexes that are best worked up with emg to localize the area of neuropathy and imaging to identify the root source .
results from the literature show that operative intervention is often pursued to explore and directly visualize the nerve with limited results in the literature showing modest relief of pain and sensory symptoms and poor restoration of motor function .

Answer:
background
 total hip arthroplasty ( tha ) is an established treatment for end - stage arthritis , congenital deformity , and trauma with good long - term clinical and functional outcomes .
 delayed sciatic nerve injury is a rare complication after tha that requires prompt diagnosis and management.methods
 we present a case of sciatic nerve motor and sensory deficit in a 52-year - old patient 2 years after index left tha .
 electromyography ( emg ) results and imaging with radiographs and ct of the affected hip demonstrated an aberrant acetabular cup screw in the posterior - inferior quadrant adjacent to the sciatic nerve.case description
 the patient underwent surgical exploration that revealed injury to the peroneal division of the sciatic nerve due to direct injury from screw impingement .
 a literature review identified 11 patients with late - onset neuropathy after tha .
 ten patients underwent surgical exploration and pain often resolved after surgery with 56% of patients recovering sensory function and 25% experiencing full recovery of motor function.conclusions
 delayed neuropathy of the sciatic nerve is a rare complication after tha that is most often due to hardware irritation , component failure , or wear - related pseudotumor formation .
 operative intervention is often pursued to explore and directly visualize the nerve with limited results in the literature showing modest relief of pain and sensory symptoms and poor restoration of motor function .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
today , the treatment of choice is surgical excision of the tongue , but before 1900 , surgery was often temida1 . only in 1673 niels
the size and shape of the teeth are directly influenced by the size of tongue3 .
the shape of the teeth is determined by forces employed on the teeth , especially the muscles of the tongue , lips and cheek . due to the effects caused by the aesthetic and functional macroglossia
the macroglossia is classified as true when there is excessive enlargement of the language and a relative when there is an imbalance between the size of the tongue and oral cavity , resulting in insufficient space for organ4 .
the goal is to establish technical bases associated with partial glossectomy orthodontic treatment of dentofacial deformity in patients with macroglossia .
three patients underwent orthognathic surgery associated with partial glossectomy from 1995 to 1999 , a multidisciplinary team - doctor and dentist .
all patients had macroglossia relative and underwent clinical assessment taking into account the respiratory function , swallowing and speech deficit , as well as changes in dental occlusion and was also performed radiological evaluation .
the main problem was manifested by the presence of steep lower dent alveolar , destabilizing the use of dentures causing joint dysfunction with severe pain .
she underwent a single surgical intervention in the partial glossectomy and orthognathic surgery for targeting sub apical segment dent alveolar anterior inferior .
the main problem of the second patient was the anterior open bite accompanied by difficulty in breathing and articulation of words .
after treatment for orthodontic tooth alignment leveling , underwent surgery for a single suspension by corticotomy posterior maxillary le fort i type , reduction of mandibullary prognathism by sagittal technical branches , targeting sub apical posterior - inferior right and partial glossectomy .
the third patient had mandibullary prognathism and , during orthodontic treatment in preparation for orthognathic surgery , the surgery was anticipated , since the interposition of the tongue between the back teeth did not allow the evolution of orthodontic treatment .
he underwent a partial glossectomy to reduce the transverse diameter of the tongue and mandibullary prognathism by sagittal technical branches .
we used rigid skeletal fixation with titanium plates and screws so that patients could stay without intermaxillary block in the immediate postoperative period . to control tongue edema ,
the technique used consist of segmental resection along the median raphe of the tongue and suture by planes - figure 1 . as a routine
the symptoms regressed completely and all skeletal segments remained stable .
 demarcation and resection of the lingual and final appearance .
the classification of macroglossia is not yet consensus in the literature . according to shafer ( 1968)5 , or
primary congenital macroglossia is due to the excessive development of the musculature , which may or may not be associated with generalized muscular hypertrophy or unilateral hypertrophy . since the secondary macroglossia may occur as a result of a tumor in the tongue , as a diffuse hemangioma or lymphangioma , neurofibromatosis , and occasionally blocking efferent vessels in cases of malignant neoplasm of the tongue .
wolford et al . ( 1996)6 refer to as macroglossia on pseudomacroglossia , separating it from the true macroglossia .
( 1980)7 macroglossia consider the functional as a third classification , occurring when the language does not fit into the oral cavity after a surgical procedure .
the true when there are histological abnormalities associated with the increase of the tongue , such as vascular malformation , stretching and tumors .
relative macroglossia includes cases of apparent increase in volume without an explanation of the language exam , as in down syndrome .
the decision to refer the patient to partial glossectomy should be based on the volume of the language , mobility , position , function , symptoms , speech intelligibility , skeletal anterior open bite , interference in orthodontic treatment , drooling , swallowing and tongue recurrent trauma9 .
the language has increased in volume expansive effect on the lower dental arch , being blamed as the cause and maintenance of open bite , bimaxillary protrusion or diastemas10 .
being interposed between the arches , is an important etiologic factor for malocclusion listed ( figures 2 and 3 ) .

