Clinical Practice

Does introduction of user fees affect the utilization of cervical cancer screening services in Nigeria? TK Nyengidiki, N Inimgba, G Bassey, RN Ogu Nigerian Journal of Clinical Practice 2019 22(6):745-749 Background: Screening for cervical cancer improves outcome. This comes at an economic price which some may not be able to afford. Objective: To evaluate the influence of user fees on the utilization of cervical cancer screening services in Port Harcourt. Materials and Methods: A cross sectional study of clients presenting for cervical cancer screening. Data on the number, socio-demographic characteristics, distance from screening center following 1 month of free cancer screening and 7 months of user fee introduction, was collated and analyzed using SPSS version 20 statistical software. Results are presented in percentages, tables and charts with test of significance set at P < 0.05. Results: Of the 167 women who presented for cervical cancer screening during the study period, the mean age was 42.08 ± 8.9 years and range was 20–70 years. The average parity of patients was 2.83 ± 2.24. Clients' utilization of cervical cancer screening facilities was negatively affected by the introduction of user fees P < 0.001). There is no association between the distance of patients' home from the hospital and the utilization of facility (X2 = 0.24, P = 0.887). There was sustained decrease in number of clients with the introduction of fees. Conclusion: The introduction of user fees had a negative impact on the utilization of cervical cancer screening facilities. Eradicating user fee and improving the socioeconomic status of patients may improve the utilization of screening services.

Up-regulation of hypoxia inducible Factor-1α in patients with diabetic nephropathy J Wang, S Ye Nigerian Journal of Clinical Practice 2019 22(6):750-753 Objective: To study the role of hypoxia inducible factor-1α (HIF-1α) in patients with diabetic nephropathy (DN). Methods: In total, 133 participants were selected to conduct the investigation, parameters such as fasting blood sugar (FBS), blood urea nitrogen (BUN), and urine albumin-creatinine ratio (UACR) were tested and recorded. The biopsy assessment was conducted when renal function or urinary abnormalities. Western blotting was used to test the expression of serum HIF-1α in all patients and control group. Results: The values of FBS, BUN, and UACR were higher in DN and diabetes groups than in the healthy control. The values of FBG, BUN, and UACR were higher in DN patients than in the diabetes patients with no nephropathy. eGFR in DN patients was lower than the other two groups. The expression of HIF-1α was higher than both diabetes patients with no nephropathy and healthy control, P < 0.05. Patients with lots of albuminuria showed the highest expression of HIF-1α than the other groups. HIF-1α in normoalbuminuria and microalbuminuria groups showed no significant difference. Conclusions: HIF-1α was up-regulated in DN patients, which might give clinical basis to the role of HIF-1α in the development of DN.

Comparison of efficiency of hyaluronic acid and/or bone grafts in healing of bone defects C Koca, N Komerik, O Ozmen Nigerian Journal of Clinical Practice 2019 22(6):754-762 Background: Reconstruction of bone defects in oral and maxillofacial surgery has widespread uses. In recent years, the capacity of various biomaterials alone or in combination with bone graft materials to increase bone healing has been an intensive research topic. The aim of this study is to evaluate the efficacy of hyaluronic acid and/or bone graft material on bone healing in defects created in the rat mandible. Methods: In our study, rats were divided into 4 groups. Group 1 is designated to be treated with no materials, Group 2 with graft material, Group 3 with only hyaluronic acid, and Group with hyaluronic acid and graft material. A critical-size defect of 5 mm in diameter was created bilaterally in the rat mandibles and the rats were divided into the indicated groups accordingly. At the end of the postoperative 6th week, the experiment was terminated. The right halves of the mandibles were evaluated immunohistochemically and histopathologically in terms of bone healing, and the left in terms of mineralization level via microcomputed tomography. Results: Histopathological evaluation showed that healing in the empty group was significantly lower than the other groups that were treated with materials (P < 0.05); but the difference between the material-treated groups was not significant. Immunohistochemical evaluation revealed that the staining was moderately positive/strongly positive in all groups, but the difference between the groups was not significant. The highest mineralization values observed in the defected areas that belonged to 2 groups using hyaluronic acid, and the difference between them was found to be statistically significant (P < 0.05). The lowest mineralization values observed in the defected areas was most frequent in the group where only the hyaluronic acid was used, and there was a statistically significant difference between the other groups (P < 0.05). Conclusion: In conclusion, the use of hyaluronic acid alone or in combination with bone grafting has been shown to contribute positively to the improvement of bone defects in the jaw area.

Repair potential of a new glass hybrid restorative system U Koc Vural, S Gurgan Nigerian Journal of Clinical Practice 2019 22(6):763-770 Background: Repair of a failed amalgam or composite resin (CR) restoration has been extremely studied and proposed as a routine clinical treatment option; however, repair potential of glass ionomer-based restorative materials was not studied sufficiently in the literature. Aim: The aim of this study is to evaluate the repair potential of a glass hybrid (GH) restorative repaired either by the same material (GH) or CR after different surface treatments using microtensile bond strength (μTBS) test. Methods and Materials: One hundred and twenty bar-shaped (2 × 2 × 8 mm) GH blocks were prepared. After aging, the specimens were divided into two groups (n = 60) and five subgroups (n = 12). The specimens in Group I were repaired with the following protocols: (a) no treatment + GH, (b) diamond bur (B) + GH, (c) cavity conditioner + GH, (d) cavity conditioner + universal adhesive (A) + GH, (e) A + GH, and specimens in Group II were repaired with (a) no treatment + CR, (b) B + CR, (c) B + A + CR, (d) 40% phosphoric acid + A + CR, (e) A + CR. The specimens that were subjected to μTBS testing, scanning electron microscopy evaluations, and fracture modes were determined. Data were analyzed using Kruskal–Wallis and Mann–Whitney U tests (P = 0.05). Results: Repair using CR resulted in higher bond strengths (P < 0.001). The lowest bond strength was obtained in Group Ie. The highest bond strength was obtained when GH was roughened in Group IIc. Conclusion: Repair of restorative GH with CR appears as a preferred option to improve the bond strength.

Evaluation of mandibular asymmetry in angle malocclusion samples by posterioanterior cephalometric radiography: A preliminary study HT Alkis, OM Bilge Nigerian Journal of Clinical Practice 2019 22(6):771-776 Objectives: The aim of this study was to evaluate the effect of different occlusion types on mandibular asymmetry in different anatomical points using posteroanterior cephalometric radiography. Materials and Methods: This study was retrospectively conducted on 100 patients whose posteroanterior images and malocclusions were registered in a patient database. Asymmetry indices were determined using four linear measurements on images, and the effect of malocclusions, age, and gender on these asymmetry indices was investigated. P <0.05 was considered statistically significant. Results: Right and left horizontal plane gonion distance values varied according to gender, right vertical plane condylar distance and left horizontal plane gonion distance values varied according to age, and right vertical plane condylar distance and left horizontal plane gonion distance values varied according to malocclusions. Conclusion: The measured values of some parameters varied according to age, gender, and malocclusion. Although vertical plane gonion asymmetry index and horizontal plane condylar asymmetry index values varied according to gender, there was no relationship between asymmetry index values of all parameters with age and malocclusion.

Assessment of cases with sharp and penetrating object injuries H Kafadar, S Kafadar Nigerian Journal of Clinical Practice 2019 22(6):777-781 Background: Sharp and penetrating object injuries (SPOIs) are seen frequently in forensic medicine practice. In this study, we aimed to retrospectively investigate cases with SPOIs. Materials and Methods: This study investigated the charts of patients treated at Adiyaman University Education and Research Hospital between January 1, 2013, and December 31, 2017. A total of 934 inpatients with sharp object injuries were included in the study. Data were assessed using a suitable computer-aided package program. Cases were examined in terms of age, gender, injury body site, suicide or homicide, radiologic findings, presence of vital danger, and severity of injury. Results: In this study, we examined the charts for 934 inpatients with stab wounds. It was stated that 124 (13.27%) of those injured were female and 810 (86.63%) male; the average age of the injured persons was 29.8 ± 18.2 years. It was found that 214 (22.91%) people were exposed to vital danger and that 720 (77.09%) suffered from soft tissue injuries (penetrating skin and muscle injuries). Also, 69.27% of the cases (n = 647) involved people less than 35 years of age. Conclusion: Considering that stab injuries are more frequent in the lower age groups, we believe that such injuries could be reduced by increasing training programs for young people.

The influence of restorative material and glass fiber posts on fracture strength of endodontically treated premolars after extensive structure loss FD Oz, N Attar, D Deniz Sungur Nigerian Journal of Clinical Practice 2019 22(6):782-789 Objective: The aim of this in vitro study was to investigate the fracture strength and cuspal deflection of endodontically treated premolars restored using different composite resins along with or without fiber post application. Materials and Method: Eighty intact premolars were randomly divided into eight groups (n = 10); CO group: intact teeth (control), OPR group: mesio-occlusal-distal-palatal (MODP) preparation (OPR) + endodontic treatment (ET), TC group: MODP preparation + ET + Tetric N-Ceram, TB group: MODP preparation + ET + Tetric EvoCeram Bulk Fill, SO group: MODP preparation + ET + SonicFill 2, TC-P group: MODP preparation + ET + Hahnenkratt glass fiber post + Tetric N-Ceram, TB-P group: MODP preparation + ET + Hahnenkratt glass fiber + Tetric EvoCeram Bulk Fill, and SO-P Group: MODP preparation + ET + Hahnenkratt glass fiber post + SonicFill 2. After thermocycling, specimens were subjected to a compressive load until fracture. Data were analyzed using analysis of variance and Tukey tests (P < 0.05). Results: The mean fracture strength of groups which received post treatment showed similar fracture strength values [TC-P (931.6 ± 97.9), TB-P (882.0 ± 59.7), SO-P (862.0 ± 143.0) (P > 0.05)] and was significantly higher than OPR (530.6 ± 41.7), TC (841.2 ± 93.1), TB (774.5 ± 101.8), and SO (735.0 ± 178.01) groups (P < 0.05). No significant difference was detected among groups considering cuspal deflection (P > 0.05). The fiber post insertion resulted in more unfavorable fractures. Conclusion: Endodontically treated teeth restored with fiber post and bulk-fill or conventional composite resins demonstrated fracture strength values similar to intact teeth.

