Anaesthesia & Intensive Care

Self-assessment Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Viyayanand Nadella

Neurological and humoral control of blood pressure Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Soumitra K. Ghosh, Jaideep J. Pandit Abstract There is a relationship between arterial blood pressure, cardiac output and vascular resistance described mathematically, that helps us to understand short-term control of blood pressure in terms of a hydraulic system. Arterial baroreceptors are specialized sensors which mediate a rapid response to sudden changes in pressure through interaction with the autonomic nervous system. This in turn influences heart rate, inotropic state and vascular tone, altering distribution of blood between arterial and venous systems, thus compensating for acute changes in total blood volume. Total blood volume is controlled predominantly by the kidney, with the renin–angiotensin–aldosterone system acting as both the 'sensor' of blood pressure/volume (via renin release in the juxtaglomerular apparatus) and the 'effector' of blood pressure/volume (via aldosterone secretion by the adrenal cortex). Overall control is shared; the baroreceptors being responsible for mediating short-term changes, and renal mechanisms determining the long-term control of blood pressure. These systems have to be adaptable in order to deal with physiological variation in the delivery of blood to tissues from rest to exercise, and with the large shifts in blood volume seen in acute haemorrhage. Pathophysiological changes in these systems lead to maladaptive responses, with systemic hypertension the most commonly seen.

Applied cardiovascular physiology Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Carla Gould, Jon Hopper Abstract Maintaining an equilibrium between oxygen supply and demand is a principal function of the cardiovascular system. In times of altered metabolic demand mechanisms exist to maintain the balance between supply and demand. Exercise, haemorrhage and pregnancy all lead to changes in oxygen demand and subsequently modification of cardiac output. During isotonic exercise, metabolic demands of muscle are greatly increased. Sympathetic stimulation and inhibition of the parasympathetic system lead to increases in heart rate and venous return, increasing cardiac output. This allows a proportional increase in blood flow to the exercising muscle. Cardiac output increases throughout pregnancy. In the first and second trimesters this rise is mainly due to an increase in stroke volume, however during the later stages of pregnancy stroke volume reaches a plateau and further increase in cardiac output is mediated by a rising heart rate. In contrast, during haemorrhage, decreased venous return leads to a reduction in cardiac output, with a baroreceptor response due to the drop in arterial blood pressure. The tachycardia and vasoconstriction which follows are compensatory mechanisms in an attempt to preserve blood pressure. The Valsalva manoeuvre illustrates several aspects of reflex control of the cardiovascular system and allows non-invasive assessment and quantification of control mechanisms. Changes in stroke volume during the respiratory cycle can be used to predict fluid responsiveness and can be measured as pulse pressure variation or stroke volume variation.

Anaesthesia for carotid surgery Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Michael Stallard, Indran Raju Abstract Carotid endarterectomy (CEA) is a surgical procedure to prevent strokes in patients with atheromatous disease at the carotid bifurcation. The effectiveness of CEA has been established in large clinical trials. Patients should have surgery performed within 2 weeks from the onset of symptoms. This time frame presents challenges to the anaesthetist and surgeon in terms of risk stratification and optimization of patients. Optimization includes blood pressure control and use of antiplatelet and lipid-lowering therapy. CEA can be carried out under general anaesthesia or regional anaesthesia with the advantages and disadvantages of both techniques discussed. Understanding surgical technique and the implications for anaesthesia is important, specifically the use of carotid shunting, eversion technique and patch angioplasty. Cerebral perfusion monitoring can be used during CEA to reduce neurological morbidity and mortality. The gold standard for monitoring remains an awake patient where sensory, motor and higher mental functions can be assessed continuously. Intraoperative and postoperative management may involve haemodynamic and neurological complications such as stroke, cerebral hyperperfusion syndrome, heart failure and myocardial infarction. Compromise to the airway can occur as a result of oedema or haematoma and the latter may require exploration in theatre.

Anaesthesia for the ruptured aortic aneurysm Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Matthew Cheesman, Andrew Maund Abstract The perioperative management of ruptured abdominal aortic aneurysms (RAAA) remains a core anaesthetic competency. Changes such as service centralization, aneurysm screening and the developing role of emergency endovascular aneurysm repair (EVAR) are altering the demands upon anaesthetists. Whereas previously on-site general anaesthesia for resuscitative open aneurysm repair (OAR) was standard, now transfer, choice of surgical technique and options for anaesthetic management may need to be considered. We present the key components of emergency anaesthesia for both OAR and EVAR and describe clinical dilemmas arising at preoperative and intraoperative stages.

Anaesthesia for open abdominal aortic surgery Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Alastair Duncan, Adam Pichel Abstract The prevalence of abdominal aortic aneurysm (AAA) and the number of patients undergoing aneurysm repair is increasing. The UK has worked tirelessly to reduce its operative mortality rates for elective open AAA repair with the introduction of a quality improvement programme. Reducing death from ruptured aortic aneurysm has been the focus of the national screening programme. Despite the increased prevalence of disease and intervention, the popularity of open repair has diminished since the advent of endovascular repair (EVAR). The short-term benefits of EVAR when compared to open repair are well described; however, the long-term survival benefits, freedom form re-intervention and cost effectiveness of EVAR are not proven. The choice of technique for emergency AAA repair is contentious, with the more traditional approach of open repair being rapidly overtaken by endovascular options. In this article we provide an overview of the evidence supporting the different treatment options, outline current approaches to risk stratification, describe the key physiological changes that occur during open repair and describe an overview of the approach to perioperative management.

Postoperative care and analgesia in vascular surgery Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Shaun McMahon, Rachael L. Bird Abstract Patients undergoing major vascular surgery are high risk for myocardial infarction, renal failure, respiratory complications and death. Invasive procedures confer greater risk of complication, with patients undergoing open aortic surgery being at highest risk. Endovascular procedures are less invasive, yet not devoid of potentially serious complications. Reduction of myocardial oxygen demand is key: stabilizing cardiovascular parameters, maintaining normothermia, adequate volume resuscitation and effective analgesia. Continuation of preoperative risk-reduction strategies including aspirin, beta-blockers and statin therapies are critical, and should be continued in the postoperative period. Maintaining a high index of suspicion for procedure-specific complications is essential in order to reduce morbidity and mortality in these patients.

Anaesthesia for vascular surgery on the extremities Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Richard J. Telford Abstract Peripheral arterial surgery is challenging, operations are frequently long and associated with insidious blood loss. Because of the high incidence of comorbidities these patients are a high-risk group with a high incidence of morbidity and mortality. They key to successful outcome is meticulous attention to detail by all those professions involved in their care.

Anaesthesia for endovascular aneurysm repair Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): John Barrett, Sian Jones Abstract A patient with an abdominal aortic aneurysm can have surgical management through either an open or endovascular approach. The use of an endovascular approach has benefits for the patient by being a less invasive approach with initially lower mortality and morbidity and lower lengths of hospital stay, although longer term outcomes match open techniques. The endovascular technique requires more specialist equipment, including stents and imaging equipment. In the UK they are usually performed in specialist hospitals with teams of interventional radiologists, vascular surgeons and anaesthetists working together. Patients presenting for endovascular repair of their abdominal aortic aneurysm can present the anaesthetist with range of complex comorbidities which require specific management and optimization pre-operatively. The intraoperative management of the patient can vary, depending on patient, surgical and anaesthetic factors, from local anaesthetic, regional techniques or general anaesthesia. The postoperative complications are generally minimal, but the patients require lifelong follow up, making the procedure more expensive than an open procedure.

Risk modification and preoperative optimization of vascular patients Publication date: May 2019 Source: Anaesthesia & Intensive Care Medicine, Volume 20, Issue 5 Author(s): Ben A. Goodman, Adam Pichel, Gerard R. Danjoux Abstract Major vascular surgery is associated with a high risk of morbidity and mortality. Targeted optimization of organ systems most likely to suffer morbidity should be made prior to elective surgery. Risk modification can reduce both perioperative and long-term complications. This article summarizes currently accepted best practice for risk modification and preoperative optimization prior to vascular surgery.