a partial glossectomy performed simultaneously with mandibullary osteotomy for treatment of patients with mandibullary prognathism and anterior open bite is advantageous to prevent recidivas11 .
the tongue can cause deformity increased dental - muscle - skeletal , instability in orthodontic treatment and orthognathic surgery , masticatory disability , communication problems and respiratory6 .
there are several clinical and radiographic findings , but not all features are always present and their existence is not necessarily path gnomonic for the diagnosis of macroglossia .
should be included the clinical , radiographic and functional for the interference with speech , mastication , airway and stability of orthodontic treatment and orthognathic surgery .
there are basically three choices in the surgical sequence : ( i ) stage 1 : partial glossectomy , stage 2 : orthognathic surgery ( ii ) stage 1 : orthognathic surgery , stage 2 : partial glossectomy and ( iii ) partial glossectomy and orthognathic surgery in a single stage surgery .

Answer:
summary
 introduction :  macroglossia is a condition which influences the size and shape of the teeth employed due to the forces on teeth .
 objective :  to establish bases for the indication of partial glossectomy associated with orthodontic treatment and surgical dento - facial deformity in patients without tumors and down syndrome as a cause of macroglossia .

 case reports :  three patients underwent orthognathic surgery associated with partial glossectomy under general anesthesia .
 all patients had macroglossia relative and underwent clinical assessment taking into account the respiratory function , swallowing and speech deficits and radiological evaluation .
 the technique used consist of segmental resection along the median raphe of the tongue and suture by planes .
 we used rigid skeletal fixation with titanium plates and screws so that patients could stay without intermaxillary block in the immediate postoperative period .
 were followed over five years .
 the symptoms regressed completely and all skeletal segments remained stable .

 discussion :  the decision to refer the patient to partial glossectomy should be based on the volume of the language , mobility , position , function , symptoms , speech intelligibility , skeletal anterior open bite , interference in orthodontic treatment , drooling , swallowing and tongue trauma applicant .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
pari passu with the progress of science in medical education , simulation in medical education is also progressing in leaps and bounds .
something which was hardly ever talked about even a couple of years ago has now become the new buzz word in medical education circles , and now india is also getting on the bandwagon .
simulation has been variably defined as  the imitation of the operation of a real - world process or system over time ;   an imitation of some real thing , state of affairs , or process  for the practice of skills , problem solving , and judgment .
the aim of medical simulation training is to imitate reality , or rather , to mimic reality to the closest extent possible so that the learner is in a state of  suspended disbelief  and he believes himself to be undergoing a real experience .
simulation has been used at its greatest effect in pilot training - indeed , it is mandatory for all pilots of commercial aircraft to undergo refresher courses on flight simulators , regardless of their real flying experience .
medical simulation has unfortunately not kept up with the development of simulation in engineering systems , flight training , etc . however , this situation is now rapidly changing .
this change has been brought about by three main reasons : firstly , a big increase in student population in medical education , both at the undergraduate and post - graduate level .
this unprecedented growth has occurred in the past two decades ( mci vision 2015 ) .
approximately 33,528 graduates pass out every year from these colleges ( mci annual report 20092010 ) .
. there has also been legislation which limits the number of hours residents can now work , reducing further the opportunity for bedside learning .
the american medical association 's accreditation council for graduate medical education has limited the time that residents can be required to work to 80 h a week .
although this action was intended to improve patient safety , it also reduced the number of patient - contact hours needed to train residents .
secondly , there is a growing awareness of patients of their rights and reluctance to be practiced upon and the growing incidence of medical litigation leading to a reduction in the number of available patients .
finally , there has been a huge technological improvement in the quality and variety of simulators .
now , high fidelity computerised human patient simulators have been developed by various companies ( e.g. simman by laerdal , the meti family of human patient simulators by cae health care ) , which mimic very realistically the response of human beings to physiological insults , whether it be an acute cardiac event , or a trauma event ; indeed , any disease process that affects the cardiovascular or respiratory system can be accurately modelled .
surgical simulators have been developed to practice laparoscopic surgery using a virtual reality environment ( e.g. the lapvr laparoscopic simulator by cae health care ) , which even provide haptic feedback ( a sense of tissue resistance ) .
, many countries are now making certification on simulators mandatory before performing procedures on actual patients . even in india
, the mci 2015 vision document says that a mandatory and desirable comprehensive list of skills has been planned and would be recommended for bachelor of medicine and bachelor of surgery ( mbbs ) graduate .
the educational technology section of the 2004 aem consensus conference for informatics and technology in emergency department health care concluded that there should be increasing use of web - based , virtual reality and human patient simulation in educating emergency medicine trainees .
the authors postulate the philosophy of  see one , simulate many , do one competently , and teach everyone .
 there are now many articles on how simulation can be used in medical training .
a key challenge for surgical training is to provide conditions for effective learning without putting patients health at risk .
simulation presents an attractive solution , offering a safe , simulated clinical environment where the training agenda can be determined by the needs of the learner , not the patient .
evidence is now available to suggest that simulation training actually improves clinical performance . in a review of simulation articles , it was found that four ( 3% ) journal articles provided evidence for the direct correlation of simulation validity with effective learning .
another study showed that the use of virtual reality surgical simulation to reach specific target criteria significantly improved the operating room ( or ) performance of residents during laparoscopic cholecystectomy .
simulation in wound management is still relatively in its infancy when compared to the use of simulation in other areas of medical education .
it is however reasonable to believe that the use of simulation in wound management will result in improvement in wound care .
simulation in relation to wounds can be divided into use of simulation to study the effect of projectiles on tissue ( wound modelling ) and the use of simulation in the management of wounds .
the purpose of this article is to outline the present status of simulation related to wounds , in terms of their creation and management .