Steroid response in primary childhood nephrotic syndrome in a tropical african environment AO Asinobi, AD Ademola, OO Ogunkunle Nigerian Journal of Clinical Practice 2019 22(6):790-795 Background: Earlier studies on childhood nephrotic syndrome (NS) in tropical Africa showed steroid resistance in the majority. More recent studies show a variable picture, necessitating a re-evaluation. This study was aimed at determining the current pattern of steroid response in childhood NS, in an environment known to be dominated by steroid resistance. Patients and Methods: This prospective study of consecutive children who received steroid therapy for primary NS was carried out at the University College Hospital, Ibadan, Nigeria between 2006 and 2013. The outcomes of interest were steroid sensitivity and death. The recruited patients received a 4-6 weeks' course of prednisolone at 60 mg/m2/day followed by alternate day doses of 40 mg/m2 up to total steroid therapy duration of 6 months in steroid sensitive patients. Statistical analysis was carried out using STATA version 12.0. P value <0.05 was considered significant. Results: Of 109 children that received steroids for at least 8 weeks, whose mean (SD) age was 7.9 (3.7) years, 69 (63.3%) were steroid sensitive. Those aged ≥6 years responded as well as those aged <6 years (P = 0.78). Boys were more likely to be steroid-sensitive than girls, 65.2% versus 34.8% (P = 0.039). There was zero mortality among the patients studied. Conclusion: This study has shown a better steroid sensitivity of 63.3% in children with primary NS compared with the previously reported 36.8-42.9% in patients with highly selective proteinuria. This improved steroid response and zero mortality show a remarkable departure from the past.

Comparative analgesic efficacy and tolerability of celecoxib and tramadol on postoperative pain after mandibular third molar extraction: A double blind randomized controlled trial AO Akinbade, KC Ndukwe, FJ Owotade Nigerian Journal of Clinical Practice 2019 22(6):796-800 Background: The choice of an efficacious and well-tolerated analgesic for the control of postoperative pain after third molar surgical extraction remains a challenge. Aim: The aim of this study was to compare analgesic efficacy and tolerability of celecoxib and tramadol following mandibular third molar extraction. Materials and Methods: This was a prospective randomized, double blind controlled trial. Ninety patients were randomly assigned equally to either celecoxib or tramadol. Appropriate doses of the assigned drugs were administered orally immediately after the surgical extraction and patients recorded the pain intensity felt before the extraction, immediately after extraction, at 4 h, 8 h, 16 h, 24 h, and 48 h after the extraction using the visual analogue scale (VAS). Adverse effects of the medications were also recorded. Results: Four of the patients dropped out of the study. Fifty five percent of patients in tramadol group experienced adverse effects but none in celecoxib group. The median VAS score of the celecoxib group was lower than tramadol group throughout the postoperative period and there was statistically significant difference in the median VAS score between the two groups 4 hours after drug administration (P = 0.001). Conclusion: In our study, celecoxib was more efficacious and better tolerated than tramadol for the management of pain after surgical extraction of mandibular third molar.

Comparison of bispectral index values and depth of sedation during deep sedation using sevoflurane anesthesia in healthy children versus children with cerebral palsy P Onal, N Oztas, G Kip Nigerian Journal of Clinical Practice 2019 22(6):801-805 Background: Patients with cerebral palsy (CP) are at significant risk by means of periodontal disease and tooth decay. Pharmacological techniques that require intensive care such as sedation and general anesthesia are generally used for dental treatment of this patient group. Aim: The purpose of this retrospective study was to compare bispectral index (BIS) values and depth of sedation recorded during deep sedation protocols performed for healthy children and children with CP in the Department of Pediatric Dentistry, Faculty of Dentistry, Gazi University. Materials and Methods: The measurements of BIS and hemodynamic variables recorded during treatment of 26 healthy children and 26 children with CP between 3 and 10 years of age who were treated under sevoflurane and 50% N2O–50% O2 mixture deep sedation method were investigated retrospectively. Results: The mean BIS values in the CP group was statistically lower at all the time points when compared with the control group (P < 0.001). While there was no statistically significant difference between groups in terms of duration of treatment (P = 0.657), the median recovery time in the CP group was significantly longer than that recorded in the control group (P < 0.001). Significant correlation was found between modified Ramsay Sedation Scale (mRSS) scores and BIS levels at 5th, 10th, and 20th min in the control group (P < 0.001). Similar correlation was found in the CP group at 15th and 20th min. Conclusion: We concluded that it is necessary to consider the dosage and effect mechanisms of drugs used in children with CP to prevent overuse of anesthetics and emergence of anesthesia-related complications.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Physical Medicine & Rehabilitation