Acupuncture and Meridians

Complete Recovery following Electroacupuncture Therapy in Refractory Unilateral Sensorineural Hearing Loss Publication date: Available online 26 April 2019 Source: Journal of Acupuncture and Meridian Studies Author(s): Warangkana Arpornchayanon, Supanimit Teekachunhatean Abstract Role of electroacupucture (EA) in refractory unilateral sensorineural hearing loss (SNHL) remains unclear but might be promising for the Meniere's disease (MD). Two cases of unilateral SNHL who were unresponsive to conventional treatment of sudden SNHL showed complete recovery after receiving EA therapy. The first case was a 46-year-old female who received EA in the seventh month after the acute onset of sudden right hearing loss and tinnitus. She had mild-to-moderate degree of sensorineural hearing loss at high frequencies in the right ear with episodic vertigo. The second was a 55-year-old female who received EA in the sixth year after developing sudden SNHL in the right ear. Before the EA began, her pure tone average (PTA) of the affected ear was 45 dB and the phonetically balanced (PB)'s score was 88%. The regimen for both patients included 12 sessions of EA over four weeks at the main acupoints (SI 19, TE 21, TE 18, TE 17, and TE 3) on the affected ear and the bilateral adjuvant acupoints (LI 4, CV 6, CV 4, KI 3, and LIV 3). Both patients regained their normal hearing thresholds three weeks following the first EA. No adverse events were observed. Hence, EA may be a useful additional therapy in unilateral SNHL, even at the late phase when other treatments have failed because the possibility of MD cannot be excluded.

Canine and Feline Patients Referred Exclusively for Acupuncture and Herbs: A Two Year Retrospective Analysis Publication date: Available online 24 April 2019 Source: Journal of Acupuncture and Meridian Studies Author(s): Justin Shmalberg, Huisheng Xie, Mushtaq A. Memon Abstract Acupuncture and the administration of herbal supplements are increasingly utilized in veterinary practice, but no retrospective studies have examined patient characteristics and treatment interventions in a population of dogs and cats presenting exclusively for such therapies. This two-year retrospective analysis of 161 referrals to an integrative medicine service at an academic teaching hospital found that dogs were more frequently treated than cats (91.9% vs. 8.1%, respectively), and that small animal patients most frequently were presented for musculoskeletal (26.7%), neurologic (16.8%), oncologic (14.9%), and dermatologic (10.6%) conditions. Cats were older than treated dogs (12.7±3.7 vs. 9.5±4.3 years) and more likely to be treated for oncologic complaints (odds ratio = 5.6). Patients received acupuncture (95.4%), herbal supplements (76.4%), acupuncture with percutaneous electrical nerve stimulation (electroacupuncture, 26.1%), and/or cyanocobalamin injections in acupuncture points (aqua-acupuncture, 23.6%). Some differences were detected between treatment groups. This retrospective analysis provides a foundation for designing future prospective studies using acupuncture and herbs in dogs and cats.

Effects Of Scalp Acupuncture On Functional Deficits Induced By Early Sensorimotor Restriction Publication date: Available online 24 April 2019 Source: Journal of Acupuncture and Meridian Studies Author(s): Angela Kemel Zanella, Jessié Martins Gutierres, Felipe Stigger Abstract The aim of this study was to investigate the effects of scalp acupuncture and electrostimulation, combined or not, in a disuse model consisted of early sensorimotor restriction in rats. Male Wistar pups received sensorimotor restriction from the second postnatal day (P2) until P28. Animals were divided in 5 different groups (n=6): control (CT), sensorimotor restricted (SR), acupuncture (AC), electrostimulation (EL) and electro-acupuncture (AC+EL). Experimental animals received sham, acupuncture or electrical stimulation, combined or not, of two scalp regions for seven days (P29-P35). Previously to treatment period (P29) and after treatment (P36) animals were evaluated with the narrow suspended bar, horizontal ladder and stride length tests. SR animals had worse performance in the narrow suspended and horizontal ladder tasks compared to SR animals at P29 (p≤0.005). Significant improvements were observed in both tasks in AC, EL and EL+AC groups comparing P29 and P36 (p<0.001). Also, at P35 all treated animals performed significantly better motor tasks compared to SR group (p<0.05). There was no difference between treated groups. Finally, acupuncture and electrical stimulation, combined or not, have beneficial effect on motor performance following early developmental disuse.

Wet Cupping; Traditional Hijamah Technique versus Asian Cupping Technique in Chronic Low Back Pain Patients: Pilot Randomized Clinical Trial Publication date: Available online 24 April 2019 Source: Journal of Acupuncture and Meridian Studies Author(s): Sulaiman M. Al-Eidi, Ashry Gad Mohamed, Raid A. Abutalib, Abdullah M. AlBedah, Mohamed K.M. Khalil Abstract Background Low back pain is a common complaint worldwide. Wet cupping (AlHijamah) therapy, which is one of the common traditional therapies in Saudi Arabia, Asia, and some European countries, is usually used to relieve low back pain. However, the majority of high-quality wet cupping trials were conducted in Asia and Europe, where they use a different cupping technique compared to our local wet cupping technique in Saudi Arabia. Objectives To evaluate the feasibility of comparing the effect of the traditional Hijamah and the Asian wet cupping techniques in the management of Chronic Low Back Pain patients. Design Randomized clinical trial comparing traditional versus Asian wet cupping techniques in CLBP; Setting Outpatient clinics in two secondary care hospitals in Saudi Arabia. Patients Seventy eligible participants with CLBP for at least three months were randomly allocated to either Traditional cupping group (34) or the Asian cupping group (36). Intervention Participants were randomized to receive one session of wet cupping using either - Asian technique or Traditional Hijamah technique. Cupping was done at four sites of the bilateral Bladder Meridian (BL 23, BL24, and BL25). Outcome measures The Numeric Rating Scale (NRS), Present Pain Intensity (PPI), and Oswestry Disability Questionnaire (ODQ) scores were measured immediately after intervention, seven days, and 14 days after. Results In both groups, there was a significant decrease in NRS, PPI, and ODS, immediately after intervention and at seven days, and 14 days after intervention. However, there was no significant difference between the two groups across all the outcome measures up to 14 days after intervention. Conclusions The study did not show a superiority of one technique compared to the other. Longer follow-up periods and more than one cupping session may be needed to evaluate the difference, if any, between both techniques. Trial Registration NCT02012205.

Transcutaneous electrical stimulation of PC5 and PC6 acupoints modulates autonomic balance in heart transplant patients: a pilot study Publication date: Available online 23 April 2019 Source: Journal of Acupuncture and Meridian Studies Author(s): Beatriz Robert Moreira, Alice Pereira Duque, Carole Sant'Ana Massolar, Rodrigo de Lima Pimentel, Mauro Felippe Felix Mediano, Tereza Cristina Fellipe Guimarães, Luiz Fernando Rodrigues Junior Abstract The increased resting heart rate (HR) in heart transplant patients is associated with enhanced metabolic demand, the potential for fatigue, and lower quality of life. In the present study, we hypothesized that transcutaneous electrical acupoint stimulation (TEAS) could modulate autonomic balance and reduce resting HR in these patients. A single-arm clinical trial was conducted with patients aged > 18 years, at ambulatorial accompaniment after heart transplantation, were submitted to a single TEAS (40 minutes at PC5 and PC6 acupoints). The arterial blood pressure and RR interval were recorded from 20 minutes before to 20 minutes after TEAS. The RR intervals were used to calculate heart rate variability (HRV) and sympathovagal index. Linear mixed models were used for comparing variables before, during and after TEAS. The significance level was set as P < 0.05. TEAS acutely improved HRV in transplant patients and enhanced the sympathovagal index during its application. Significant increases in systolic, diastolic blood pressure and mean arterial pressure, were observed at recovery, such as a slight, but significant, decrease in heart rate. In conclusion, TEAS at PC5 and PC6 acutely modulates HRV and hemodynamics in transplant patients.

Concurrent Effects of Dry Needling and Electrical Stimulation in the Management of Upper Extremity Hemiparesis Publication date: Available online 23 April 2019 Source: Journal of Acupuncture and Meridian Studies Author(s): Maryam Selk Ghaffari, Ardalan shariat, Roshanak Honarpishe, Azadeh Hakakzadeh, Joshua A. Cleland, Sepehr Haghighi, Tohid Seif-Barghi Abstract Stroke is one of leading causes of disability in western countries. A variety of rehabilitation programs for the treatment of patients post stroke have been proposed. We describe the outcomes of a 49-year-old female patient with 5-year history of right upper extremity hemiparesis post stroke. Physical examination revealed a right wrist extensor strength grade of 1 according to the Medical Research Council Manual Muscle Testing (MMT) scale, stage 4 according to the Brunnstrom hand functional recovery and grade 1 in finger flexor and in wrist flexor according to the Modified Modified Ashworth Scale (MMAS) system of muscle spasticity. Magnetic Resonance Imaging taken immediately after the stroke was indicative of an abnormal signal in left paraventricle and lentiform nucleus. After receiving a single session of dry needling and electrical stimulation, the patient had significant improvement including a strength grade of 3 for the right wrist extensor muscles, stage 6 according to Brunnstrom hand functional recovery and a grade 0 in finger flexor and in wrist flexor according to MMAS system of muscle spasticity. This case report found that dry needling combined with electrical stimulation may be an effective in hand function recovery, wrist extensor muscles strength and decreased wrist and finger spasticity.