moulage is the art of creating mock injuries to simulate wounds . theatrical makeup and common everyday materials
moulage is commonly used in mass casualty and disaster drills to add realism to the simulation .
it is reasonable to believe , though not proven , that the use of moulage would create a more realistic environment to enhance learning in mass casualty and other trauma situations . as far back as in 1964 , omissions and deficiencies in disaster ability were dramatically and conclusively revealed by use of what appeared to be a
live  disaster setting with smoke , fire , explosions ; adverse weather and light conditions ; realistically simulated  casualties  especially prepared not only to look but also to act the part .
moulage by author ( drp ) showing bleeding thigh wound and evisceration on metiman ( cae health care ) mannequin
another area where simulation is used in wounds is to simulate the effect of injuring agents on the body so as to understand the various forces that are at work on the tissues during the causation of an injury .
this would help in accurate wound assessment and anticipation of likely tissue damage if the causative agent is known .
work has mainly been done on cavitating injuries produced by high - velocity projectiles . because gelatin and glycerin soap have approximately the same density as human tissue , the gunshot effects in them are comparable with those in human tissue . the experiments with these substitutes make it possible to understand what happens to the human body as the result of , for example , a penetrating gunshot .
some other authors have used transparent gel candles [ 15% kraton ( polymers ) in 85% white paraffin oil ] for the same purpose . a synthetic skin  skull
 brain model has been developed to simulate gunshot wounds to the head in such a realistic manner as to reconstruct the specific physical characteristics of a given trauma , including its progressive formation .
this model uses a silicon cap containing synthetic fibres for artificial skin , a layered polyurethane sphere for the skull ( containing the outer and inner tables as well as the diploe ) , a periosteum of latex and the brain itself is simulated with ordnance gelatin .
high fidelity simulators are now available which can mimic the physiological effects of wounds on the body .
the aim of management of a wounded individual in the emergency department is mainly to correct and prevent the life - threatening physiological derangements associated with the wound like airway obstruction , hypovolemia , respiratory distress , etc . as such
these physiological derangements can be mimicked extremely realistically by these high fidelity systems , examples of which are the meti family of mannequins from cae health care or the simman family from laerdal .
these simulators are used the world over to train emergency medical care providers , medical students , post - graduates and practicing physicians and surgeons in emergency trauma management [ figure 2 ] .
military specific simulators ( e.g. caesar from cae healthcare ) are now in advanced stages of development to train soldiers with non - medical backgrounds at the  point of injury .
john 's ambulance team ( malaysia ) demonstration of trauma scenario on ecs ( meti ) simulator
there are a few articles on the emergence of simulation in wound management , which deal essentially with teaching learners local wound management .
this includes wound dressing techniques , performance of local surgery like escharotomy or wound debridement .
wound management simulators can be divided into basic part task trainers which use low - technology solutions that are cheap and high - technology virtual reality simulators which , of course , will be much more expensive . the low - technology solutions are discussed first , followed by the high - technology virtual reality solutions .
simulated wounds have been created on animal models like pig trotters to teach the technique of wound debridement . a simulated wound covered with thick slough
can be created on a pig trotter by excising an area of skin and then applying a layer of hydrocolloid paste ( e.g. adapttm , hollister ) on the denuded area . a layer of toothpaste
may then be applied and covered with a piece of glad wrap to simulate the application of emla cream . a small curette
is then used to debride the wound as in a human patient , after washing away the layer of toothpaste ( = topical anaesthetic ) .
another study has created a simulated abscess in chicken breast by injecting mock purulent material under the chicken breast skin .
the author felt that this new simulation model may be an effective tool to teach skin abscess management .
physicians who evaluated the simulated abscess found that it replicates the classic palpable fluctuance and ultrasound findings of an actual abscess , and it can be surgically incised and drained in a similar fashion .
yet another researcher has used an orange to simulate debridement - the student is required to remove the peel and the white fibres ( representing slough ) off the orange without puncturing the inner orange itself . burn wounds offer a challenge to learners in terms of local wound care , and as a result
this helps train burn care trainees in the management of such wounds , specifically to perform escharotomy .
a major technological development has been that of a thigh wound virtual reality model by delp et al .
they have used the data from the visible human project as the basis of reconstruction of the thigh anatomy , on which they superimposed wound models of bullet wounds gleaned from data available in the literature .
functional consequences of the injuries were also modelled , which provided both short - term consequences as well as long - term disability of the simulated patient .
the user could interact with the virtual thigh model using virtual surgical instruments from a virtual tray to stop the bleeding , assess muscle bleeding and contractility , perform debridement , align bone , etc .
the overall effect on the patient 's physiology was also calculated and displayed in terms of vital signs readouts , which changed depending upon appropriate treatment , e.g. control of bleeding , etc .
the virtual reality medical center ( vrmc ) conceptualised and developed a unique injury simulator as an adjunct to current combat medic training .
this initial technology , called injury creation science ( ics ) , very realistically simulated a number of battlefield injuries such as amputations , eviscerations , blast injuries , punctures and burns . since the initial prototypes , vrmc has developed this technology into wearable
part - task trainers  that simulate injuries as well as allow combat medics to practice actual medical procedures common to the battlefield .
the procedures currently available or under development include treatment of pneumothorax , hemoperitonium and gunshot wounds to an artery . by integrating medical science with cutting - edge simulation and training technologies , realistic prosthetic tissue , wounds and part - task trainers
one of the major issues with wounds is the risk of hospital - acquired wound infections , which are usually preventable by simple personal hygiene techniques .