A randomized control trial of comparing ultrasound-guided ozone (O2-O3) vs corticosteroid injection in patients with shoulder impingement Introduction Ozone has been recently used as a safe alternative treatment in musculoskeletal disorders with fewer side effects than corticosteroids. The aim of this study was to compare the efficacy of a single injection of ozone with that of a corticosteroid in the treatment of shoulder impingement. Design 30 patients with shoulder pain and clinical signs and symptoms of impingement were randomly assigned into two groups: ultrasound-guided injection with ozone or corticosteroid. Patients' symptoms were evaluated by Visual Analog Scale (VAS), Constant score, Shoulder Pain and Disability Scale (SPADI), shoulder range of motion (ROM) and ultra-sonographic measures before treatment, two weeks and two months after injections. Results Patients' VAS, SPADI and Constant score improved significantly in both groups (P<0.001), but the benefits were in favor of corticosteroid group (P<0.001). At intervals between the two follow-ups, an improvement was observed in the VAS score among patients receiving ozone, while during the same interval, patients' pain slightly worsened in the corticosteroid group. The ROM and ultra-sonographic measures did not show statistical differences between the two groups. Conclusion Corticosteroid injection improves the pain and disability scores more significantly than a one-time ozone injection. Ozone may serve as an alternative modalities in treating shoulder impingement when the use of steroids is contraindicated. *Corresponding author: Mohamad Sadegh Khabbaz All correspondence should be addressed to: Mohamad Sadegh Khabbaz, MD. Department of Physical Medicine and Rehabilitation, Firoozgar hospital, Valieasr square, Tehran, Iran. Fax: +98[21]88942970, Tel: +98[21]88908519, Mobile: +989120766393, E-mail: m.sadegh.khabbaz@gmail.com Author Disclosures: There is no conflict of interest. No funding or grants or equipment provided for the project from any source and there are no financial benefits to the authors. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effect of 4-channel Neuromuscular Electrical Stimulation on Swallowing Kinematics and Pressures: A Pilot Study Objective The purpose of this study was to evaluate the effectiveness of the sequential 4-channel neuromuscular electrical stimulation (NMES) system. Design As a prospective case-control study, ten healthy subjects and ten patients with dysphagia were prospectively enrolled. Swallowing with and without sequential 4-channel NMES (suprahyoid, infrahyoid muscles) was evaluated via videofluoroscopic swallowing study (VFSS) and high-resolution manometry (HRM). Results Results showed that the sequential 4-channel NMES significantly improved the videofluoroscopic dysphagia scale (VDS) during thick-fluid swallowing in patients with dysphagia. Furthermore, the kinematic analysis of VFSS showed a tendency that NMES reduced duration of hyoid bone movement during thin- or thick-fluid swallowing. The HRM parameters –maximal pressure of velopharynx (VP), tongue base (TB), cricopharyngeal pressure (CP), minimal upper esophageal sphincter (UES) pressure, area of VP, UES activity time, and duration of nadir UES – during thin-fluid swallowing were significantly improve in both groups compared with the HRM parameters without NMES. Conclusion The sequential 4-channel NMES may help improve the parameters of VFSS, kinematic analysis of the hyoid bone movement, and HRM during swallowing. Further investigations are needed to better examine the effects of NMES in patients with dysphagia. Donghwi Park and Jee Hyun Suh contributed equally to this paper and should therefore be regarded as equivalent first authors. Address corresponding author: Ju Seok Ryu, M.D., Ph.D. Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea, 463-707 (e-mail: jseok337@snu.ac.kr), Tel : 82-31-787-7739, Fax : 82-31-787-4051 Acknowledgement: The authors gratefully appreciate MRCC team of Seoul National University Bundang Hospital for their work in the area of statistics in this study Financial support: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (NRF-2016R1D1A1B03935130) Conflict of interest: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effect of Expiratory Muscle Strength Training on Swallowing and Cough Functions in Patients with Neurological Diseases: A meta-analysis Objective The aim of this review is to evaluate and summarize the results of published studies exploring the effects of expiratory muscle strength training (EMST) on swallowing and cough functions in patients with neurological diseases. Data sources Embase, PubMed, and the Cochrane Library. Review methods Randomized controlled trials or pretest/posttest studies of adults with neurological diseases were included. The data included basic population characteristics, penetration-aspiration scores (PAS), peak expiratory flow rate (PEFR), cough volume acceleration (CVA) and maximum expiratory pressure (PEMax). Results Ten studies were included in this meta-analysis. Compared with the control groups, EMST in patients with neurological diseases significantly reduced the PAS (risk ratio (RR)=-0.94, 95% confidence interval (CI), 1.27–-0.61, P<0.01) but did not increase the voluntary cough PEFR (RR=0.57, 95% CI, 0.62–1.77, P=0.35), CVA (RR=33.87, 95% CI, 57.11–124.85, P=0.47) or PEMax (RR=14.78, 95% CI, 16.98–46.54, P=0.36). Conclusion EMST might improve swallowing function in patients with neurological diseases. However, conclusive evidence supporting the use of this approach in isolation for improving cough function is unavailable. Additional multicenter, randomized clinical trials performed using reliable and valid cough function outcome measures are required to explore the effects of EMST on cough function. Correspondence: Qi Fang. Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China. Tel:+86-13606213892. E-mail: fangqi_008@126.com; Huiling Li, The First Affiliated Hospital of Soochow University/School of Nursing, Soochow University, No. 188 Shizi Street, Suzhou, China. Tel: +86-512-65221437 Author Disclosures: The authors read and approved the final manuscript and declare that there was no conflict of interest. This work was funded by Postgraduate Research & Practice Innovation Program of Jiangsu Province; Integrated Care Model For Patients With Dysphagia After Stroke [grant number KYCX18_254], and National Key Research And Development Program of China [grant number 2017YFC0114302] Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Painful Foot Disorders in the Geriatric Population: A Narrative Review Painful foot disorders are highly prevalent among older adults causing a significant impact on mobility, function, and risk of falls. Despite its significance, foot pain is often interpreted as a normal part of aging and relatively ignored by health care providers as well as by the elderly themselves. Accurate diagnosis of the cause of foot pain is possible for most cases via clinical evaluation without a costly workup. Clinicians should consider, not only musculoskeletal pathologies, but also vascular and neurological disorders in older patients with foot pain. Fortunately, a majority of patients improve with physiatric, non-operative interventions involving biomechanical analysis, function oriented rehabilitation programs and therapeutic exercise, the use of proper footwear and orthoses, and selected percutaneous interventions, as indicated. In this review, we discuss the physiologic changes of the aging foot relevant to foot pain, the impact of painful foot disorders on function and other key outcomes, and principles of diagnosis and intervention. We also briefly describe painful foot disorders of the elderly commonly encountered in a physiatric practice. Previous presentation of the data: not applicable Financial support: none Corresponding author: Mooyeon Oh-Park, M.D. Address: Burke Rehabilitation Hospital, 785 Mamaroneck Av, White Plains, NY, 10605, U.S.A. Email: mohpark@burke.org Painful Foot Disorders in the Geriatric Population: A Narrative Review Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Use of Platelet Rich Plasma for the Treatment of Acetabular Labral Tear of the Hip: A Pilot Study Objective This study aims to assess whether ultrasound guided injection of platelet rich plasma (PRP) can safely and effectively treat symptoms associated with acetabular hip labral tears. Design Institutional Review Board (IRB) approval was gained for a prospective study of eight patients (N=8), who have previously failed conservative management, to receive ultrasound-guided injection of PRP at the site of hip labrum tear. We assessed pain reduction and functional ability at baseline, and then 2, 6, and 8 weeks after injection, using the Visual Analogue Scale (VAS) and Harris Hip Score (HHS), respectively. Results Statistically significant differences in HHS were seen two (86.5 +/- 10.8, p<0.01), six (88.0 +/- 10.7) p<0.01), and eight weeks (92.1 +/- 11.6, p<0.01) after injection as compared to baseline (76.0 +/- 13.4). Corresponding improvements were seen in VAS two (1.0, p<0.01 at rest, 2.5, p<0.01 with activity), six (0.9, p<0.01 at rest, 2.3, p<0.01 with activity), and eight weeks (0.5, p<0.01 at rest, 1.3, p<0.01 with activity) compared to baseline (3.8 at rest, 5.4 with activity). Conclusions Ultrasound-guided injection of PRP holds promise as an emerging, minimally-invasive technique toward symptom relief, reducing pain, and improving function in patients with hip labral tears. Correspondence: Arthur Jason De Luigi, DO, MHSA, 10825 N. 140th Way, Scottsdale, AZ 85259301793-2136. ajweege@yahoo.com Author Disclosures: Arthur Jason De Luigi, DO, MHSA Daniel Blatz, MD Christopher Karam, MD Zachary Gustin, MD Andrew H. Gordon, MD Competing Interests-None for any author Funding or grants or equipment provided for the project from any source-None for any author Financial benefits to the authors-None to any author Details of any previous presentation of the research, manuscript, or abstract in any form: Please note that we have presented this research at both national and local conferences. This research was selected as a Scientific Paper Presentation at the 2015 Association for Academic Physiatrists conference held in San Antonio, Texas. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Administration of Platelet Rich Plasma to Hip Labral Tears Reduces Pain and Improves Function.Scientific Paper (Podium) Presentation, Annual Meeting of the Association of Academic Physiatrists. 2015. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Improved Hip Function and Pain Alleviation after Single Administration of Platelet Rich Plasma for Hip Labral Tears: A Prospective Cohort Study.Oral Poster Presentation, Annual Meeting of the American Medical Society for Sports Medicine. 2015. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Functional Improvement and Pain Reduction after Single Injection of Platelet Rich Plasma for Hip Labral Tears: A Prospective Cohort Study.Poster Presentation, MedStar Health Research Institute Research Symposium. 2015. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A NEW THRESHOLD FOR APPENDICULAR LEAN MASS DISCRIMINATES MUSCLE WEAKNESS IN WOMEN WITH HIP FRACTURE: A CROSS-SECTIONAL STUDY. Objective To investigate the relationship between measures of muscle mass and grip strength in women with subacute hip fracture. Firstly, we aimed to assess the capability of the current thresholds for appendicular lean mass (aLM), aLM-to-body-mass-index ratio and aLM/height2 to separate weak and non-weak women. Secondly, we aimed to explore alternative thresholds for the 3 measures of muscle mass to discriminate weakness. Design Cross-sectional study of 160 women with hip fracture admitted to a rehabilitation hospital. We assessed aLM by dual-energy x-ray absorptiometry and grip strength by a Jamar hand dynamometer. Weakness was defined as grip strength <16 kg. Results Weakness was not significantly associated with aLM <15.02 kg, aLM-to-body-mass-index ratio <0.512 or aLM/height2 <5.67 kg/m2. For aLM (but not for the other 2 measures of muscle mass) an alternative threshold (11.87 kg instead of 15.02 kg) significantly discriminated weakness: χ2 (1, n=160)=10.77 (p=0.001). The association between aLM <11.87 kg and grip strength <16 kg persisted after adjustment for age and body mass index: odds ratio =2.50 (95% CI 1.17-5.34; p=0.018). Conclusions Data suggests that the current thresholds for measures of muscle mass do not discriminate weakness in women with subacute hip fracture. For aLM an alternative cutoff-point actually separated weak and non-weak women. CORRESPONDING AUTHOR: Dr. Marco Di Monaco, Osteoporosis Research Center, Division of Physical Medicine and Rehabilitation, Presidio Sanitario San Camillo, Strada Santa Margherita 136, 10131, Torino, Italy. Tel. 0039 011 8199411; Fax 0039 011 8193012; Email Marco.di.monaco@alice.it,m.di-monaco@h-sancamillo.to.it DISCLOSURES: All the authors have no conflicts of interest. The study was not funded. The authors had no financial benefits for the study. The results have not been previously presented. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Letter to the Editor Regarding the Article "Dynamic Ultrasound Imaging for the Diagnosis of Superior Labrum Anterior to Posterior (SLAP) lesion" No abstract available

Authors' Response to the Letter to the Editor on "Dynamic Ultrasound Imaging for the Diagnosis of Superior Labrum Anterior to Posterior (SLAP) Lesion" No abstract available

EMG Evaluation of Bodyweight Exercise Progression in a Validated ACL Injury Rehabilitation Program: Cross-sectional Study Objectives Regaining muscle strength is essential for successful outcome after anterior cruciate ligament (ACL) injury, why progression of exercise intensity in ACL injury rehabilitation is important. Thus, this study evaluated hamstring and quadriceps muscle activity progression during bodyweight exercises used in a validated ACL injury rehabilitation program. Design The study design involved single-occasion repeated measures in a randomized manner. Twenty healthy athletes (nine females) performed nine bodyweight exercises (three exercises per rehabilitation phase). Surface electromyography signals were recorded for hamstring (semitendinosus, biceps femoris) and quadriceps (vastus medialis, vastus lateralis) muscles, and normalized to isometric peak EMG (nEMG). Results Hamstring muscle activity did not increase from one rehabilitation phase to the next, ranging between 8-45% nEMG for semitendinosus and 11-54% nEMG for biceps femoris. Only one exercise (Cook hip lift) exhibited hamstring muscle activities above 60% nEMG. By contrast, quadriceps muscle activity increased, and late phase exercises displayed high nEMG (vastus lateralis >60% and vastus medialis >90% nEMG). Conclusion The examined bodyweight exercises did not progress for hamstring muscle activity but successfully progressed for quadriceps muscles activity. This study highlights the need for consensus on exercise selection when targeting the hamstring muscles in the rehabilitation after ACL injury. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Conflicts of interest None declared. Funding None declared. Corresponding author: Mette Kreutzfeldt Zebis E-mail corresponding author: mzeb@kp.dk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Differences in the mitochondrial and lipid droplet morphology in female office workers with trapezius myalgia, compared to healthy controls. A muscle biopsy study Objective Trapezius myalgia, or more specific, myofascial dysfunction of the upper trapezius mainly affects women performing jobs requiring prolonged low level activation of the muscle. This continuous low muscle load can be accompanied by a shift to a more anaerobic energy metabolism, causing pain. To investigate whether morphological signs of an impaired aerobic metabolism are present in female office workers with trapezius myalgia. Design Muscle biopsy analysis, using electron and light microscopy, was performed to compare mitochondrial and fat droplet morphology, and irregular muscle fibers, between female office workers with (n=17) and without (n= 15) work-related trapezius myalgia. Results The patient group showed a significantly higher mean area (P=0.023) and proportion (P=0.029) for the subsarcolemmal and intermyofibrillar mitochondria respectively, compared to the control group. A significantly lower mean area of subsarcolemmal lipid droplets was found in the patient group (P=0.015), which also displayed a significantly higher proportion of lipid droplets touching the mitochondria (P=0.035). A significantly higher amount of muscle fibers with COX deficient areas were found in the patient group (P=0.030). Conclusion The results of the present study may be indicatve for an impaired oxidative metabolism in work-related trapezius myalgia. However, additional research is necessary to confirm this hypothesis. Corresponding author: Kayleigh De Meulemeester Corneel Heymanslaan 10, 9000 Ghent (Belgium) Kayleigh.demeulemeester@ugent.be No conflicts of interest were present in writing this article. Kayleigh De Meulemeester is funded by BOF- UGent 01N04215. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Medicine and Health Sciences

Understanding physician burnout syndrome: Antithesis of physician well-being Bhaskara P Shelley Archives of Medicine and Health Sciences 2019 7(1):1-10

Learning with emotions: The relationship between emotions, cognition, and learning in medical education Meghan McConnell Archives of Medicine and Health Sciences 2019 7(1):11-12