Accuracy and Precision in Acupuncture Point Location: A Critical Systematic Review Publication date: April 2019 Source: Journal of Acupuncture and Meridian Studies, Volume 12, Issue 2 Author(s): Debra R. Godson, Jonathan L. Wardle Abstract A number of studies have examined the accuracy and precision of acupuncture point location across various point location methods. Accuracy of point location is essential for safe, efficacious and reliable treatments and valid reproducible research outcomes. This review aims to identify, summarize, compare and critically appraise available empirical studies relating to the accuracy and precision of acupuncture point location. A comprehensive search of five electronic databases, World Journal of Traditional Chinese Medicine and Google scholar was performed for studies investigating accuracy and precision in acupuncture point location. 771 studies were screened of which 14 studies were identified, including 9 studies that investigated the localization of acupoints and 5 studies that examined the cun measurement system. Considerable variation in localization of acupoints was reported among qualified medical acupuncturists. Variation in point location among qualified non-medical acupuncturists is unknown due to lack of any identified study. The directional method was found to be significantly inaccurate and imprecise in all studies that evaluated the method. Suitability of other methods for clinical and research purposes and influencing factors such as education, training and experience were identified as topics for future studies.

Acupuncture for the Treatment of Cardiovascular Diseases: A Systematic Review Publication date: April 2019 Source: Journal of Acupuncture and Meridian Studies, Volume 12, Issue 2 Author(s): Rodrigo de Lima Pimentel, Alice P. Duque, Beatriz R. Moreira, Luiz F. Rodrigues Abstract Acupuncture, for the westerns countries, is an innovative and low-cost therapy for treatment and prevention of cardiovascular diseases (CVDs). However, most of its effects and mechanisms are poorly understood. Thus, the objective of this work was to systematically review the literature regarding the clinical effects of acupuncture for the treatment and prevention of CVDs. A search for papers published in English or Portuguese in the past 20 years was conducted at PubMed, SciELO, and PEDro databases. Clinical trials conducted on the effects of acupuncture were included in this review. Two reviewers extracted the data independently from the remaining 17 articles after screening. The most used acupoint was PC6 (10 studies, 64.7%), followed by ST36 (6 studies, 35.3%) and auricular acupoints (4 studies, 23.5%). Among the clinical applications, hypertension was the most studied CVD, with acupuncture being the most reported method among the studies (70.6%). Only three articles reported no benefit in the treatment of CVDs for the methodology used. We conclude that although several studies indicated an improvement in the response of the cardiovascular system in CVDs by acupuncture, electroacupuncture, or electrostimulation treatment, the heterogeneity of the studies does not allow a standardization of its application for each specific disease, making further studies necessary for its use to become a reality.

Editorial Board Publication date: April 2019 Source: Journal of Acupuncture and Meridian Studies, Volume 12, Issue 2 Author(s):

The Effect of Manual Acupressure (Point BL32) on Pain Associated with Intramuscular Injections of Magnesium Sulfate Publication date: April 2019 Source: Journal of Acupuncture and Meridian Studies, Volume 12, Issue 2 Author(s): Seyed S. Najafi, Setareh Nazaribin, Marzieh Momennasab, Amin Kordi Yoosefinejad Abstract The aim of this study was determining the effect of acupressure on the severity of pain associated with intramuscular injections of magnesium sulfate administered by the Z-track technique in patients with eclampsia and preeclampsia. Forty-eight patients participated in this single-group clinical trial, which was conducted in three stages. For each patient, three intramuscular injections were administered by the Z-track technique. The first injection was administered by the conventional method. The second injection at a sham control point and the third injection using acupressure (BL32) were administered. Pain severity was measured on a visual analogue scale. The mean pain intensity was 7.22 in the first, 4.75 in the second and 1.94 in the third injections (p < 0.001). The results of the study showed that acupressure at the BL32 point before intramuscular injection of magnesium sulfate significantly reduced the injection-related pain.

Journal of Dr. NTR University of Health Sciences

Study of outcome of management of MDR-TB cases under programmatic condition in India Ajay Agarwalla, Somnath Bhattacharya, Atin Dey, Saurav Kar, Arunabha Datta Chaudhuri Journal of Dr. NTR University of Health Sciences 2019 8(1):1-4 Background: Multi-drug resistant tuberculosis is a grave challenge for tuberculosis control program in India. These patients are treated with standardized 2nd line antitubercular drugs for a period of at least 24 months and are followed up by serial sputum cultures under RNTCP. Aims: This study aims to analyze various outcomes of treatment of MDR-TB patients under DOTS-Plus program and impact of different parameters over the outcome. Materials and Methods: In this retrospective study treatment outcome all the MDR-TB patients who have initiated treatment from concerned DRTB centre over a period of six months, have been taken for analysis, after 30–36 months of starting the therapy. Outcomes are categorized as cured, treatment completed, treatment default, treatment failure, and death as per program guideline. Outcome of different group of patients are compared also. Results: Out of total 71 patients 54 resides in rural area and 52 have low BMI (<18.5). Total 27 (38%) patients are successfully treated. Treatment failure observed in 11 (16%). 20 (28%) patients defaulted. Rural patients have lower success rate (33%) and high default rate (30%). Low BMI patients have poor success (29%). Conclusion: The present study finds a low success rate in comparison to WHO reports from India. Default rate is also found to be high. Majority of patients are from rural area and they have higher default rate compared to urban patients. Patients with low BMI have lower success rate and these patients constitutes about three-fourth of total patients. But as the total number of patients is very small, the significance of this observation cannot be ascertained.

Fetal transcerebellar diameter to abdominal circumference ratio (TCD/AC) and to femur length ratio (TCD/FL) in the assessment of normal fetal growth Karumanchi Ashok Hussain, Silpa Kadiyala, Amancharla Yadagiri Lakshmi, Manchala Hindumathi Journal of Dr. NTR University of Health Sciences 2019 8(1):5-10 Context: Intrauterine growth retardation (IUGR) is a major risk factor for perinatal mortality and morbidity, and its early detection is useful in deciding frequency of antenatal surveillance, optimal delivery timing, and early neonatal management to avoid perinatal mortality and morbidity. Most of the parameters for detection of IUGR are gestational age dependent. Transcerebellar diameter to abdominal circumference ratio (TCD/AC) is a gestational age independent parameter. IUGR due to uteroplacental insufficiency can present as isolated femur length reduction. So, transcerebellar diameter to femur length ratio (TCD/FL) can be useful in early detection of IUGR. Aims: To evaluate the accuracy of TCD/AC and utility of TCD/FL in normal pregnancy at varying periods of gestation and to derive a cut-off value for assessment of fetal growth. Materials and Methods: In this prospective study, 200 patients with cumulative ultrasound age (CUA) between 14-40 weeks. Routine ultrasound parameters and transcerebellar diameter were measured. TCD/AC and TCD/FL was calculated in all patients and for individual subgroups formed according to CUA. Statistical Analysis: Mean and standard deviation, 3rd, 50th and 97th percentile for TCD/AC and TCD/FL was determined for all patients to determine age specific cut off values. Relationship between continuous variables is studied using correlation and simple regression. Results: In our study, TCD with AC and FL show strong correlation throughout pregnancy. TCD/AC dispersed normally with mean value of 14.013 and SD of 0.738 and cut off value is 15.49. TCD/FL is dispersed normally throughout pregnancy with mean value 64.592 and SD of 3.998. TCD/AC, TCD/FL in subgroups also shows similar mean and SD as compared to entire study population. Conclusion: A cut off value of mean +/- SD (15.49), (72.588) for TCD/AC and TCD/FL could be used as a growth parameter for detection and determine the severity of IUGR.