unfortunately , many hospital workers are either unaware of them or unwilling to follow these steps .
training of all hospital staff to prevent cross infection is therefore high on the agenda for most hospital administrators , impinging as it does on patient safety .
if the movement of bacteria that cause wound infection , and their removal from hands and other inanimate hospital objects could be seen , then it would be a very useful training tool and could markedly increase staff compliance with hygiene measures .
this is exactly what was done in one study wherein ultraviolet polyethylene microspheres were able to simulate the spread of bacteria through direct and indirect contact on different surfaces and had the ability to be washed off under specific hand washing guidelines .
the authors felt that due to the positive results , the use of microspheres as a simulator of bacterial presence and spread should be explored further in order to improve hand washing techniques and compliance .
a simulation - based training system for surgical wound debridement has been developed and comprises a multimedia introduction , a surgical simulator ( tutorial component ) and an assessment component .
the multimedia training component describes varieties of wound categories ( e.g. burns , lacerations , etc . ) , methods of debridement ( e.g. sharp , mechanical , etc . ) and equipment / materials used in the procedure .
this module provides the pedagogical context for skills training and assessment , linking together all of the required elements for mastering the procedure .
a software virtual agent is included and performs the role of an instructor by providing verbal guidance and assessment feedback . designed to be comprehensive in order to reduce the need for a more senior instructor , the software addresses the patient 's condition , initial description of the injury , and provides instruction on operation of the simulator .
specific instructions cover the removal of foreign objects with forceps , scrubbing with a brush , rinsing with saline solution and the maintenance of sterility .
trainees are instructed to remove debris with forceps , scrub with a brush and rinse with saline solution to maintain sterility . in conclusion ,
increasing sophistication in simulation technology has been also used in simulation of wounds , both in wound modelling and wound management .
the available simulators include low - technology solutions and high - technology virtual reality simulators , all of which train learners in the art of wound management .
however , this technology is yet to be validated in wound management to see if simulator training can result in better management of wounds in actual patients .
future developments would include research on application of simulator training to real patient care , and the development of better technology to make virtual reality simulators even more realistic by the improvement of design , graphics and haptic feedback .

Answer:
simulation in medical education is progressing in leaps and bounds .
 the need for simulation in medical education and training is increasing because of a ) overall increase in the number of medical students vis -  - vis the availability of patients ; b ) increasing awareness among patients of their rights and consequent increase in litigations and c ) tremendous improvement in simulation technology which makes simulation more and more realistic .
 simulation in wound care can be divided into use of simulation in wound modelling ( to test the effect of projectiles on the body ) and simulation for training in wound management .
 though this science is still in its infancy , more and more researchers are now devising both low - technology and high - technology ( virtual reality ) simulators in this field .
 it is believed that simulator training will eventually translate into better wound care in real patients , though this will be the subject of further research .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
unilateral absence of pulmonary artery ( uapa ) is a rare congenital abnormality , with an estimated prevalence of 1 in 200,000 .
some patients with uapa are totally asymptomatic while others may have severe pulmonary hypertension , hemoptysis , congestive heart failure , and cyanosis .
we report a 2.5-year - old girl with congenital absence of the right pulmonary artery with associated congenital cystic adenomatoid malformation ( ccam ) of the right lower lobe , patent ductus arteriosus ( pda ) , and atrial septal defect ( asd ) , who presented with ortner 's syndrome due to severe pulmonary hypertension .
a 2.5-year - old girl presented with hoarseness of voice noticed since 3 months of age , breathlessness for the past 15 days and failure to thrive .
she had been admitted elsewhere for lower respiratory tract infection at 3 months of age .
the child was noticed to have a weak cry and an exaggerated suck - rest - suck cycle and sweating over the forehead while feeding .
pulse oximetry in room air showed an oxygen saturation varying between 60% and 70% in all four limbs .
weight and height were 7 kg and 77 cms , respectively both below the third percentile for age and sex .
an ejection systolic murmur grade 3 was heard in the right parasternal region in the fourth and fifth intercostal spaces .
the liver was palpable 2 cm below the right costal margin in the mid - clavicular line .
chest x - ray [ figure 1 ] revealed cardiomegaly with a cardio - thoracic ratio of 0.6 and deviation of the trachea and mediastinum to the right .
two - dimensional ( 2d ) echocardiography showed decreased flow in the right pulmonary artery , a small asd with a right - to - left shunt , and a dilated right atrium and right ventricle with severe tricuspid regurgitation , suggestive of severe pulmonary hypertension .
multiple detector computerized tomography aortogram [ figure 2 ] confirmed the findings of asd with pulmonary hypertension , absent right pulmonary artery and hypoplastic right lung with small cystic lesions suggestive of ccam in the right lower lobe .
chest x - ray posterioranterior view showing cardiomegaly and shift of trachea and mediastinum to the right multiple detector computerized tomography aortogram showing absent right pulmonary artery , and cystic lesions in the right lower lobe suggestive of congenital cystic adenomatoid malformation ( arrow ) of lung at admission , the patient was started on oxygen , furosemide , enalapril and intravenous cefotaxime , on a provisional diagnosis of congenital cyanotic heart disease with increased pulmonary blood flow , lower respiratory infection , and congestive cardiac failure . despite these measures ,
there was persistent hypoxemia and worsening of cardiac failure in the form of tachycardia and bilateral basal crepitations .
the child was intubated and ventilated and started on pressors , but sustained a cardiac arrest on the 4 hospital day from which she could not be resuscitated .