Lycopene restores liver function and morphology of ifosfamide-intoxicated rats Elias Adikwu, Bonsome Bokolo Archives of Medicine and Health Sciences 2019 7(1):13-17 Introduction: Low incidence of liver toxicity has been anticipated with the clinical use of ifosfamide (IFO); however, there is possible hepatotoxic concern with its use. There is a paucity of effective drugs that can protect liver or regenerate hepatocytes during damage. In this light, the protective effect of lycopene (LYP) was examined against a rat model of IFO-induced liver injury. Materials and Methods: Forty adult albino rats were randomized into eight groups (A–H). Group A (control) was orally treated with water, whereas groups B–D were orally treated with 10–40 mg/kg of LYP daily for 7 days, respectively. Group E was treated with 150 mg/kg of IFO on the 7th day intraperitoneally (ip), whereas groups F–H were pretreated orally with 10, 20, and 40 mg/kg of LYP daily, respectively, before treatment with IFO on the 7th day (ip). On the 8th day, rats were sacrificed, blood was collected, and serum was separated and evaluated for biochemical parameters. Rats were dissected; liver was collected, weighed, and evaluated for biochemical parameters and histology. Results: Significant (P < 0.001) increases in aminotransferases, total bilirubin, conjugated bilirubin, gamma-glutamyl transferase, lactate dehydrogenase, and malondialdehyde levels with significant (P < 0.001) decreases in superoxide dismutase, glutathione, catalase, and glutathione peroxidase levels were obtained in IFO-treated rats when compared to control. Liver of IFO-treated rats showed periportal and pericentral necroses of hepatocytes. However, The aforementioned parameters were significantly restored in a dose-dependent manner at 10 mg/kg (P < 0.05), 20 mg/kg (P < 0.01) and 40 mg/kg (P < 0.05) of LYP-pretreated rats. Conclusion: This study showed that IFO-induced liver damage was restored in a dose-dependent manner by pretreatment with LYP.

Utilization of noncommunicable disease services provided by public health facilities in Kasaragod, Kerala CK Bhagyalakshmi, Prakash Babu Kodali Archives of Medicine and Health Sciences 2019 7(1):18-24 Background: The burden of noncommunicable diseases (NCDs) is high with significant impact on households in the form of out-of-pocket expenditure. Provision of NCD services through public health facilities is considered as cost-effective and efficient means. Aim: The study aimed to assess the proportion of individuals using NCD services provided through public health facilities and identify the factors associated with its use in Kasaragod district of Indian state of Kerala. Materials and Methods: A cross-sectional survey of 375 individuals was conducted in Kasaragod District of Kerala state. The data obtained were analyzed using descriptive and analytical statistical methods using Statistical Package for the Social Sciences version 20. Results: About 56.28% of individuals with NCD, received NCD services from public health facilities; these services were primarily comprised screening services. In addition, 40.69% of total individuals with NCDs received treatment services from government health facilities. Insurance coverage, perception about quality, perceived barriers in accessing health services, health worker visit, knowledge about NCD services, and information provided by frontline health workers were significantly influencing NCD service utilization in public health facilities. Conclusion: Individual's usage of screening services provided by government facilities is higher than that of treatment services. Overall, the utilization of NCD services provided through the public health system could be said to be less than satisfactory. It could be improved by addressing the perceived barriers with respect to the quality of services provided in public health facilities. In addition, employing the frontline health workers to bridge the awareness gap in NCD service provision could help in improving NCD service utilization.

Correlation between sputum and bronchoscopy-guided cytology (bronchoalveolar lavage fluid, transbronchial needle aspiration, and bronchial brush) with bronchial biopsy in the diagnosis of pulmonary pathology Pushpanjali R Ojha, Renu Madan, Reena Bharadwaj Archives of Medicine and Health Sciences 2019 7(1):25-32 Background: Pulmonary pathologies constitute a major ailment in terms of morbidity and mortality. Recent technological advancements provide cytological analysis that accentuates accurate diagnosis, early intervention, management, and ease of clinical follow-up with improved outcomes. This study aimed to correlate the sensitivity and describe advantages and disadvantages of the various cytological means of the diagnosis of lung pathologies along with the sequential approach. Materials and Methods: This was a prospective study performed during the period of January 2013 to January 2015. Samples of sputum and bronchoscopy-mediated bronchoalveolar lavage (BAL) fluid, air-dried and alcohol-fixed smears of bronchial brushing (BB), transbronchial needle aspiration (TBNA), and formalin-fixed bronchial biopsy tissues were received, processed, and analyzed from all clinically and radiologically suspected cases of pulmonary pathologies. Results: Two hundred cases of lung lesions were included with all the four cytological sampling interventions and tissue biopsy in the present study with an age range of 21–90 years and male:female ratio of 2.45:1. There were 111 neoplastic and 89 nonneoplastic cases. The diagnostic sensitivity was maximum with BB cytology for nonneoplastic as well as neoplastic lesions. The overall diagnostic utility observed in 200 cases reveals sputum cytology as least sensitive and BB cytology as most sensitive investigation. Conclusion: Sputum cytology is used in patients who are unfit for bronchoscopy and inpatients for their routine evaluation of underlying infection. BAL enhances yield from intraluminal lesions, and TBNA enhances yield in submucosal and mediastinal lesions. The proposed protocol for cytomorphological diagnosis should be as sputum > BAL > TBNA > BB in order of ease.

Risk factors related to human papillomavirus infection in oral squamous cell carcinoma Alberto Rodriguez-Archilla, Adriana Stuardo-Parada Archives of Medicine and Health Sciences 2019 7(1):33-37 Background: In addition to tobacco and alcohol consumption, some infectious pathogens such as human papillomavirus (HPV) have been proposed as carcinogenic factors in oral cancer. Objective: The objective of the study is to assess the possible influence of HPV detection in oral squamous cell carcinoma (OSCC). Materials and Methods: A PubMed search through April 2018, using the following Medical Subject Headings terms, was performed: “mouth neoplasms” and “papillomavirus infections.” Studies with findings on HPV detection in OSCCs were assessed. From 77 studies with full-text availability, 59 were excluded for several reasons: no usable/irrelevant data (32), tonsils, base of tongue and non-OSCC cases studies (26), and animal testing studies (1). The data were analyzed using statistical software RevMan 5.3 (The Cochrane Collaboration, Oxford, UK). For dichotomous outcomes, the estimates of effects of an intervention were expressed as odds ratios (ORs) using Haenszel–Mantel method with 95% confidence intervals. Results: Eighteen studies on HPV detection in OSCCs were included in this meta-analysis. The mean percentage of HPV detection in OSCC was 37.1%. Oral cancer patients showed a higher risk of being infected with HPV than controls (OR: 4.85) and they were more likely to be infected with high-risk HPV (OR: 11.46). A larger number of smokers had HPV-infected tumors (OR: 1.45). Younger age, gender, tobacco and/or alcohol consumption, tumor differentiation degree, tumor size (T-status), and lymph node metastasis (N-status) were factors that did not have a significant influence on HPV-infected oral cancers. Conclusion: HPV infection, especially of high-risk HPV, is more frequent in patients with OSCC.

Primary localized cutaneous amyloidosis – A clinicopathological study Suguna Belur Venugopal, Aparna Muralidhar Archives of Medicine and Health Sciences 2019 7(1):38-41 Introduction: Cutaneous amyloidosis can be a manifestation of a systemic disorder or can result from localized process confined to the skin. Involvement of apparently normal skin is known as primary localized cutaneous amyloidosis. Histopathologically, amyloid appears as amorphous, eosinophilic material with hematoxylin and eosin stain. Congo red staining with apple-green birefringence under polarized microscopy confirms the diagnosis. Materials and Methods: Thirty-nine patients with a differential diagnosis of cutaneous amyloidosis reporting to the dermatology outpatient department of our hospital from November 2015 to May 2018 were studied. Twenty-six cases showed features of amyloidosis on histopathology. These were categorized into morphologic types of amyloidosis and correlated with the available clinical history. Congo red staining and observation under polarized microscope were done. Results: We encountered lichen and macular types of cutaneous amyloidosis with slight female predominance. Majority of the lesions were pruritic with involvement of the pretibial region. A history of friction was given by a few. All cases diagnosed clinically were concordant histopathologically. However, a single case of lichen amyloidosis was diagnosed solely based on histology. Microscopically, hyperkeratosis, amyloid deposits in the papillary dermis, and perivascular inflammation were the most consistent findings. All the cases showed apple-green birefringence with Congo red stain under polarized microscope. Conclusion: Cutaneous amyloidosis can have a wide range of differential diagnosis due to its varied clinical presentation. Histopathology, with the use of special stains, helps in identifying amyloid with a high degree of accuracy.

Pro-life or pro-abortion – Women's attitude toward abortion in Darjeeling, India Pallabi Dasgupta, Romy Biswas, Dilip Kumar Das, Jayanta Kumar Roy Archives of Medicine and Health Sciences 2019 7(1):42-47 Background and Objective: Despite liberal abortion law in India, majority of abortions are unsafe. Behavioral theory suggests that women's attitudes may influence their abortion decisions. The present study was conducted to find out women's attitude toward abortion and its predictors. Materials and Methods: A community-based cross-sectional study was conducted in Naxalbari block of Darjeeling district, West Bengal, India, among 420 women aged 15–49 years using a predesigned, pretested interview schedule. The women's attitude regarding abortion practices was determined based on Likert's three-point scale. Two-stage cluster analysis was used to classify the overall attitude of women. Binary logistic regression was used for finding out predictors of abortion attitude. Results: More than half (53.5%) of the women had an overall pro-life attitude and 46.5% women had an overall pro-abortion attitude. Women who were less educated with <5 years' schooling, unaware of legality of abortion, and never aborted had significantly higher odds of having overall pro-life attitude. Majority women viewed abortion as a sin (81.4%); 62.1% of women disagreed with abortion as a method of family planning; 87.4% disagreed with sex selection before abortion; and 57.4% women agreed on women's right to decide for abortion. Conclusion: Women's attitude of abortion depicted complex personal and moral choices marred with social stigma within which abortion decisions are made. For developing a pro-choice outlook, life skills education for women, creating supportive family environment, sensitizing young men through extensive awareness campaigns, and advocacy through health-care providers are needed.