Application of the Milan system of reporting salivary cytopathology – A retrospective cytohistological correlation study Ramya Katta, Devi Padmavathi Chaganti Journal of Dr. NTR University of Health Sciences 2019 8(1):11-17 Context: Fine needle aspiration cytology for salivary gland lesions has shown to be adequately sensitive and specific for diagnosing and treating salivary gland pathologies. The Milan System for Reporting Salivary Gland Cytopathology was developed and introduced to provide enhanced communication and improved overall care. Aims: The present study was taken up to assess the accuracy (sensitivity, specificity, positive and negative predictive values) and risk of malignancy of various diagnostic categories when the Milan system is applied and particular emphasis has been laid on cases that showed varied cytohistopathological correlation to highlight the analytical intricacies. Settings and Design: The present study is a two-year retrospective descriptive study conducted in a tertiary care hospital, Vijayawada. Methods and Material: Fine needle aspiration smears, relevant clinical details, histopathological slides and final reports were retrieved from the Departmental archives. The FNA results of the present study were re-categorized according to the Milan system and number of false positives, false negatives, true positives and true negatives were assessed in comparison with the final histopathological diagnosis and thus the accuracy and risk of malignancy of each diagnostic category were calculated. Results: The overall cytological diagnostic accuracy for differentiating malignant from benign tumors in the present study is 90%, with a sensitivity of 73.34%, specificity of 95.56%, positive and negative predictive values of 84.62% and 91.49% respectively.In the present study the highest risk of malignancy was seen in Atypia of undetermined significance (category III-100%) according to the Milan system. Conclusions: Use of The Milan System of Reporting salivary gland Cytopathology can increase the overall effectiveness and communication with clinicians and between institutions thus improving the overall patient care.

Serum and gingival crevicular fluid macrophage inflammatory protein-1β (MIP-1β): Their relationship in periodontal health, disease, and after treatment with nonsurgical therapy Ravindra R Nagireddy, Bindu Sighinam, Deepa Anumla, Sravani R Cheppali, Lakshmi S Shellysistla, Madhu B Dandu Subramanyam Journal of Dr. NTR University of Health Sciences 2019 8(1):18-23 Objectives: Earlier studies have revealed high macrophage inflammatory protein-1β (MIP-1β) levels in the gingival crevicular fluid (GCF) and the serum of patients with chronic periodontitis. However, reports correlating effect of non surgical theraphy on levels of GCF and serum MIP-1βlevels are inadequate. Therefore, the present study estimates the GCF and serum MIP-1β levels in periodontal health, disease and after periodontal treatment with non surgical theraphy. Materials and Methods: Periodontal examination and collection of GCF and serum was performed for 60 subjects categorized into four groups with 20 subjects in each group: Group I (healthy); group II (gingivitis), group III (chronic periodontitis). Twelve weeks after scaling and root planing, the GCF and serum were collected from 20 patients of group III, who were considered as group IV. MIP-1β levels were estimated using the enzyme-linked immunosorbent assay. Results: MIP-1β was detected in all samples. However, the levels reduced significantly in group IV (P < 0.05). Mean MIP-1β levels in GCF and serum were the highest in group III (1.404 ng/μL,1.712 ng/μl) and the lowest in group I (0.342 ng/μl,0.465 ng/μl), and those in groups II and IV appeared between those of groups I and III. Conclusions: The GCF and serum MIP-1β levelsincreased proportionally with the progression of periodontal disease (PD) and decreased after treatment. Because MIP-1β levels in the GCF and serum correlated positively with clinical parameters, MIP-1βmay be considered a “novel biomarker” in PD progression. However, controlled longitudinal studies are required to confirm this possibility.

Comparative assessment of effectiveness of Biomin, NovaMin, herbal, and potassium nitrate desensitizing agents in the treatment of hypersensitive teeth: A clinical study Guntakala Vikram Reddy, Jayaprada Reddy Surakanti, Harikumar Vemisetty, Suryasowjanya Doranala, Jayasree Reddy Hanumanpally, Suryakanth Malgikar Journal of Dr. NTR University of Health Sciences 2019 8(1):24-28 Aim and Objectives: To compare the efficacy of four commercially available toothpastes in the treatment of dentinal hypersensitivity (DH). Materials and Methods: In a single-centered clinical trial, a total of 160 subjects were divided equally into four groups: group 1 – a toothpaste containing 5% fluoro calcium sodium phosphosilicate with fused silica (Biomin); group 2 – a toothpaste containing 5% CSPS (NovaMin); group 3 – herbal formulation; and group 4 – a toothpaste containing 5% potassium nitrate. The patient's DH scores for tactile, evaporative stimuli were recorded on a visual analog scale at baseline, 2 weeks, and at the end of 4 weeks. Results: All the four desensitizing toothpastes containing different active agents were effective in relieving DH. However, the Biomin group showed a better clinical response at the end of 4 weeks when compared with others. Conclusion: The Biomin group showed significantly better results compared with either NovaMin, herbal, and potassium nitrate toothpastes in the treatment of dental hypersensitivity symptoms.

Prevalence of dental caries and dental fluorosis among 6-12 years old school children in relation to fluoride concentration in an endemic fluoride belt of Mahabubnagar district, Telangana state, India Srikanth Reddy Kola, Manoj Kumar Mallela, Ravindar Puppala, Balaji Kethenaeni, P Tharasingh, Venumbaka Sivakalyan Reddy Journal of Dr. NTR University of Health Sciences 2019 8(1):29-36 Aim: The aim of the study is to evaluate the prevalence of dental caries and dental fluorosis among the school going children in Mahabubnagar district, and also to assess F- levels in drinking water from different areas of Mahabubnagar district. Materials and Methods: The study was carried out in 2,000 children of age group 6–12 years. The dental caries status was assessed by Decayed/missed filled tooth (DMFT)/deft index using WHO criteria 1997 and dental fluorosis status using Modified Dean's fluorosis index. Alizarin visual method was used to estimate F levels in water. Statistical Analysis: All data entered to an SPSS (18) program (IBM Corporation, Chicago, USA); both descriptive and analytic approaches were used in the data analysis. The correlation of deft with different F- levels using ANOVA test. The P < 0.005 was considered statistically significant. Results: The prevalence of dental caries in primary teeth and permanent dentition was 64.2% and 26.6%, respectively. Indicating that dental caries was more among 7–8 years old children and less in 11–12 years old children (P > 0.005). Dental fluorosis in primary dentition was 15% and 70.3% in the permanent dentition; it was more in 9–10-year-old children and less in 6-year-old children. Conclusion: The dental caries and dental fluorosis were more in Northern, Eastern region of Mahabubnagar district, whereas dental caries and dental fluorosis were less in local villages of Mahabubnagar district. The F- content in Northern, Eastern zone of Mahabubnagar district was about 2 mg/l, whereas in local villages of Mahabubnagar is 1.2 mg/l.

Efficacy of autologous platelet-rich fibrin in osseous regeneration after mandibular third molar surgery: A comparative study K Surekha, Sudhakar Gudipalli, Praveen Peramulla, T Prathima, Y Narendra Kumar, Anil Budumuru Journal of Dr. NTR University of Health Sciences 2019 8(1):37-41 Aims and Objectives: To evaluate the efficacy of soft tissue healing and bone regeneration in mandibular third molar extraction sockets after placement of platelet-rich fibrin (PRF). Patients and Methods: A split-mouth study was carried out in 15 patients requiring extraction of bilateral impacted mandibular third molars. Patients were divided into group I (test group) and II (control group) of 15 sites in each. Results were compared within the parameters of postoperative pain, facial swelling, soft tissue healing and bone density. Radiological assessment of the extraction site was done. Results: This study clearly indicates a definite improvement in the wound healing, decrease in postoperative edema, wound dehiscence, and increase in the bone density, which signifies and highlights the use of PRF certainly as a valid method inducing hard tissue regeneration. Conclusion: The procedure of PRF preparation is simple, cost-effective, and has demonstrated good results.

Dental students persepctive towards a learning environment and in determining the learning barriers P Gayathri, L Gayathri, D Sravya Sai, Vikram Simha Bommireddy, Y Suresh Chand Journal of Dr. NTR University of Health Sciences 2019 8(1):42-47 Background: Dental education is relatively complex, demanding and a unique pedagogical procedure. The purpose of this study was to determine dental student's perception of the learning environment and to determine the learning barriers among dental students in a private college located in Guntur district, Andhra Pradesh. Materials and Methods: The source of the data includes 306 dental under-graduate students, from academic years 1-4. There are divided into two groups i.e. 159 pre-clinical students and 147 clinical students. They were posed with a validated structured questionnaire, which includes 28 closed ended questions along with questions on 3 different domains i.e. administrative, academic and environmental learning barriers. Results: The overall response rate is 100%. At the administrative level, maximum number of students identified that there was poor academic guidance for the students during courses registration given and there are inadequate extra-curricular activities for the students such as conferences, workshops and seminars. At academic level, 20.6% dental students proposed that questions in the exam are depending on memorising rather than understanding and analysing. 12.2% of the clinical students stated that there was lack of appropriate teaching strategies of the lecturers which are acting as learning barriers. As environmental factors, most of the students agree that inadequate number of computers and the unavailability of internet connection, unavailability of entertainment facilities that motivate the learning process and that the laboratories aren't equipped in terms of space and equipment's for training which would affect the learning process. Conclusion: This study has emphasized on the factors which requires improvement with respect to student's perspective. These learning barriers are to be noted by the educational institutions and the required modifications are done in the infrastructure as well as in the curriculum proposed to the students. Better dental education will instill positive reinforcement, social well-being and a better professional and personality development in the dental students which would guide them into their future.