complete arrest of pulmonary artery supply results in the arrest of early bronchial development leading to agenesis of the affected lobe or segment .
pulmonary agenesis is usually unilateral , right sided absence of pulmonary artery being more common .
more than 50% of children with pulmonary agenesis have associated congenital anomalies that involve the cardiovascular ( pda and patent foramen ovale ) , gastrointestinal , skeletal , and genitourinary systems . our patient had asd and pda .
while some patients with uapa are totally asymptomatic , others may have severe pulmonary hypertension , hemoptysis , congestive heart failure , and cyanosis .
chest x - ray may show an absent hilar shadow , a shrunken affected lung , and shift of the mediastinum to the affected side .
an early interruption in the development of the pulmonary artery could result in the continued development of the primitive capillary supply to a region of the lung with resultant abnormal development of the supplied region .
the magnitude of the insult would determine the exact development of the affected lung tissue and final blood supply , resulting in pulmonary sequestration , ccam , or a combination of the two lesions .
the incidence of pulmonary hypertension in patients with isolated uapa varies between 18% and 44% . in patients with uapa with pda as in our patient , the incidence of pulmonary hypertension was observed to be as high as 86% , those with pulmonary hypertension dying at an early age .
ortner syndrome or cardiovocal syndrome refers to hoarseness of voice due to recurrent laryngeal nerve paralysis secondary to cardiovascular disease .
this syndrome was first described by ortner in 1897 in two patients who had mitral stenosis and left recurrent laryngeal nerve paralysis .
the syndrome has since been described in adults with various cardiovascular disorders , but reports in children are less common .
the pulmonary artery , enlarged due to pulmonary hypertension , has been implicated as the main mechanism of nerve injury .
fetterolf and norris studied the anatomic relations of the left recurrent laryngeal nerve in cadavers and concluded that the nerve must be squeezed between the enlarged left pulmonary artery and the aorta or ligamentum arteriosum .
unilateral absence of pulmonary artery should be considered in the differential diagnosis of children who present with cyanosis , pulmonary hypertension , or recurrent lower respiratory tract infections .

Answer:
we report a 2.5-year - old girl who presented with hoarseness of voice since 3 months of age and failure to thrive .
 chest x - ray showed cardiomegaly with a deviation of the trachea and mediastinum to the right side .
 two - dimensional echocardiography showed decreased flow across the right pulmonary artery , a small atrial septal defect ( asd ) with a right - to - left shunt , and a dilated right atrium and right ventricle with severe tricuspid regurgitation suggestive of severe pulmonary hypertension .
 a silent large patent ductus arteriosus was also seen .
 multiple detector computerized tomography aortogram confirmed the findings of absent right pulmonary artery and hypoplastic right lung with small cystic lesions suggestive of congenital cystic adenomatoid malformation in the right lower lobe .
 hoarseness of voice was due to the left vocal cord palsy probably secondary to severe pulmonary hypertension ( ortner 's syndrome ) .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
healthy skin protects against the effects of environmental hazards , such as ultraviolet radiation in sunlight , low humidity , and wind.2 dry skin affects many people , occurring when skin loses its water content , causing the skin to appear dry , rough , and scaly , possibly with reddening , cracking , and itching.3 when the skin becomes dry , the epidermal layer loses its ability to retain moisture . without protection or treatment ,
the skin can not repair itself , leading to persistently dry skin.4 several treatments can be used to restore dry skin or protect it from dryness .
a topically applied moisturizer is the main treatment , which makes the epidermal layer of the skin softer and more pliable by enhancing hydration and decreasing water evaporation .
application of an occlusive mask to the skin can also improve hydration and protect against water loss from the epidermis.5 masks can be produced from various sources .
cellulose masks obtained from natural sources , such as bacteria , are of interest because of their low toxicity and biodegradable properties .
acetobacter xylinum , a bacterium , can produce acid from glucose and synthesize cellulose.6 it creates cellulose from sugars and related substrates via the pentose cycle.7 bacterial cellulose has been widely used as a stabilizer in foods and cosmetics . in the form of a film , it can be used in surgical procedures and for dental implants.8 recently , bacterial cellulose obtained from acetobacter xylinum culture was characterized and found to be composed of long , smooth , and oriented fibrils and to exhibit considerable thermal stability.9 therefore , it was of interest for use as a bacterial cellulose cosmetic device , in particular as a facial mask . the objectives of this study were to determine the in vivo efficacy of a cellulose mask obtained from acetobacter xylinum in changing skin characteristics and to evaluate user satisfaction after a single application .
if a product can provide the expected results and achieve a high level of user satisfaction after single use , it is likely that the user will purchase that product again .
briefly , broken - milled rice ( oryza sativa ) was used as the feeding substrate and distilled water was used as a medium for growth of acetobacter xylinum . under appropriate incubation , the bacterium could synthesize cellulose .
the cellulose with absorbed water obtained was cut into a face shape with holes for the eyes , nose and mouth at the correct positions .
the finished products were sterilized by steam in an autoclave at 121c for 15 minutes .
the manufacturer reported that the masks were nonirritant and satisfactory when studied in 16 thai women.10 thirty healthy thai volunteers aged 2140 years participated in testing of the efficacy of the cellulose mask for improvement of skin characteristics .
twenty - three , five , and two volunteers were in the age ranges of 2125 , 2630 , and 3140 years , respectively .