Correlation of cord blood bilirubin values with neonatal jaundice in healthy newborns: A prospective observational study Jehangir Allam Bhat, Sajad Ahmad Sheikh, Roshan Ara Archives of Medicine and Health Sciences 2019 7(1):48-52 Background and Objective: Hyperbilirubinemia is the most common clinical condition requiring evaluation and treatment in the newborn and a frequent reason for hospital readmission during the 1st week of life. Although generally a benign, postnatal, transitional phenomenon, a few neonates develop marked potentially hazardous bilirubin levels that can pose a direct threat of serious brain injury. The present study was conducted to investigate the predictability of pathological jaundice on cord blood bilirubin (CBB) values. Materials and Methods: This was a prospective observational study conducted on 289 healthy newborns. Babies were divided into two groups: Group A who developed physiological jaundice and Group B who developed pathological jaundice. CBB was estimated in all newborns who were then followed up to the 5th day of life. Babies who developed jaundice requiring treatment were admitted in neonatal intensive care unit for phototherapy. Other neonates were checked regularly up to the 5th day of life and values were recorded on the 5th day by estimation of serum bilirubin. Results: Incidence of pathological hyperbilirubinemia in our study was 11.2%. A statistically significant correlation between CBB and development of pathological jaundice was observed. Gender, age, mode of delivery, and birth weight has no correlation with cord bilirubin and the subsequent development of jaundice. CBB <2.5 mg/dl when compared with subsequent development of jaundice has high specificity (83.92%) and negative predictive value (87.35%). Cord blood value of >3.5 mg/dl has high sensitivity (97.06%), specificity (99.22%), positive predictive value (94.29%), and negative predictive value (99.61%) in predicting future development of future pathological jaundice. Conclusion: The present study suggests that in healthy term babies (CBB ≤2.5 mg/dl), cord serum bilirubin can help to identify those newborns who are unlikely to require further evaluation and intervention. These newborns can be discharged with assurance to parents. Babies with CBB level ≥3 mg/dl should be followed more frequently. Thus, this study concludes that cord blood total bilirubin levels reliably predict the occurrence of pathological hyperbilirubinemia.

Growth changes in two age groups with different malocclusions in individuals of Central India Shail Kumari, Shirish M Bapat, Kshitij Gupta Archives of Medicine and Health Sciences 2019 7(1):53-56 Objective: Comparative evaluation of McNamara's analysis in Class I, Class II, and Class III individuals of Central India in two different age groups. Materials and Methods: 240 individuals belonging to Central India were divided into two main groups: Group I comprised 120 children (10–14 years) and Group II comprised 120 adults (18–22 years). McNamara's analysis was used to assess skeletal, dental, and soft tissue parameters. Results: Statistically significant difference was found for facial axis angle, mandibular length, and maxillary length in children and adults in dental/skeletal Class I individuals. In Class II division 1 individuals, statistically significant difference was found in children and adults for maxillary length, mandibular length, and lower anterior facial height. In Class II division 2 individuals, statistically significant difference was found in children and adults in maxillomandibular difference and lower anterior facial height. In Class III individuals, the difference was in nasolabial angle. Conclusion: The growth of maxilla is usually completed by 10-14 years of age. The present study suggests that the growth of maxilla is continuous in adults, and nasolabial angle decreases with age in Class III individuals. Hence, planning of extractions in earlier age should be decided with caution.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Nephrology and Transplantation

Preface Journal of The Egyptian Society of Nephrology and Transplantation 2019 19(2):0-0

Parasitic infestation in organ transplant recipients: a comprehensive review in the absence of robust evidence Fedaey Abbas, Mohsen El Kossi, Jon J Kim, Ihab S Shaheen, Ajay Sharma, Ravi Pararajasingam, Ahmed Halawa Journal of The Egyptian Society of Nephrology and Transplantation 2019 19(2):31-61 The real effect of parasitic infection on transplant recipients is not known. Interestingly, only 5% of human parasitic infections can affect functioning of transplanted organs. Parasitic infections manifest in two different ways: first, systemic illness, including anemia and constitutional symptoms, and second, local syndromes, which are usually confined to the lower gastrointestinal tract. Examples for pathogens causing systemic disease are Plasmodium malaria, Leishmania, Trypanosoma, and Toxoplasma. On the contrary, protozoal infection with Cryptosporidium and microsporidia, or the nematodes such as Strongyloides, may manifest with the local syndromes. Management of these infections in transplant recipients entails the following: prevention, timely diagnosis, cultures, specific serological tests, and PCR testing. Once the diagnosis is established, prompt medical/surgical interventions should be instituted to save these patients from developing hyperinfection or disseminated parasitic syndromes, involving, for example, the lungs or the central nervous system.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Allergy, Asthma and Immunology

Homologous allergens: A regulatory and clinical perspective SN Gaur Indian Journal of Allergy, Asthma and Immunology 2019 33(1):1-3

Environmental triggers in allergic diseases: An overview AB Singh Indian Journal of Allergy, Asthma and Immunology 2019 33(1):4-7 Allergy and asthma are increasing all over the world including India. The most effective method of management of allergic diseases is prevention and avoidance where ever possible natural history of allergy is influenced by many triggering Biological and non biological agents. Identification of these triggers such as pollen, moulds, mites and insect debris etc., are major factors for secondary prevention of environmental allergens. It is suggested in this brief review that educational programs should focus on avoidance of these triggers for effective management in addition to other forms of therapy.

Allergy asthma practice in India: Beyond the guidelines "Shivpuri Oration 2017" PA Mahesh Indian Journal of Allergy, Asthma and Immunology 2019 33(1):8-13 This article summarizes two decades of allergy and asthma research in Mysore, South India, encompassing epidemiologic, mechanistic and biomarker studies as well as diagnostic and prognostic studies. The deficiencies of some of the current guidelines in the diagnosis and treatment of allergic diseases. Two of the most important considerations for future guidelines are to adopt the concept of progression of allergic disease and discuss plans to prevent or mitigate them to reduce the burden of morbidity as well as the enormous costs that go along with disease progression. The other is to consider serial spirometry for the diagnosis of asthma and COPD in difficult to diagnose subjects. The future directions for research in the field are discussed.

An Indian perspective on dust mites SN Gaur Indian Journal of Allergy, Asthma and Immunology 2019 33(1):14-18 Dust mites are the most important group of indoor allergens. The dust mites have been classified as house dust mites and storage mites, however, with recent knowledge the different dust mite species are now labelled as “domestic mites.” The dust mites have been isolated at numerous Indian locations and their sensitization in Indian population has also been documented. In view of high sensitization in India, it is important to recognize the role of dust mites and their allergens in the precipitation of allergic diseases including allergic rhinitis and asthma. Allergies to dust mites can be confirmed by a classical clinical history of perennial, early morning and indoor symptoms substantiated by a positive skin prick test to these allergens. Further management of allergies to mites is possible using appropriate allergen avoidance measures and allergen immunotherapy. Multifaceted avoidance measures can be used, but, allergen avoidance by the means of an allergen impermeable bed encasings has the best evidence and is recommended in different guidelines. Allergen immunotherapy, the disease-modifying modality, has been proven to efficacious for house dust mite allergies.

A cross-sectional study of skin prick test to Aspergillus fumigatus antigen in asthmatic patients seen at a tertiary healthcare center Jayanthi Savio, Priya Ramachandran, Vinutha Jairaj, Uma Devaraj, George D'Souza Indian Journal of Allergy, Asthma and Immunology 2019 33(1):19-24 INTRODUCTION: Asthma is a significant public health problem. The severity of asthma varies from patient to patient and the reasons for this are not fully understood. Atopy is known to play an important part in the pathogenesis of asthma. Sensitization to aeroallergens like house dust mite, animal dander from pets and environmental fungi are evaluated in asthmatics. Severe asthma seems to be associated to environmental fungi with sensitization especially to Aspergillus species. AIMS AND OBJECTIVE: The study aimed at determining the prevalence of Cutaneous Sensitization to Aspergillus species by Skin Prick Test (SPT) in moderate- severe asthmatics. MATERIAL AND METHODS: This study was done on 205 clinically diagnosed asthmatic patients, between September 2012 and August 2013. SPT and spirometry was done in all subjects along with a detailed history. RESULTS: The prevalence rate of Aspergillus sensitized patients is 59.5%. Observations of this study also suggest that the severity of asthma is more in Aspergillus sensitized patients when compared to non-sensitized patients and the duration of asthma was more in Non sensitized. There was no significant association between AEC, total IgE levels and Aspergillus species culture positivity in Aspergillus sensitized patients. Aspergillus terreus was the predominant fungal isolate from both SPT positive and negative patient. There was no significant correlation of fungal culture with SPT. CONCLUSIONS: High levels of Aspergillus sensitization is seen in south Indian subjects and is associated with greater severity and shorter duration of asthma.

Comparative study of effectiveness of autologous serum and histaglobulin in autologous serum skin test positive and negative cases of chronic urticaria Anamika Chaudhari, Hita Mehta, Neha Agrawal Indian Journal of Allergy, Asthma and Immunology 2019 33(1):25-31 AIMS AND OBJECTIVES: The aim of our study is to compare the effectiveness of autologous serum therapy (AST) with histaglobulin in patients of chronic urticaria. MATERIALS AND METHODS: This was a prospective, comparative, randomized controlled, single-blinded study. Based on inclusion and exclusion criteria, patients were selected and divided into two groups by randomization. Autologous serum skin test was done in each patient irrespective of their groups. Group A (n = 30) received AST and Group B (n = 30) received histaglobulin. Patients' assessment was done every week for urticaria activity score (UAS) for 8 weeks. STATISTICAL ANALYSIS: We used Mann–Whitney test to compare the means between two groups. Wilcoxon signed-rank test was used to compare pre- and posttreatment UAS scores. RESULTS: Both therapies reduced UAS significantly (P = 0.01) at 8 weeks, and the reduction was observed every week. AST reduced UAS more than histaglobulin. However, within intergroup, difference was not significant. All patients had reduced severity of urticaria; however, complete remission (UAS = 0) was observed in three patients of Group A. CONCLUSION: Group A (AST) showed statistically significant improvement than Group B (histaglobulin), but both showed a reduction in UAS with a longer treatment-free interval.