Reconstruction of lost ear lobule Subodh Kumar Arige, Ramesh Pokkula, Avula Krishnaveni Journal of Dr. NTR University of Health Sciences 2019 8(1):48-51 Introduction: An absent ear lobule may be congenital or the result of trauma, infection, etc. Many procedures have been described for reconstruction. Aim: To present our experience with the Zenteno Alanis and the Gavello techniques. Materials and Methods: The lobule was reconstructed in four patients. Reconstruction of the lobule in the first patient was done by Zenteno Alanis technique and in the next three patients, it was done by Gavello's technique. Results: Results were satisfactory with both techniques. Division and inset were needed in Zenteno Alanis technique to correct the bunched skin behind the lobule at the base of the flap. The scar was inferior and visible. In Gavello's technique, the surgery was single-staged and the scar was retroauricular. Conclusions: Zenteno Alanis technique needed “division and inset” and the scar was visible. Gavello's single-staged reconstruction resulted in a scar, which could be concealed.

Prenatal diagnosis of intrauterine fetal goiter a rare case report Joji Reddy Onteddoo, J Abdul Gafoor, I Pratyusha, N Bhavana Journal of Dr. NTR University of Health Sciences 2019 8(1):52-54 The incidence of fetal goiters is rare and can have poor neonatal outcomes due to tracheal and esophageal obstruction. This makes prenatal diagnosis and treatment pertinent. We report a case of a 25-year-old fifth gravida diagnosed with a large solid homogenous bilobed hypervascular mass noted on the anterior of the fetal neck, causing hyperextension of the cervical spine. A Fetal MRI was performed which revealed intermediate to hyper intensity on T2 weighted image, which were consistent with fetal goiter. The fetus was delivered at 38 weeks of gestation, and the intrapartum and postpartum period was uneventful. Postnatal TSH FT3 and FT4 were done which were consistent with hypothyroidism. With appropriate treatment, the size of the thyroid gland was observed to decrease. The neonate was found to be doing well postnatally.

Neurosurgery

Spinal cord stimulation in pregnant patients: Current perspectives of indications, complications, and results in pain control: A systematic review Bruno Camporeze, Renata Simm, Marcos Vinícius Calfat Maldaun, Paulo Henrique Pires de Aguiar Asian Journal of Neurosurgery 2019 14(2):343-355 Spinal cord stimulation (SCS) has been described as a valuable neuromodulator procedure in the management of chronic medically untreated neuropathic pain. Although the use of this technique has been published in many papers, a question still remains regarding its applicability in pregnant patients. The goal of this paper is to discuss the risks, complications, and results as well as the prognosis of SCS in pregnant patients. We performed a systematic review from 1967 to 2018 using the databases MEDLINE, LILACS, SciELO, PubMed, and BIREME, utilizing language as selection criteria. Eighteen studies that met our criteria were found and tabulated. SCS is a reversible and adjustable surgical procedure, which results in patients that demonstrated a significant effect in the reduction of pain intensity in pregnant patients. The etiologies most frequent were complex regional pain and failed back pain syndromes, which together represented 94% of analyzed cases. The technical complications most frequent were lead migration (3%, n = 1). Regarding the risks, the authors did not show significative factors among the categorical variables that can suggest a teratogenicity, while the maternal risks have been associated to the consequences of technical complications due to, among other factors, improvement of abdominal pressure during pregnancy and delivery. Finally, although there are not significative cohorts of pregnant patients, the procedure is still an effective surgical approach of neuropathic pain associated to lower rates of complications and significative improvement in the quality of life of patients during pregnancy.

Diffuse low-grade glioma – Changing concepts in diagnosis and management: A review Rashid Jooma, Muhammad Waqas, Inamullah Khan Asian Journal of Neurosurgery 2019 14(2):356-363 Though diffuse low-grade gliomas (dLGGs) represent only 15% of gliomas, they have been receiving increasing attention in the past decade. Significant advances in knowledge of the natural history and clinical diversity have been documented, and an improved pathological classification of gliomas that integrates histological features with molecular markers has been issued by the WHO. Advances in the radiological assessment of dLGG, particularly new magnetic resonance imaging scanning sequences, allow improved diagnostic and prognostic information. The management paradigms are evolving from “wait and watch” of the past to more active interventional therapy to obviate the risk of malignant transformation. New surgical technologies allow more aggressive surgical resections with a reduction of morbidity. Many reports suggest the association of gross total resection with longer overall survival and progression-free survival in addition to better seizure control. The literature also shows the use of chemotherapeutics and radiation therapy as important adjuncts to surgery. The goals of management have has been increasing survival with increasing stress on quality of life. Our review highlights the recent advances in the molecular diagnosis and management of dLGG with trends toward multidisciplinary and multimodality management of dLGG with an aim to surgically resect the primary disease, followed by chemoradiation in cases of progressive or recurrent disease.

Simulation training methods in neurological surgery Louise Makarem Oliveira, Eberval Gadelha Figueiredo Asian Journal of Neurosurgery 2019 14(2):364-370 Simulation training plays a paramount role in medicine, especially when it comes to mastering surgical skills. By simulating, students gain not only confidence, but expertise, learning to apply theory in a safe environment. As the technological arsenal improved, virtual reality and physical simulators have developed and are now an important part of the Neurosurgery training curriculum. Based on deliberate practice in a controlled space, simulation allows psychomotor skills augment without putting neither patients nor students at risk. When compared to the master-apprentice ongoing model of teaching, simutation becomes even more appealing as it is time-efficient, shortening the learning curve and ultimately leading to error reduction, which is reflected by diminished health care costs in the long run. In this chapter we will discuss the current state of neurosurgery simulation, highlight the potential benefits of this approach, assessing specific training methods and making considerations towards the future of neurosurgical simulation.

The role of decompressive craniectomy in traumatic brain injury: A systematic review and meta-analysis Nida Fatima, Ghaya Al Rumaihi, Ashfaq Shuaib, Maher Saqqur Asian Journal of Neurosurgery 2019 14(2):371-381 The objective is to evaluate the efficacy of early decompressive craniectomy (DC) versus standard medical management ± late DC in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies, and prospective cohort studies on DC in moderate and severe TBI. Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and extended GCOS, and mortality. Data were extracted to Review Manager software. A total of 45 articles and abstracts that met the inclusion criteria were retrieved and analyzed. Ultimately, seven studies were included in our meta-analysis, which revealed that patients who had early DC had no statistically significant likelihood of having a favorable outcome at 6 months than those who had a standard medical care alone or with late DC (OR of favorable clinical outcome at 6 months: 1.00; 95% confidence interval (CI): 0.75–1.34; P = 0.99). The relative risk (RR) of mortality in early DC versus the standard medical care ± late DC at discharge or 6 months is 0.62; 95% CI: 0.40–0.94; P = 0.03. Subgroup analysis based on RR of mortality shows that the rate of mortality is reduced significantly in the early DC group as compared to the late DC. RR of Mortality is 0.43; 95% CI: 0.26–0.71; P = 0.0009. However, good clinical outcome is the same. Early DC saves lives in patients with TBI. However, further clinical trials are required to prove if early DC improve clinical outcome and to define the best early time frame in performing early DC in TBI population.