the sample size was estimated to be sufficient to detect a difference between two population means when the probability of type i error (  ) and that of type ii error (  ) was set at 0.05 and 0.20 , respectively .
the study was carried out with the approval of the ethics committee of the faculty of pharmaceutical sciences at prince of songkla university , songkhla , thailand .
all volunteers gave their informed written consent and underwent testing for any skin irritation that might be caused by the cellulose mask before the study .
no skin irritation occurred when the cellulose mask was applied to the lateral arm for 24 hours , so all volunteers were able to be included in the study .
the experiment was done in a laboratory room where the temperature and relative humidity was controlled at 25c and 50% , respectively .
for the first test , volunteers in the group were assigned to apply moist towels to the face for 25 minutes , while volunteers in the other group were assigned to apply the trial masks to the face for the same time period .
one week later the experiment was repeated , with the volunteers changing over to the alternative treatment .
skin moisture , sebum , elasticity , texture , dullness , and desquamation levels were assessed before applying the sample and five minutes after removing it using a tool normally used as part of routine skin counseling ( moritex corporation , tokyo , japan).11 the skin counseling system consists of a touch screen computer with a sensor and a scope to evaluate sebum , moisture , elasticity , texture , and dullness of the skin . the values obtained are reported as percentages , and ranked as low , medium and high , in comparison with reference values in a population of the same age range provided by the manufacturer . to evaluate desquamation , a 2 cm  1 cm
the sticker was applied to the experimental area of skin for one minute and then peeled off .
afterwards , the surface of the sticker containing a sample of the skin from each volunteer was attached to the lens window of the scope , which was then used to rate the condition of the skin .
texture , dullness , and desquamation were ranked as a , b , or c good , fair , or poor , respectively , when compared with reference values . at the end of the study ,
all volunteers completed a questionnaire rating their degree of satisfaction with the cellulose mask on a five - point scale ( excellent = 5 , good = 4 , fair = 3 , poor = 2 , very poor = 1 ) .
the paired t - test and t - test were used to identify statistically significant differences in skin characteristics before and after using the trial product and between the trial product and the control , respectively .
briefly , broken - milled rice ( oryza sativa ) was used as the feeding substrate and distilled water was used as a medium for growth of acetobacter xylinum . under appropriate incubation , the bacterium could synthesize cellulose .
the cellulose with absorbed water obtained was cut into a face shape with holes for the eyes , nose and mouth at the correct positions .
the finished products were sterilized by steam in an autoclave at 121c for 15 minutes .
the manufacturer reported that the masks were nonirritant and satisfactory when studied in 16 thai women.10
thirty healthy thai volunteers aged 2140 years participated in testing of the efficacy of the cellulose mask for improvement of skin characteristics .
twenty - three , five , and two volunteers were in the age ranges of 2125 , 2630 , and 3140 years , respectively .
the sample size was estimated to be sufficient to detect a difference between two population means when the probability of type i error (  ) and that of type ii error (  ) was set at 0.05 and 0.20 , respectively .
the study was carried out with the approval of the ethics committee of the faculty of pharmaceutical sciences at prince of songkla university , songkhla , thailand .
all volunteers gave their informed written consent and underwent testing for any skin irritation that might be caused by the cellulose mask before the study .
no skin irritation occurred when the cellulose mask was applied to the lateral arm for 24 hours , so all volunteers were able to be included in the study .
the experiment was done in a laboratory room where the temperature and relative humidity was controlled at 25c and 50% , respectively .
for the first test , volunteers in the group were assigned to apply moist towels to the face for 25 minutes , while volunteers in the other group were assigned to apply the trial masks to the face for the same time period .
one week later the experiment was repeated , with the volunteers changing over to the alternative treatment .
skin moisture , sebum , elasticity , texture , dullness , and desquamation levels were assessed before applying the sample and five minutes after removing it using a tool normally used as part of routine skin counseling ( moritex corporation , tokyo , japan).11 the skin counseling system consists of a touch screen computer with a sensor and a scope to evaluate sebum , moisture , elasticity , texture , and dullness of the skin .
the values obtained are reported as percentages , and ranked as low , medium and high , in comparison with reference values in a population of the same age range provided by the manufacturer . to evaluate desquamation , a 2 cm  1 cm
the sticker was applied to the experimental area of skin for one minute and then peeled off .
afterwards , the surface of the sticker containing a sample of the skin from each volunteer was attached to the lens window of the scope , which was then used to rate the condition of the skin .
texture , dullness , and desquamation were ranked as a , b , or c good , fair , or poor , respectively , when compared with reference values .
at the end of the study , all volunteers completed a questionnaire rating their degree of satisfaction with the cellulose mask on a five - point scale ( excellent = 5 , good = 4 , fair = 3 , poor = 2 , very poor = 1 ) .
the paired t - test and t - test were used to identify statistically significant differences in skin characteristics before and after using the trial product and between the trial product and the control , respectively .
the cellulose mask was a translucent patch which could be fitted onto the face as demonstrated in figure 1 .
the skin sebum level after moist towel application was 51.43  12.24% and after using the trial cellulose mask was 50.57  12.09% .
the skin elasticity level after moist towel application was 44.30  12.73% and after using the trial cellulose mask was 46.70  8.78% .
the skin moisture content after moist towel application was 47.33  7.81% and after using the trial cellulose mask was 61.23  10.84% .
it was also noted that , after using the cellulose mask , skin moisture levels increased by between 7% and 28% , without changes in the other parameters , ie , sebum and elasticity levels , as shown in table 1 .