A clinico-epidemiological study on urticaria cases in various tertiary care hospitals affiliated to a medical college in Mangalore, India Nitin Joseph, Akriti Suman, Siddhika Dangayach, Khushboo Sahni, Piyush Chaturvedi, NN Ramachandran Indian Journal of Allergy, Asthma and Immunology 2019 33(1):32-38 BACKGROUND: Urticaria affects one in every five persons in the population. OBJECTIVES: This study was done to study the risk factors, clinical presentation, and management practices among patients with urticaria. METHODS: Information from the medical case records of confirmed cases of urticaria at a government and private tertiary care hospital over the recent 4 years were recorded in a semi-structured pro forma. RESULTS: Mean age of 115 patients was 31.2 ± 20.7 years. Majority of patients (69, 60%) had acute urticaria. The most common risk factors of urticaria in this study were allergy to food substances (27, 23.5%) and allergy to medications (18, 15.6%), followed by insect bites (16, 13.9%). Family history of urticaria was present in 8 (7%) patients. The most common symptom in urticaria was pruritus (68, 59.1%) and the most common sign was hives (40, 34.8%). Lesions were present all over the body in 52 (45.2%) and were bilateral in distribution in 59 (51.3%) patients. Sixty-eight (59.1%) and 69 (60%) urticaria patients were prescribed nonsedating and second-generation antihistamine (sgAH) drugs, respectively. Among chronic urticaria (CU) cases, 35 (76.1%) each received nonsedating and sgAH. Systemic steroids and topical steroid creams were prescribed in 21 (18.3%) and 7 (6.1%) urticaria patients, respectively. Mean duration of application of the topical steroid creams was 10 ± 4.8 days. Leukotriene antagonists were used in the management of greater proportion of patients (54.5%) with dermographism in comparison to 16.1% without dermographism (P < 0.001). CONCLUSION: The study reported few important risk factors and certain common clinical presentation in urticaria. Second-generation nonsedating type of antihistamine drugs was the most preferred drug for the management of urticaria.

Applicability of established regression equations in the prediction of peak expiratory flow rate in Indian adults Himel Mondal, Shaikat Mondal, Amita Kumari Panigrahi, Sarika Mondal Indian Journal of Allergy, Asthma and Immunology 2019 33(1):39-44 BACKGROUND: Peak expiratory flow rate (PEFR) helps in the assessment of airflow limitation. Its relationship with age and height has been established in several previous studies with different sample size in different regions from India. A large-scale study (in 2014) established a set of regression equations with a national level reference regression equation. AIM: The aim of this study was to check the applicability of established regression equations in the prediction of PEFR in apparently healthy young adults. MATERIALS AND METHODS: A cross-sectional study was conducted with 104 young adults (males &#61; 55, females &#61; 49). PEFR (L/min) was measured using computerized spirometer. Established regression equations from the previous study were used to predict PEFR from the age and height of the participants. Measured PEFR values were compared with predicted values by the paired t-test with &#945; &#61; 0.05. Further, the prediction was considered &#8220;comparable&#8221; if the value was <&#177;10&#37; of the measured value. RESULTS: Measured versus predicted mean PEFR (from regression equation established for adult Indian national) for male was 481.99 &#177; 63.52 L/min versus 496.04 &#177; 20.70 L/min (P &#61; 0.096) and female was 365.19 &#177; 61.36 L/min versus 336.82 &#177; 13.78 L/min (P &#60; 0.001). In male, 54.55&#37; and in female, 44.90&#37; was comparable prediction from regression equation established for Indian adult national. CONCLUSION: Estimated PEFR in male showed fair comparable prediction and female showed poor comparable prediction. Further studies, including all Indian states with a large sample, may help in the establishment of more accurate prediction equations.

Bronchial asthma: Prevalence and risk factors among children in urban population from Raipur, Chhattisgarh Vandana Kumari, Tushar Bharat Jagzape Indian Journal of Allergy, Asthma and Immunology 2019 33(1):45-50 OBJECTIVES: Bronchial asthma is an important chronic disease in children leading to school absenteeism, hospitalization, economic and psychological stress in the family. Worldwide, the prevalence of asthma is on rise. There is a paucity of information on the prevalence of bronchial asthma in childhood in Central India. Hence, this community-based study was conducted with an objective to estimate the prevalence of asthma and identify associated risk factors in children between 6 and 14 years of age. MATERIALS AND METHODS: This cross-sectional study using modified International Study of Asthma and Allergies in Childhood questionnaire was conducted in the urban area of Raipur, Chhattisgarh, India. The calculated study sample of 175 children in the age group of 6&#8211;14 years was recruited using multistage random sampling. RESULTS: Of 175 (88 males and 87 females), 13.14&#37; (23) of the participants had wheezing at any time in the past and 5.14&#37; had wheezing in the past 1 year (asthma prevalence). The prevalence was slightly more (5.9&#37;) in 6&#8211;9 years. Boys had more prevalence (5.6&#37;) than girls (4.6&#37;). However, more girls were affected (5.4&#37; vs. 3.7&#37;) in the age group of 10&#8211;14 years. Major risk factors with statistically significant &#8220;P&#8221; values were allergic rhinitis (66.6&#37;) (Relative Risk (RR) &#61; 6.9), family history of bronchial asthma (66&#37;) (RR &#61; 4.6), maternal asthma (33.3&#37;) (RR &#61; 6.9), and upper socioeconomic class (55.5&#37;) (RR &#61; 2.9&#37;). Important triggers were inhalants, cold exposure, exercise, irritants, and infections. CONCLUSION: The prevalence of asthma in children was 5.14&#37;. The significant risk factors were allergic rhinitis and family history of asthma, specifically maternal asthma.

Characteristics of bronchial asthma with persistent airflow limitation Deependra Kumar Rai, Shiv Kumar, Alok Ranjan, Ravi Kirti Indian Journal of Allergy, Asthma and Immunology 2019 33(1):51-55 BACKGROUND: Asthma is a chronic inflammatory disorder of airway characterized by variable symptoms and variable airflow limitation. There are many patients developed persistent airflow limitation in due course of disease due to many factors. The present study was conducted to characterize this phenotype and to identify the factors which are implicated in causing persistent airflow limitation. MATERIALS AND METHODS: We recruited consecutive 164 patients aged &#60;40 years (to exclude chronic obstructive pulmonary disease [COPD]), diagnosed, and treated as bronchial asthma in our asthma clinic for at least 6 months. We took all clinical, lung function detail and compared between asthma with or without persistent airflow limitation. The patients were assigned to the group with persistent airflow obstruction if they presented postbronchodilator forced expiratory volume in 1 s (FEV1) or FEV1/forced vital capacity values &#60;70&#37; predicted. RESULTS: A total of 114 patients included in the study and 42 (36.84&#37;) patients had persistent airflow limitation. The patients with persistent airflow limitation have a higher age and more proportion of patients were male. History of allergic rhinitis is an important risk factor found associated with asthma with persistent airflow limitation (P&#8804; 0.001). 26.19&#37; of patients with persistent airflow limitation had a history of symptom since childhood and generally having a longer disease duration compared to patient without airflow limitation (P &#60; nonsignificant). Reversibility criteria (&#62;12&#37; and &#62;200 ml increase in FEV1) was fulfilled by only 26.7&#37; of the study patients. The factors such as onset of disease after 18 years, history of atopy, serum IgE level, family history of asthma, and biomass fuel exposure did not differ between groups with or without airflow limitation. CONCLUSIONS: Bronchial asthma is more having a COPD such as spirometry features if it has been started since childhood, longer disease duration, and history of allergic rhinitis. Reversibility in spirometry, which is specific for asthma diagnosis, is found only in one-fourth of the patients.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Perioperative Practice

Dental clearance and postoperative heart infections: Observations from a preoperative evaluation clinic for day-admission surgery Journal of Perioperative Practice, Ahead of Print.

A controlled trial to investigate whether the orientation of the bevel and angle of approach determine the side of endobronchial intubation in an adult manikin Journal of Perioperative Practice, Ahead of Print.

The story of 'cutting for the stone' – Lithotomy for bladder calculus Journal of Perioperative Practice, Ahead of Print.

The perioperative Team Brief: A patient safety initiative or another tick-box exercise? Journal of Perioperative Practice, Ahead of Print.

A preoperative predictive model for prolonged post-anaesthesia care unit stay after outpatient surgeries Journal of Perioperative Practice, Ahead of Print.

Florence Nightingale: creator of modern nursing and public health Journal of Perioperative Practice, Ahead of Print.  In his 2008 series of articles on notable women in healthcare, Professor Harold Ellis celebrates Florence Nightingale's contribution to nursing, research and public health. This month, we republish his article to coincide with the 2020, 'Year of the Nurse and Midwife', celebrating the famous lady with the lamp's work in the Crimean War, as well as her pioneering work in the fields of nursing and public health, that helped shape current practice and research.

The story of appendicitis and its treatment Journal of Perioperative Practice, Ahead of Print.

The story of Caesarean section Journal of Perioperative Practice, Ahead of Print.

Compliance to the Surgical Safety Checklist over time in late and early adopters Journal of Perioperative Practice, Ahead of Print.