Hypertonic solutions in traumatic brain injury: A systematic review and meta-analysis Nida Fatima, Ali Ayyad, Ashfaq Shuaib, Maher Saqqur Asian Journal of Neurosurgery 2019 14(2):382-391 This study aims to evaluate the efficacy of hypertonic saline versus crystalloids (normal Saline/lactated Ringers) in improving clinical outcome in patients with traumatic brain injury (TBI). Electronic databases and grey literature (unpublished articles) were searched under different MeSH terms from 1990 to present. Randomized control trials, case–control studies and prospective cohort studies on decompressive craniectomy in TBI (>18-year-old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS), Extended GCOS, and mortality. Data were extracted to Review Manager Software. A total of 115 articles that met the inclusion criteria were retrieved and analyzed. Ultimately, five studies were included in our meta-analysis, which revealed that patients with TBI who had hypertonic saline had no statistically significant likelihood of having a good outcome at discharge or 6 months than those who had crystalloid (odds ratio [OR]: 0.01; 95% confidence interval (CI): 0.03–0.05; P = 0.65). The relative risk (RR) of mortality in hypertonic saline versus the crystalloid at discharge or 6-month is RR: 0.80; 95% CI: 0.64–0.99; P = 0.04. The subgroup analysis showed that the group who had hypertonic solution significantly decreases the number of interventions versus the crystalloid group OR: 0.53; 95% CI: 0.48–0.59; P < 0.00001 and also reduces the length of intensive care unit stay (OR: 0.46; 95% CI: 0.21–1.01; P = 0.05). Hypertonic saline decreases the financial burden, but neither impacts the clinical outcome nor reduces the mortality. However, further clinical trials are required to prove if hypertonic saline has any role in improving the clinical and neurological status of patients with TBI versus the normal saline/lactated Ringers.

Impact of comorbidities on outcome following revision of recurrent single-level lumbar disc prolapse between revision microdiscectomy and posterior lumbar interbody fusion: A single-institutional analysis Chiazor U Onyia, Sajesh K Menon Asian Journal of Neurosurgery 2019 14(2):392-398 Objectives: Reports exist in the literature on the relationship between comorbid conditions and recurrence of lumbar disc herniation. Meanwhile, documented evidence abound on microdiscectomy and posterior lumbar interbody fusion (PLIF) as techniques of managing recurrent disc prolapse. Some surgeons would choose to perform PLIF instead of microdiscectomy for a first time re-herniation, because of the possibility of higher chances of further recurrence as well as increased likelihood of spinal instability following treatment with microdiscectomy. In this study, the authors sought to determine whether PLIF is better than microdiscectomy for first-time recurrent single-level lumbar disc prolapse and to compare the impact of comorbidities on outcome following revision. Patients and Methods: This was retrospective review of surgical treatment of patients with recurrent single-level disc prolapse with either microdiscectomy or PLIF at a tertiary health institution in India. Results: A total of 26 patients were evaluated. There was no statistically significant correlation between the presence of comorbidity and outcome in terms of improvement of pain (P > 0.05 at 95% degree of confidence; Spearman's ρ =0.239). Patients who had PLIF were neither more nor less likely to have a better outcome compared to those who had microdiscectomy, though this finding was not statistically significant (odds ratio = 0.263; P = 0.284). Conclusion: There was no significant relationship between the presence of comorbidity and outcome following revision. Microdiscectomy did not prove to be a better option than PLIF for surgical management of recurrent single-level disc prolapse. A quality randomized controlled study would help to validate these findings.

Endoscopic third ventriculostomy in children with failed ventriculoperitoneal shunt Bijan Heshmati, Zohreh Habibi, Mehdi Golpayegani, Farhad Salari, Mousarreza Anbarlouei, Farideh Nejat Asian Journal of Neurosurgery 2019 14(2):399-402 Context: Endoscopic third ventriculostomy (ETV) is an accepted procedure for the treatment of obstructive hydrocephalus. The role of endoscopic treatment in the management of shunt malfunction was not extensively evaluated. The aim of this study is to evaluate the success rate of ETV in pediatric patients formerly treated by ventriculoperitoneal (V-P) shunt implantation. Materials and Methods: Thirty-three patients with their first shunt failure and obstructive hydrocephalus in brain imaging between 2008 and 2014 were enrolled in this study. Results: The most common causes of hydrocephalus in these patients were aqueductal stenosis and myelomeningocele with or without associated shunt infection. Of these 33 cases, 20 ETV procedures were successful, and 13 cases needed shunt revision after ETV failure. There was no serious complication during ETV procedures. The follow-up period of patients with successful ETV was 6–50 months (mean 18 months). The time interval between ETV and new shunting subsequent to ETV failure was 24.4 days (10–95). Conclusions: ETV can be considered as an alternative treatment paradigm in patients with previous shunt or new shunt failure with an acceptable success rate of 6o%, although long-term follow-up is needed for these patients.

Predictive factors for seizures accompanying intracranial meningiomas Moamen Mohamed Morsy, Waleed Fawzy El-Saadany, Wael Mohamed Moussa, Ahmed Elsayed Sultan Asian Journal of Neurosurgery 2019 14(2):403-409 Objective: Seizures represent a common manifestation of intracranial meningiomas. Their predictive factors before and after excision merit studying. Materials and Methods: Patients having intracranial meningioma were prospectively studied. There were two groups; Group “A” with seizures and Group “B” with no preoperative epilepsy. Results: This study included 40 patients. Their ages ranged from 40 to 60 years old, and female-to-male ratio was 2.3:1 in both groups. In Group A, partial seizures were the most common pattern (60%). Manifestations other than fits included headache in most patients (97.5%), symptoms of increased intracranial pressure were found in 50% in Group A and 20% in Group B patients, peritumoral edema was present in 14 (70%) patients of Group A, compared to 6 (25%) patients of Group “B.” There was a statistically significant relation between peritumoral edema and presentation with fits (P < 0.1). Complication after surgery included nonsurgical hematoma in three patients and contusion in 7 patients. Following surgery for Group “A”, 8 (40%) patients had good seizure control. While, in Group “B” 3 (15%), patients developed new-onset seizures. Good seizure control in 7 (53%) patients with frontal, frontotemporal tumors than in other locations. In addition, better control was obtained in left sided, small tumors, and no peritumoral edema. Postoperative complication was significantly associated with new-onset epilepsy and poor seizure control (P < 0.05). Neither tumor size nor location had a significant relation to either pre or postoperative epilepsy. Conclusion: Predictive factors for epilepsy accompanying intracranial meningioma included males, elderly patients and patients with small lesions, frontal and left-sided locations but were statistically insignificant predictors. Peritumoral edema and postoperative complications are the most significant predictors.

Compound elevated skull fracture presented as a new variety of fracture with inimitable entity: Single institution experience of 10 cases Ashok Kumar, Vivek Kumar Kankane, Gaurav Jaiswal, Pavan Kumar, Tarun Kumar Gupta Asian Journal of Neurosurgery 2019 14(2):410-414 Background: Compound elevated Skull fracture (CESF) is a rare variety of fracture with rare presentation in comparison to other type of skull fracture. The mechanical force being applied is tangential causing high impact over skull as comparison to structure underlying the cranium. Objective: Aims of this study are bring attentiveness and management to deal this rare type of fracture and its outcomes. Materials and Methods: In this study, we demonstrated 10 cases of CESF in adult patients from January 2014 to January 2018 in the Department of Neurosurgery at RNT Medical College and M. B. Hospital, Udaipur, Rajasthan, India. Recorded documents were prospectively studied for age of distribution, sex, mode of injury, mechanism of injury, clinical profile, radiological investigations, neurosurgical management, and outcome asses by Glasgow outcome scale. Results: Totally 10 patients had CESF. Six are males and four are females. Male to female ratio was 3:2. Their age range was 20–45 years. The most common mode of injury was Road traffic accident in 60%. Wound exploration, cleaning, debridement, and reduction of fracture segment was done in eight cases, frontal bone craniotomy with evacuation of pneumocephalus done one case, frontal bone craniotomy, and extradural hematoma evacuation was done in one case. The postoperative course was uneventful, and outcome was good (GOS 5) in 8 (80%) cases. Conclusion: In compound elevated fracture, early recognition and immediate surgical intervention should be done to avoid related morbidity and mortality. Any delay in surgery may lead to a high possibility of wound infection and poor outcome.

Outcome analysis of surgical clipping for incidental internal carotid posterior communicating and anterior choroidal artery aneurysms Ameen Abdul Mohammad, Yamada Yasuhiro, Liew Boon Seng, Niranjana Rajagopal, Kato Yoko Asian Journal of Neurosurgery 2019 14(2):415-421 Introduction: Surgical outcome and ischemic complications of Internal carotid Posterior Communicating (IC PC) and anterior choroidal aneurysms have been questionable due to frequent occlusion of the anterior choroid artery and also due to low incidence of true anterior choroid artery aneurysms. The present series describes the postoperative outcome after clipping of such aneurysms at a single centre. Methods: A retrospective analysis of 73 cases with IC PC and Anterior choroidal aneurysms performed at a Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan from 2014 to 2018 have been studied and emphasis is made on the demography and ischemic complications. Results: A total of 73 patients with IC PC and anterior choroidal aneurysms were studied, out of which 57 patient had a true IC PC aneurysm, 14 patients had aneurysms involving the anterior choroidal artery and only 2 patients had aneurysms which involved both the IC PC and the anterior choroidal arteries. None of the patients had a permanent Anterior Choroidal Artery syndrome, whereas only 2 out of the 73 patients had postoperative complications in the form of transient hemiparesis. Conclusion: Ischemic complications following surgical clipping of IC PC and anterior choroidal aneurysms can be minimised by meticulous micro dissection to identify the anterior choroidal artery thus preserving the patency of the same.