data for skin texture and dullness and keratin desquamation are also reported in table 1 .
there was no significant difference between grades obtained for skin texture after moist towel application and those after application of the cellulose mask .
skin transparency improved in eight of the 30 volunteers ( 26.7% ) when using the cellulose mask .
however , there was no detectable change in degree of pigmentation between the two treatments .
signs of keratin desquamation were not significantly different after moist towel application , but changed from grade b
c to grade a in seven cases ( 23.3% ) after using the cellulose mask .
all the volunteers completed and returned their satisfaction questionnaires , the answers to which are reported in table 2 .
these results indicate that a single application of the cellulose mask did not significantly reduce sebum levels or increase elasticity of the skin ( p > 0.05 ) . however , it did significantly enhance moisture uptake ( p < 0.05 ) .
the water content in formulations or devices used for skin hydration is an important consideration.12 like many moisturizers , cellulose masks can absorb moisture from the environment.13 using the cellulose mask , absorption of moisture by the skin occurred due to the high concentration gradient of water between the mask and the skin . the occlusive effect of the cellulose mask administered to facial skin for 25 minutes can reduce transepidermal water loss,14 with efficacy of moisture uptake varying according to the skin condition of the individual volunteers .
the increased skin moisture content achieved by the cellulose mask did not improve skin texture , dullness , and desquamation significantly when compared with moist towel application ( p > 0.05 ) .
however , a minority of the volunteers did achieve improved skin transparency and desquamation after applying the cellulose mask , the reasons for which are unclear .
it is possible that different subjects responded differently to hydration after topical application of the cellulose mask depending on their general health , skin condition , age , gender , and possibly other factors . in a previous study
, it was reported that eight of thirty - four volunteers had a significantly greater reduction in eye puffiness after application of caffeine gel than after placebo ( p < 0.05 ) , while most volunteers did not show a differential response to these two products.15 the results from our questionnaires demonstrated that the odor , color , and texture of the cellulose masks were acceptable to the subjects , the majority of whom rated the cellulose mask comfortable to use and able to provide skin hydration within an acceptable period .
overall , user satisfaction with the cellulose mask was rated as good . in the future , it is possible that cosmetically active compounds , eg , for skin - whitening and antiageing , will be able to be incorporated into such cellulose masks as nanoformulations , which are likely to meet user demands further.16,17
the cellulose mask derived from acetobacter xylinum could be used as a natural cosmetic product in order to increase moisture uptake in the skin .
single application of the cellulose mask significantly enhanced moisture uptake by the skin when compared with moist towel application ( p < 0.05 ) . however , it did not change skin characteristics to a significant degree .
the responses to the satisfaction questionnaire used in this trial suggest that the cellulose mask is acceptable to users .

Answer:
backgroundcellulose masks obtained from natural sources such as bacteria are of interest as cosmetic devices for the treatment of dry skin because they not only improve hydration of the skin , but have low toxicity and are biodegradable .
 the aims of this study were to determine the in vivo effects of a cellulose mask obtained from acetobacter xylinum on skin characteristics and to evaluate user satisfaction with the product.methodsthirty healthy thai volunteers aged 2140 years participated in the study .
 the volunteers were randomly separated into a control group and an experimental group . for the control group ,
 volunteers were assigned to apply moist towels to the face for 25 minutes .
 for the experimental group , the volunteers were assigned to apply the masks , ie , translucent patches which could be fitted onto the face for the same period .
 the following week , the groups were changed over to the alternative treatment .
 skin moisture , sebum , elasticity , texture , dullness , and desquamation levels were assessed using a system used for routine skin counseling before applying the trial product and five minutes after its removal .
 degree of satisfaction with use of the cellulose mask was investigated using a five - point rating scale.resultsthe cellulose mask increased moisture levels in the skin significantly more than moist towels ( p < 0.05 ) after a single application . no obvious effects on other skin characteristics were found .
 the cellulose mask product rated around 4/5 on the satisfaction rating scale.conclusionsa single application of the trial cellulose mask enhanced moisture uptake by facial skin .
 users also reported being satisfied with the trial product .


Question:
You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
modern insulin analogues are a convenient new approach or tool to glycaemic control , associated with low number of hypoglycaemia and favourable weight change .
a1chieve , a multinational , 24-week , non - interventional study , assessed the safety and effectiveness of insulin analogues in people with t2 dm ( n = 66,726 ) in routine clinical care .
please refer to editorial titled : the a1chieve study : mapping the ibn battuta trail ..
the patient characteristics for the entire cohort divided as insulin - nave and insulin users is shown in the table 1 .
the majority of patients ( 81.1% ) started on or were switched to biphasic insulin aspart .
other groups were insulin detemir ( n = 22 ) , insulin aspart ( n = 6 ) , basal insulin plus insulin aspart ( n = 2 ) and other insulin combinations ( n = 4 ) . overall demographic data after 24 weeks of treatment , overall hypoglycaemia decreased for both insulin user ( from 30.1 events / patient - year to 13.8 events / patient - year ) and insulin nave ( from 24.9 events / patient - year to 12.7 events / patient - year ) groups .
the hypoglycaemia incidence in insulin naive group at 24 weeks was lower than that observed in insulin users at baseline .
also a decrease in body weight was observed for both the groups at 24 weeks [ tables 2 and 3 ] .
all parameters of glycaemic control improved from baseline to study end in the total cohort [ table 4 ] .