Perioperative nurses' experiences of caring for donation after cardiac death organ donors and their family within the operating room Journal of Perioperative Practice, Ahead of Print.  The impact of education Journal of Perioperative Practice, Volume 29, Issue 6, Page 151-152, June 2019.  Supporting and encouraging the next generation of perioperative practitioners – A privilege and a passion Journal of Perioperative Practice, Volume 29, Issue 6, Page 153-153, June 2019.  Supervision & Mentoring in Healthcare 4th Edition Journal of Perioperative Practice, Volume 29, Issue 6, Page 154-155, June 2019.  News Update Journal of Perioperative Practice, Volume 29, Issue 6, Page 156-158, June 2019.  Intravenous versus inhalational techniques for rapid emergence from anaesthesia in patients undergoing brain tumour surgery Journal of Perioperative Practice, Volume 29, Issue 6, Page 159-160, June 2019.  Getting in the Flo: My year as a scholar Journal of Perioperative Practice, Volume 29, Issue 6, Page 161-165, June 2019.  Who's who? Championing the '#TheatreCapChallenge' Journal of Perioperative Practice, Volume 29, Issue 6, Page 166-171, June 2019.  How can the presence of a surgical care practitioner improve training for staff who are learning how to scrub for robotics cases in a urology theatre? Journal of Perioperative Practice, Volume 29, Issue 6, Page 172-178, June 2019.  Preparation for Objective Structured Clinical Examination: A student perspective Journal of Perioperative Practice, Volume 29, Issue 6, Page 179-184, June 2019.  The HOTSHOT taxonomy and a signature pedagogy framework for operating department practice: The juxtaposition to the academic apartheid surrounding higher order thinking Journal of Perioperative Practice, Volume 29, Issue 6, Page 185-192, June 2019.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Anaesthesiology

A systematic review of randomised controlled trials investigating prehabilitation before major intra-abdominal cancer surgery: An analysis of prehabilitation content and outcome measures BACKGROUND Although prehabilitation programmes for patients undergoing major intra-abdominal cancer surgery have been shown to improve pre-operative physical fitness, the conclusions regarding any postoperative benefits are inconsistent. OBJECTIVES The aim of this study was to evaluate the content of and the outcome measures used in studies of prehabilitation programmes for these patients. It was hypothesised that the content of prehabilitation programmes is often therapeutically invalid, and that the postoperative outcomes assessed are inadequate to evaluate the impact of complications. DESIGN A systematic review of randomised controlled trials. DATA SOURCES Studies published between January 2009 and January 2019 were retrieved from PubMed, Embase and PEDro. ELIGIBILITY CRITERIA Studies were included when they investigated the effects of prehabilitation in patients undergoing intra-abdominal surgery for cancer, reported pre-operative and/or postoperative outcome measures and were conducted as a randomised controlled trial. Studies for which the full text was not available were excluded, as were studies of patients undergoing nonabdominal cancer surgery. RESULTS Eight studies (565 patients) were included. Therapeutic validity was low in five studies. Most studies included low-risk surgical patients and considerable variation was observed between prehabilitation programmes in terms of supervision, training context, frequency, intensity, duration and training type. Objective monitoring of training progression was typically not performed, and most trials did not include nutritional or psychological support. Postoperative complications were reported in seven studies, but no study reported the impact of postoperative complications, nor on long-term postoperative outcomes. CONCLUSION The content of prehabilitation programmes was heterogeneous. Studies with a high therapeutic validity found unequivocal evidence that prehabilitation had beneficial effects on postoperative outcomes. Future research should focus on adequate selection and inclusion of high-risk surgical patients and provide personalised and probably multimodal (partly) supervised prehabilitation, with objective monitoring of progress. Measuring the incidence and impact of postoperative complications may contribute to demonstrating the clinical value of prehabilitation. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Correspondence to Bart C. Bongers, PhD, Maastricht University, Department of Nutrition and Movement Sciences, P.O. Box 616, 6200 MD Maastricht, The Netherlands Tel: +0031433882236; e-mail: bart.bongers@maastrichtuniversity.nl Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Ultrasound-assisted vs. landmark-guided paramedian spinal anaesthesia in the elderly: A randomised controlled trial BACKGROUND Neuraxial ultrasound might improve the efficacy of spinal anaesthesia but this has not been tested for the paramedian approach in the elderly. OBJECTIVE The current study aims to assess whether the ultrasound-assisted paramedian technique can decrease the number of needle passes required for success compared with the landmark-guided paramedian technique in the elderly. DESIGN Prospective randomised controlled study. SETTING Single-institution, tertiary-level hospital in Seoul, Republic of Korea from October 2017 to January 2018. PATIENTS Eighty patients aged at least 60 years undergoing orthopaedic surgery. INTERVENTION All received paramedian spinal anaesthesia by either the landmark-guided or preprocedural ultrasound-assisted technique. MAIN OUTCOME MEASURES The number of needle passes required for successful dural puncture. RESULTS The number of needle passes (median [interquartile range]) was significantly lower (1.0 [1.0 to 2.0] vs. 4.5 [2.0 to 7.0]) and the success rate at first pass significantly higher at 65.0 vs. 17.5% in the ultrasound compared with the landmark group (both P < 0.001). The ultrasound-assisted technique required a longer time for establishing landmarks 117.5 [85.5 to 150.7] vs. 17.5 [14.0 to 23.0] s, and for total procedure 181.5 [133.5 to 212.5] vs. 92.5 [62.5 to 176.5] s, but a shorter time for administering spinal anaesthesia 39.5 [31.5 to 71.3] vs. 77.0 [45.8 to 136.5] s (all P < 0.001) than the landmark-guided technique. The ultrasound group showed lower periprocedural pain scores 3 [2 to 4] vs. 4 [4 to 6] (P = 0.009) and discomfort scores 2 [0 to 3] vs. 5 [2 to 6] (P = 0.003) than the landmark group. CONCLUSION Compared with the landmark-guided paramedian technique, the ultrasound-assisted paramedian technique decreases the number of needle manipulations and periprocedural pain and discomfort scores in the elderly. Our results suggest that neuraxial ultrasonography facilitates the performance of spinal anaesthesia in the elderly. TRIAL REGISTRATION NCT03316352. Correspondence to Jin-Tae Kim, Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea E-mail: jintae73@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Bilateral subcostal transversus abdominis plane block does not improve the postoperative analgesia provided by multimodal analgesia after laparoscopic cholecystectomy: A randomised placebo-controlled trial BACKGROUND Laparoscopic cholecystectomy might be considered minor surgery, but it may result in severe postoperative pain. Subcostal transversus abdominis plane (TAP) block, which produces long-lasting supra-umbilical parietal analgesia, might improve analgesia after laparoscopic cholecystectomy. OBJECTIVE We investigated whether subcostal TAP block would reduce opioid consumption and pain after laparoscopic cholecystectomy in patients provided with multimodal analgesia. DESIGN A randomised, placebo-controlled, double-blind study. SETTING The study was conducted at a university teaching hospital from December 2017 to June 2018. PATIENTS Sixty patients scheduled for laparoscopic cholecystectomy were included. Anaesthesia and postoperative analgesia (etoricoxib, paracetamol, ketamine and dexamethasone) were standardised. INTERVENTION After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral subcostal TAP block with 20 ml of levobupivacaine 0.375% and epinephrine 5 μg ml−1 or 0.9% saline with epinephrine 5 μg ml−1. MAIN OUTCOME MEASURES Opioid consumption in the recovery room and during the first 24 h after surgery were recorded. Postoperative somatic and visceral pain scores, fatigue and nausea were measured. Intra-operative end-tidal concentrations of sevoflurane (FETSEVO) were also recorded. RESULTS Twenty-four hour postoperative opioid consumption were similar in both groups: 21.2 mg (95% CI 15.3 to 27.1) vs. 25.2 (95% CI 15.1 to 35.5) oral morphine equivalent in the levobupivacaine and 0.9% saline groups, respectively; P = 0.48. No significant between-group differences were observed with regards to parietal (P = 0.56) and visceral (P = 0.50) pain scores, fatigue and nausea. FETSEVO was slightly lower in the levobupivacaine group (P < 0.01). CONCLUSION Subcostal TAP block does not improve the analgesia provided by multimodal analgesia after laparoscopic cholecystectomy. It allows for a small reduction in intra-operative sevoflurane requirements. CLINICAL TRIAL REGISTRATION NCT0339153 Correspondence to Jean L. Joris, MD, PhD, Department of Anaesthesiology, CHU Liège, Domaine du Sart Tilman, Avenue de l'hôpital Bat B35, Liège B-4000, Belgium. Tel: +32 4 3667180; fax: +32 4 3667636; e-mail: jean.joris@chuliege.be © 2019 European Society of Anaesthesiology

Effects of goal-directed crystalloid vs. colloid fluid therapy on microcirculation during free flap surgery: A prospective randomised clinical trial BACKGROUND Macro, and microcirculatory effects of crystalloids and colloids are difficult to compare, because interventions to achieve haemodynamic stability seldom follow similar criteria. OBJECTIVES Our aim was to compare the effects of crystalloids and colloids on the microcirculation during free flap surgery when management was guided by detailed haemodynamic assessment. DESIGN A prospective randomised, controlled clinical trial. SETTINGS The investigation was performed at the University of Szeged, Hungary. PATIENTS Patients undergoing maxillofacial tumour resection and free flap reconstruction were randomised into groups treated with either intra-operative crystalloid (Ringerfundin, n = 15) or colloid (6% hydroxyethyl starch, HES, n = 15) solutions. INTERVENTIONS Macrohaemodynamics were monitored by a noncalibrated device (PulsioFlex-PULSION). Central venous oxygen saturation, venous-to-arterial PCO2-gap, lactate levels and urine output were measured hourly. Maintenance fluid was Ringerfundin (1 ml kg−1 h−1), and a multimodal, individualised, approach-based algorithm was applied to guide haemodynamic support. Hypovolaemia was treated with Ringerfundin or HES fluid boluses, respectively. The microcirculatory effects were assessed by laser-Doppler flowmetry (PeriFlux 5000 LDPM), with the probe placed on the flap and on a control area. Measurements were performed after the flap was prepared, then 1 and 12 h later. MAIN OUTCOME MEASURES The primary end-point was microcirculatory perfusion as determined by laser-Doppler flowmetry. RESULTS There was no difference between the groups regarding patient characteristics. Both groups remained haemodynamically stable throughout due to the use of approximately a 1.5 times higher total fluid volume in the Ringerfundin group than in the HES group: mean ± SD: 2581 ± 986 and 1803 ± 497) ml, respectively, (P = 0.011). There was no significant difference in the microcirculatory blood flow between the groups. CONCLUSION Our results showed that when fluid management was guided by detailed haemodynamic assessment, more crystalloid than colloid was needed to maintain haemodynamic stability, but there was no difference between the effects of crystalloids and colloids on the microcirculation. TRIAL REGISTRATION ClinicalTrials.gov (NCT03288051). Correspondence to Ildikó László, Department of Anaesthesiology and Intensive Therapy, University of Szeged, 6 Semmelweis St., Szeged 6725, Hungary; E-mail: laszlo.ildiko@med.u-szeged.hu © 2019 European Society of Anaesthesiology