Pharmacy And Bioallied Sciences

A completely polyherbal conditioning and antioxidant shampoo: A phytochemical study and pharmaceutical evaluation Riham O Bakr, Reham I Amer, Marwa A A Fayed, Tamer I M Ragab Journal of Pharmacy And Bioallied Sciences 2019 11(2):105-115 Aim: A recent approach in shampoo research has been to find a natural alternative for synthetic detergents that have deteriorative effects on hair follicles. This study aimed at the formulation of a completely herbal shampoo containing a natural foaming agent, in addition to having conditioning, antioxidant, and antimicrobial effects. Material and Methods: The leaves of Salix babylonica L., Ziziphus spina-christi L. (Willd), and Glycyrrhiza glabra rhizomes were extracted with 70% methanol then quantified for their phenolic and flavonoid contents using colorimetric assays that were qualitatively identified by Ultra-performance liquid chromatography (UPLC) with tandem mass spectrometry (MS-MS). The mineral content was also estimated. The radical scavenging activity was estimated using 1,1-diphenyl-2-Picrylhydrazyl (DPPH) and the half maximal inhibitory concentration (IC50) was determined. Additionally, the antimicrobial activity was tested using agar diffusion assay and compared to vancomycin and ketoconazole. Four formulations, consisting of the different plant extracts and a combination of the extracts, were prepared and evaluated for several physicochemical properties. The best formula was evaluated for its conditioning effects using scanning electron microscope and blind touch tests by asking volunteers for grading the formulations. Results and Discussion: UPLC-MS-MS analysis of S. babylonica and Z. spina-christi allowed tentative identification of 12 phytoconstituents in each. Z. spina-christi showed the highest phenolic content and a high copper, zinc, and manganese content beside the best antioxidant activity, whereas G. glabra had a high potency against Bacillus cereus and Candida albicans. The polyherbal shampoo formulation (F4) was selected as an optimized formulation because of a high foam stability after 4 min, low wetting time (2 s), surface tension reduction, and comparable results for percent solid content. F4 showed good conditioning effect and consumer contentment. Conclusion: The formulated polyherbal shampoo is chemical free, extra-nourishing shampoo with excellent conditioning, cleansing, and antimicrobial effects.

Comparative evaluation of wound healing potential of manuka and acacia honey in diabetic and nondiabetic rats Rupam Gill, Basavaraj Poojar, Laxminarayana K Bairy, Kumar S E Praveen Journal of Pharmacy And Bioallied Sciences 2019 11(2):116-126 Background: Manuka honey has attracted the attention of the scientific community for its antimicrobial and antioxidant properties. The active compounds of manuka honey to which its myeloperoxidase activity inhibition is owed are methyl syringate (MSYR) and leptosin (a novel glycoside of MSYR). The non-peroxide antibacterial activity is attributed to glyoxal, 3-deoxyglucosulose, and methylglyoxal. These properties make it an inexpensive and effective topical treatment in wound management. This study has focused on the evaluation of the effect of manuka honey and acacia honey on wound healing in nondiabetic and streptozotocin-induced diabetic rats. Materials and Methods: This study was conducted on a total of 42 rats (six rats in each group) and respective drug/substance was topically applied once daily on the excision wound for 21 days. Induction of diabetes was carried out in rats in groups IV, V, VI, and VII only. Measurement of wound contraction was carried out on days 3, 6, 9, 12, 15, 18, and 21 after operation. Time taken for the complete epithelization was recorded along with a histopathological examination of the healed wound bed. Results: Topical application of manuka honey achieved ≥80% wound contraction on day 9 after operation in both the nondiabetic and diabetic group. Complete epithelization was achieved 2 days earlier than the normal epithelization time in the manuka group. Histopathological examination showed well-formed keratinized squamous epithelium with normal collagen tissue surrounding hair follicles. Conclusion: This study provides good outcome with respect to wound healing (especially in diabetic condition) when manuka honey was compared to acacia honey and standard treatment.

Vitamin D and elevated serum uric acid as novel predictors and prognostic markers for type 2 diabetes mellitus Abdulbari Bener, Abdulla O A A Al-Hamaq, Mustafa Öztürk, Ihab Tewfik Journal of Pharmacy And Bioallied Sciences 2019 11(2):127-132 Aim: To ascertain the active role of uric acid and vitamin D as potential biomarkers for impaired glucose metabolism among people living with type 2 diabetes mellitus (T2DM) in Turkish community. Subjects and Methods: This study was based on 680 patients with T2DM and 680 healthy subjects aged between 25 and 70 years, who visited the diabetes and endocrinology department of Istanbul Mega Medipol University Teaching Hospital, Istanbul, Turkey, during January 2016 to April 2018. The investigated biochemical indices included lipid profiles (low-density lipoprotein [LDL], high-density lipoprotein, total cholesterol, and triglyceride [TG]), uric acid, blood pressure (BP), serum creatinine, glycosylated hemoglobin (HbA1c), thyroid-stimulating hormone (TSH), postprandial glucose, and any related comorbidities. Results: This study reported significant differences between family history duration of patients with T2DM of ≤5 and >5 years when compared to that of control subjects with respect to body mass index (BMI), smoking habit, sheesha smoking, income, family history of metabolic syndrome, hypertension, coronary heart disease, and nephropathy. Similarly, significant differences were found between patients with T2DM (with family history T2DM duration of less than 5 years and more than 5 years in contrast to healthy subjects’ level of LDL, TG, fasting blood glucose, HbA1c, systolic BP (SBP), bilirubin, albumin, magnesium, potassium, calcium, number of sleeping hours, and TSH. We uncovered the correlation between serum uric acid level with the clinical biochemical indices related to T2DM: serum calcium (r = 0.336), magnesium (r = 0.272), potassium (r = 0.205), HbA1c (r = 0.638), fasting blood glucose (P = 0.486), bilirubin (r = 0.251), albumin (r = 0.285), LDL (r = 0.322), TG (r = 0.434), diastolic BP (DBP) (r = 0.392), SBP (r = 0.344), BMI (r = 0.482), waist circumference (WC) (r = 0.366), age (r = 0.217), number of sleeping hours (r = 0.275), and TSH (r = 0.445). Multivariate stepwise logistic regression showed that variables, such as serum vitamin D, uric acid, TSH, HbA1c, DBP, WC, BMI, and SBP, were considered at higher risk as significant (P < 0.001) predictors for T2DM. Conclusion: The results suggest strong positive correlation between serum uric acid level with BP (SBP and DBP), age, BMI, and WC among patients with T2DM. This study ascertains that an increase in uric acid level may be due to elevated level of HbA1c, metabolic syndrome, diabetes, obesity, and/or hypertension.

Applying Beers Criteria for elderly patients to assess rational drug use at a university hospital in Northern Cyprus Sarah Khamis, Abdikarim Mohamed Abdi, Ali Uzan, Bilgen Basgut Journal of Pharmacy And Bioallied Sciences 2019 11(2):133-141 Background: Several regulations for potentially inappropriate medications (PIMs) have been published specifically for elderly patients to rationalize drug use in such vulnerable communities. Objectives: To determine the proportion and characteristics of PIMs in patients receiving one or more drugs according to Beers Criteria 2015. Materials and Methods: A cross-sectional prospective analysis of 451 inpatients admitted between September 25 and October 25, 2016, was conducted in Near East University Hospital, Northern Cyprus. Data were extracted from the patient medical records using special forms. Results: A total of 119 elderly patients were identified (26.4%) and evaluated, of which 107 were eligible and 12 were excluded. Of the 1039 prescribed medicines, 16.9% were PIMs during hospitalization, whereas 12% were at discharge. The most prevalent PIM group during hospitalization was identified as the “medications to be avoided in older adults” (48.8%), whereas it also formed 52% of medications prescribed at discharge. PIMs of the class “drugs used with caution” formed 19.4% of prescribed medicine during hospitalization and 18.4% on discharge. The prevalence of polypharmacy was 79.4%, mainly identified as unpreventable polypharmacy of elders. Conclusion: A significantly higher prevalence of PIMs was observed in hospitalized patients than those discharged, with high prevalence of polypharmacy. These results necessitate a nationwide assessment, and responsible bodies who adopt strategies should act to reduce or overcome the aforementioned high prevalence in Northern Cyprus.