overall efficacy data of the total cohort , 146 patients started on biphasic insulin aspart  ogld , of which 95 ( 65.1% ) were insulin nave and 51 ( 34.9% ) were insulin users .
after 24 weeks of treatment , hypoglycaemic events or episodes increased for both the groups ( insulin nave : from 26.4 events / patient - year to 14.7 events / patient - year and insulin users : from 29.6 events / patient - year to 14.1 events / patient - year ) .
quality of life improved at the end of the study [ tables 5 and 6 ] .
biphasic insulin aspartoral glucose - lowering drug safety data all parameters of glycaemic control improved from baseline to study end in those who started on or were switched to biphasic insulin aspart for both insulin nave and insulin user groups [ table 7 ] .
biphasic insulin aspartoral glucose - lowering drug efficacy data of the total cohort , 2 patients started on or were switched to basal + insulin aspart and both of them were insulin users .
of the total cohort , 22 patients started on insulin detemir  ogld , of which 17 ( 77.3% ) were insulin nave and 5 ( 22.7% ) were insulin users .
after 24 weeks of starting or switching to insulin detemir , hypoglycaemic events decreased for both insulin nave ( from 0.4 events / patient - year to 0.6 events / patient - year ) and insulin user ( from 2.9 events / patient - year to 1.9 events / patient - year ) group .
quality of life improved at the end of 24 weeks [ tables 8 and 9 ] .
insulin detemiroral glucose - lowering drug safety data all parameters of glycaemic control improved from baseline to study end in those who started on or were switched to insulin detemir  oglds for insulin - nave group [ table 10 ] .
insulin detemiroral glucose - lowering drug efficacy data of the total cohort , 6 patients started on insulin aspart  ogld of which 1 ( 16.7% ) was insulin nave and 5 ( 83.3% ) were insulin users .
after 24 weeks of treatment , hypoglycaemic events reduced from 13.0 events / patient - year to 0.0 events / patient - year for insulin user group [ tables 11 and 12 ] .
of the total cohort , 146 patients started on biphasic insulin aspart  ogld , of which 95 ( 65.1% ) were insulin nave and 51 ( 34.9% ) were insulin users .
after 24 weeks of treatment , hypoglycaemic events or episodes increased for both the groups ( insulin nave : from 26.4 events / patient - year to 14.7 events / patient - year and insulin users : from 29.6 events / patient - year to 14.1 events / patient - year ) .
quality of life improved at the end of the study [ tables 5 and 6 ] .
biphasic insulin aspartoral glucose - lowering drug safety data all parameters of glycaemic control improved from baseline to study end in those who started on or were switched to biphasic insulin aspart for both insulin nave and insulin user groups [ table 7 ] .
of the total cohort , 2 patients started on or were switched to basal + insulin aspart and both of them were insulin users .
of the total cohort , 22 patients started on insulin detemir  ogld , of which 17 ( 77.3% ) were insulin nave and 5 ( 22.7% ) were insulin users .
after 24 weeks of starting or switching to insulin detemir , hypoglycaemic events decreased for both insulin nave ( from 0.4 events / patient - year to 0.6 events / patient - year ) and insulin user ( from 2.9 events / patient - year to 1.9 events / patient - year ) group .
quality of life improved at the end of 24 weeks [ tables 8 and 9 ] .
insulin detemiroral glucose - lowering drug safety data all parameters of glycaemic control improved from baseline to study end in those who started on or were switched to insulin detemir  oglds for insulin - nave group [ table 10 ] .
of the total cohort , 6 patients started on insulin aspart  ogld of which 1 ( 16.7% ) was insulin nave and 5 ( 83.3% ) were insulin users .
after 24 weeks of treatment , hypoglycaemic events reduced from 13.0 events / patient - year to 0.0 events / patient - year for insulin user group [ tables 11 and 12 ] .
our study reports improved glycaemic control following 24 weeks of treatment with any of the insulin analogues ( biphasic insulin aspart ; insulin detemir ; insulin aspart ) with or without ogld .
bodyweight decreased and quality of life improved after 24 weeks in the total cohort . though the findings are limited by number of patients , still the trend indicates that insulin analogues can be considered effective and possess a safe profile for treating type 2 diabetes in oriental morocco .

Answer:
background : the a1chieve , a multicentric ( 28 countries ) , 24-week , non - interventional study evaluated the safety and effectiveness of insulin detemir , biphasic insulin aspart and insulin aspart in people with t2 dm ( n = 66 726 ) in routine clinical care across four continents.materials and methods : data was collected at baseline , at 12 weeks and at 24 weeks . this short communication presents the results for patients enrolled from oriental , morocco.results:a total of 180 patients were enrolled in the study .
 four different insulin analogue regimens were used in the study .
 study patients had started on or were switched to biphasic insulin aspart ( n = 146 ) , insulin detemir ( n = 22 ) , insulin aspart ( n = 6 ) , basal insulin plus insulin aspart ( n = 2 ) and other insulin combinations ( n = 4 ) . at baseline glycaemic control was poor for both insulin nave ( mean hba1c : 9.0% ) and insulin user ( mean hba1c : 8.8% ) groups .
 after 24 weeks of treatment , both the study groups showed improvement in hba1c ( insulin nave : 1.7% , insulin users : 1.6% ) .
 sadrs including major hypoglycaemia did not occur in any of the study patients.conclusion:starting or switching to insulin analogues was associated with improvement in glycaemic control with a low rate of hypoglycaemia .