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial BACKGROUND It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation. OBJECTIVE The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients. DESIGN Prospective observational study. SETTING Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand. PATIENTS Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy. INTERVENTIONS Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5). MAIN OUTCOME MEASURES Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA. RESULTS From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically. CONCLUSION Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass. TRIAL REGISTRATION The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216. Correspondence to Benno von Bormann, Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok 10700, Thailand Tel: +66 918825723/+66 24197990; e-mail: bvb@jodu.de © 2019 European Society of Anaesthesiology

Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial BACKGROUND Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation. OBJECTIVE The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures. DESIGN A randomised controlled trial. SETTING Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden. PARTICIPANTS Thirty healthy volunteers. INTERVENTIONS Pre-oxygenation without or with CPAP 10 cmH2O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH2O after anaesthesia induction. MAIN OUTCOME MEASURES A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures. RESULTS The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH2O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP. CONCLUSION Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02238691. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Correspondence to Per Cajander, Department of Anaesthesia and Intensive Care Örebro University Hospital, Södra Grev-Rosengatan, 701 85, Örebro, Sweden Tel: +46 19 602 03 53; e-mail: per.cajander@regionorebrolan.se © 2019 European Society of Anaesthesiology

Effect of sevoflurane-based or propofol-based anaesthesia on the incidence of postoperative acute kidney injury: A retrospective propensity score-matched analysis BACKGROUND Propofol may help to protect against ischaemic acute kidney injury (AKI); however, research on this topic is sparse. OBJECTIVE The current study aimed to investigate whether there were differences in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based total intravenous anaesthesia (TIVA) and those who received sevoflurane-based inhalational anaesthesia. DESIGN A retrospective observational study. SETTING A single tertiary care hospital. PATIENTS Medical records of patients aged 19 years or older who underwent curative lung resection surgery for nonsmall cell lung cancer between January 2005 and February 2018 were examined. MAIN OUTCOME MEASURES After propensity score matching, the incidence of AKI in the first 3 postoperative days was compared between patients who received propofol and those who received sevoflurane. Logistic regression analyses were also used to investigate whether propofol-based TIVA lowered the risk of postoperative AKI. RESULTS The analysis included 2872 patients (1477 in the sevoflurane group and 1395 in the propofol group). After propensity score matching, 661 patients were included in each group; 24 (3.6%) of the 661 patients in the sevoflurane group developed AKI compared with 23 (3.5%) of the 661 patients in the propofol group (95% confidence intervals of difference in incidence −0.019 to 0.022, P = 0.882). The logistic regression analyses revealed that the incidence of AKI was not different in the two groups (odds ratio 0.96, 95% confidence interval 0.53 to 1.71, P = 0.882). CONCLUSION In this retrospective study, no significant difference was found in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based TIVA and those who received sevoflurane-based inhalational anaesthesia. Considering the methodological limitation of this retrospective study, further studies are required to confirm these results. Correspondence to Tak Kyu Oh, Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam-si 13620, Gyeonggi-do, South Korea Tel: +82 31 787 7501; fax: +82 31 787 4063; e-mail: airohtak@hotmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Colour Doppler ultrasound after major cardiac surgery improves diagnostic accuracy of the pulmonary infection score in acute respiratory failure: A prospective observational study BACKGROUND Postoperative pneumonia is a frequent complication after cardiac surgery, and its diagnosis is difficult. Little is known about the diagnostic accuracy of lung ultrasound (LUS) in the detection of pneumonia in cardiac surgical patients. The substitution of chest radiography by colour Doppler LUS (LUS-sCPIS) in the simplified clinical pulmonary infection score (sCPIS) could improve the diagnosis of pneumonia following cardiac surgery. OBJECTIVE The aim of this study was to compare the diagnostic accuracy of LUS-sCPIS and of sCPIS alone in the detection of postoperative pneumonia after cardiac surgery. DESIGN A prospective study of diagnostic accuracy. SETTING A Surgical Intensive Care Unit of a French University Hospital. PATIENTS Fifty-one patients with acute respiratory failure within 72 h after cardiac surgery were enrolled between January and May 2015. MAIN OUTCOME MEASURE The two index tests, LUS-sCPIS and sCPIS, were calculated for all patients at the onset of acute respiratory failure. The reference standard for the diagnosis of pneumonia was based on the consensus of three physicians, blind to the sCPIS and LUS-sCPIS data, based on a posthoc review of all the clinical, radiological and microbiological evidence. The diagnostic accuracy of LUS-sCPIS was compared with that of sCPIS in the detection of postoperative pneumonia. RESULTS Pneumonia was diagnosed in 26 out of 51 patients. The LUS-sCPIS detected the presence of pneumonia with a sensitivity of 92% (95% CI 0.85 to 0.99) and a specificity of 68% (95% CI 0.55 to 0.81). The sCPIS detected the presence of pneumonia with a sensitivity of 35% (95% CI 0.22 to 0.48) and a specificity of 84% (95% CI 0.74 to 0.94). The area under the curve (AUC) of LUS-sCPIS at 0.80 (95% CI 0.69 to 0.91) was higher than the AUC of sCPIS at 0.59 (95% CI 0.47 to 0.71; P = 0.0008). CONCLUSION Compared with sCPIS, LUS-sCPIS improved diagnostic accuracy in the detection of postoperative pneumonia in patients with acute respiratory failure after cardiac surgery. It could be a useful bedside tool to guide pneumonia management. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03279887. https://clinicaltrials.gov/ct2/show/NCT03279887?term=bougl%C3%A9&rank=4 Correspondence to Adrien Bouglé, MD, PhD, Département d'Anesthésie et de Réanimation, Réanimation de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital Universitaire La Pitié-Salpêtrière, 47–83 boulevard de l'Hôpital, Paris 75013, France; e-mail: adrien.bougle@aphp.fr Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Reintubation in the ICU following cardiac surgery: is it more difficult than first-time intubation in the operating room?: A prospective, observational study BACKGROUND After cardiac surgery, a patient's trachea is usually extubated; however, 2 to 13% of cardiac surgery patients require reintubation in the ICU. OBJECTIVE The objective of this study was to compare the initial intubation in the cardiac operating room with reintubation (if required) in the ICU following cardiac surgery. DESIGN A prospective, observational study. SETTING Department of Anesthesiology and Intensive Care Medicine, Clinical Hospital of Santiago, Spain. PATIENTS With approval of the local ethics committee, over a 44-month period, we prospectively enrolled all cardiac surgical patients who were intubated in the operating room using direct laryngoscopy, and who required reintubation later in the ICU. MAIN OUTCOME MEASURES The primary endpoint was to compare first-time success rates for intubation in the operating room and ICU. Secondary endpoints were to compare the technical difficulties of intubation (modified Cormack–Lehane glottic view, operator-reported difficulty of intubation, need for support devices for direct laryngoscopy) and the incidence of complications. RESULTS A total of 122 cardiac surgical patients required reintubation in the ICU. Reintubation was associated with a lower first-time success rate than in the operating room (88.5 vs. 97.6%, P = 0.0048). Reintubation in the ICU was associated with a higher incidence of Cormack–Lehane grades IIb, III or IV views (34.5 vs. 10.7%, P < 0.0001), a higher incidence of moderate or difficult intubation (17.2 vs. 6.5%, P = 0.0001) and a greater need for additional support during direct laryngoscopy (20.5 vs. 10.7%, P = 0.005). Complications were more common during reintubations in the ICU (39.3 vs. 5.7%, P < 0.0001). CONCLUSION Compared with intubations in the operating room, reintubation of cardiac surgical patients in the ICU was associated with more technical difficulties and a higher incidence of complications. CLINICAL TRIAL NUMBER Ethics committee of Galicia number 2015-012. Correspondence to Dr Manuel Taboada, Department of Anesthesiology and Intensive Care Medicine, Servicio de Anestesiología y Reanimación del Hospital Clínico Universitario de Santiago de Compostela, Choupana sn, CP:15706 Santiago de Compostela, A Coruña, España Tel: +00 34 678195618; e-mail: manutabo@yahoo.es © 2019 European Society of Anaesthesiology

Propofol intravenous anaesthesia with desflurane compared with desflurane alone on postoperative liver function after living-donor liver transplantation: A randomised controlled trial BACKGROUND Propofol is an anaesthetic that resembles α-tocopherol and it has been suggested that it protects against ischaemia-reperfusion injury in liver transplantation. Living-donor liver transplantation (LDLT) presents an opportunity to test this hypothesis in both donors and recipients. OBJECTIVES We compared clinical outcomes after LDLT following anaesthesia with propofol and desflurane against desflurane alone. DESIGN A prospective, randomised, parallel study. SETTING Single-centre trial, study period June 2014 and May 2017. PATIENTS Sixty-two pairs of adult donors and recipients who underwent LDLT. INTERVENTION Patients were randomised to receive either desflurane balanced anaesthesia or propofol total intravenous anaesthesia combined with desflurane anaesthesia. MAIN OUTCOME MEASURES The primary outcome was peak liver transaminase levels during the first 7 days after surgery. Liver function was assessed at 10 different time-points (before surgery, 1 h after reperfusion, upon arrival in the ICU, and daily until postoperative day 7). Creatinine was measured to evaluate the incidence of acute kidney injury. TNF-α, IL-1β, IL-6 and TGF-β1 were assessed in 31 donors after induction, at hepatectomy and at the end of surgery and in 52 recipients after induction, and 1, 3 and 24 h after reperfusion. RESULTS Peak liver transaminase levels were not significantly different between the two groups. Liver function tests and creatinine were also similar between groups at all time-points. There was no difference in the incidence of postoperative complications, including acute kidney injury. With the exception of higher TNF-α in donors of the Propofol group at hepatectomy (0.60 ± 0.29 vs. 1.03 ± 0.53, P = 0.01) cytokine results were comparable between the two groups. CONCLUSION Despite the simultaneous administration of propofol infusion in both donors and recipients, no improvement in laboratory or surgical outcome was observed after LDLT compared with patients who received desflurane anaesthesia alone. TRIAL REGISTRATION NCT02504138 at clinicaltrials.gov. Correspondence to Young C. Yoo, Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea Tel: +82 2 2228 2420; fax: +82 2 2227 7897; e-mail: seaoyster@yuhs.ac © 2019 European Society of Anaesthesiology

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