Antidiabetic activity of ajwain oil in different in vitro models Nilamaideen Noorul Aneesa, Roy Anitha, Sheeja Varghese Journal of Pharmacy And Bioallied Sciences 2019 11(2):142-147 Context: Ajwain oil is an essential oil with thymol as its major constituent which is known for many pharmacological activities.Aims: To evaluate the anti-hyperglycaemic potential of ajwain oil using different in vitro models.Methods and Material: In vitro α-amylase and α-glucosidase inhibitory effect of ajwain oil was carried out by the method of Bernfeld and Shibano et al. 1997 with minor modifications respectively. Cytotoxicity of the ajwain oil was assessed using MTT assay. Glucose uptake potential was assessed in differentiated L6 myotubes using fluorescent tagged 6-NBDG.Results: Ajwain oil showed very good α – amylase inhibitory activity. A maximum inhibition of 88.55 ±0.43 % was achieved at a concentration of 4µL/ml by ajwain oil which was comparable to that of standard acarbose, 90.96 ± 1.81%. The IC50 of the extract was found to be 0.47µL/ml and for acarbose 0.69µL/ml. The maximum in vitro α – glucosidase inhibitory activity was found to be 89 ± 0.72 % and 91.67 ± 1.09% at 4µL/ml for ajwain oil and acarbose. The IC50 of the extract and acarbose were found to be 0.37µL/ml and 0.41µL/ml respectively. Ajwain oil has enhanced glucose uptake in L6 myotubes in a dose dependent manner.Conclusion: The anti-hyperglycaemic activity of the ajwain oil strongly support its ability to decrease sugar level hence it may be further validated for its use as an antidiabetic agent.

Use of phosphate binders in end-stage renal disease: An experience from a secondary care hospital in United Arab Emirates Syed Arman Rabbani, Sathvik B Sridhar, Padma G M Rao, Martin T Kurian, Basset E Essawy Journal of Pharmacy And Bioallied Sciences 2019 11(2):148-154 Objective: Hyperphosphatemia in end-stage renal disease (ESRD) is associated with many serious patient-level consequences including cardiovascular events and mortality. The purpose of this study was to investigate the use of phosphate binders in ESRD patients on maintenance hemodialysis. Materials and Methods: The study was a prospective observational cohort study including adult ESRD patients undergoing hemodialysis at a secondary hospital in United Arab Emirates. Patient characteristics were compared as per type of phosphate binder used. Bivariate and multivariate multinomial logistic regression analyses were carried out to determine variables that were independently associated with use of different phosphate binders. Results: Phosphate binders used at our study site were sevelamer, calcium carbonate, and a combination of sevelamer and calcium carbonate. Bivariate multinomial logistic regression analysis revealed that serum phosphorous (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.04–1.09, P = 0.047; OR: 0.10, 95% CI: 0.03–0.89, P = 0.042), calcium (OR: 0.11, 95% CI: 0.02–0.86, P = 0.041; OR: 0.22, 95% CI: 0.01–0.96, P = 0.012), and calcium–phosphorous product (OR: 0.20, 95% CI: 0.06–0.64, P = 0.008; OR: 0.16, 95% CI: 0.05–0.54, P = 0.003) levels were significantly lower in patients on sevelamer per se as well as in patients on combination therapy, respectively when compared to calcium carbonate per se. Multivariate multinomial logistic regression analysis revealed that in sevelamer and combination groups, cardiovascular diseases (OR: 0.12, 95% CI: 0.02–0.65, P = 0.022; OR: 0.10, 95% CI: 0.01–0.88, P = 0.038) were significantly lesser compared to calcium carbonate group after being adjusted for other variables in the model. Conclusion: We observed that hyperphosphatemia and related events in our study population were better controlled by sevelamer per se and combination therapy than calcium carbonate per se. Further large scale, multicenter studies are required to confirm and establish these findings.

Screening of potential phytocompounds from Euclea crispa (Thunb.) leaves targeting human epidermal growth factor receptor 2 (HER2) signaling pathway Chella Perumal Palanisamy, Anofi Omotayo Tom Ashafa Journal of Pharmacy And Bioallied Sciences 2019 11(2):155-161 Background: Overexpression of human epidermal growth factor receptor 2 (HER2) plays an important role in the development and progression in a variety of cancers and it is a novel therapeutic target for breast cancer and ovarian cancer. Euclea crispa (E. crispa) is a South African medicinal plant in the family Ebenaceae used in the management of different human diseases and disorders. Aims: The aim of this study was to evaluate the potential inhibitors against HER2 from hexane extract of E. crispa leaves. Materials and Methods: Chemical fingerprinting method was used to identify the presence of natural compounds from the extract whereas their inhibitory activities were analyzed by molecular docking analysis against HER2. Absorption, distribution, metabolism, and excretion (ADME) properties also predicted to establish the pharmacokinetics and pharmacodynamics profiles of the selected compounds. Results: The molecular docking analysis expressed that phenyl glucuronide, hydrocortisone acetate, and 6-(4,6-dioxo-1,4,5,6-tetrahydropyrimidin-2-yl-amino)hexanoic acid trifluoroacetate possess good inhibitory activities with good glide score of −6.63, −5.41, and −5.40 and glide energy of −35.03, −42.51, and −31.38 kcal/mol, respectively when compared with standard Food and Drug Administration–approved drug and other compounds. All the screened compounds were within the acceptable and permissible limits of ADME properties. Conclusion: Thus, from this study it can be concluded that, these screened natural compounds from E. crispa leaves may serve as potential inhibitors for HER2 and they might lead to development of new therapeutic agents against cancer and its associated complications.

Relationship between antimicrobial prescribing and antimicrobial resistance among UTI patients at Buraidah Central Hospital, Saudi Arabia Sulaiman I A Alsohaim, Abdulkader A Bawadikji, Ramadan Elkalmi, Mohammed Imad Al-deen M Mahmud, Mohamed Azmi Hassali Journal of Pharmacy And Bioallied Sciences 2019 11(2):162-169 Introduction: Most of the decisions regarding diagnosis and treatment are based on laboratory test results. Urinary tract infections (UTIs) are among the most common infections in humans. The changing antimicrobial sensitivity in UTI requires appropriate antibiotics. Antimicrobial resistance is an emerging problem in the Kingdom of Saudi Arabia where the complete reversal of antimicrobial resistance is difficult due to irrational use of antibiotics. Objectives: This study aimed to determine the most common bacterial agents causing UTI in different seasons among patients who were admitted to Buraidah Central Hospital (BCH), Saudi Arabia. The study also evaluated the link between prescribing and resistance toward antimicrobials. Materials and Methods: A 6-month retrospective study was conducted among adult patients who were admitted to the inpatient department at BCH. A total of 379 files were collected from microbiological laboratory for inpatients. Results: Most UTI-causing bacteria prevailed in the same season. Of 15 bacterial strains, 12 were significantly correlated with 20 (of a total of 40) antibiotics that were used. Most bacteria were gram-negative. Gram-negative bacilli including Escherichia coli, Klebsiella spp., and Pseudomonadaceae and gram-positive Enterococcus faecalis were most frequently causing UTIs. Conclusion: Overall prevalence of antibiotic resistance was negative in bacterial isolates. However, the relationship between antimicrobial prescribing and antimicrobial resistance was significantly negative among UTI patients in BCH, Saudi Arabia.

Prevalence of depression among health sciences students: Findings from a public university in Malaysia Abdul Rahman M Fata Nahas, Ramadan M Elkalmi, Abdulkareem M Al-Shami, Tarek M Elsayed Journal of Pharmacy And Bioallied Sciences 2019 11(2):170-175 Background: High rates of psychological problems including depression among university students have been reported in various studies around the world. The objectives of this study were to explore the prevalence of depressive disorder, as well as the associated sociodemographic factors (gender, origin, school, and year of study) among health sciences students. Materials and Methods: This cross-sectional study was conducted among 425 students from 5 different schools of health sciences at International Islamic University Malaysia, using the Patient Health Questionaire-9 (PHQ-9). Results: With a response rate of 85.9% (n = 365), the results showed a depressive disorder prevalence of 36.4%. The mean PHQ-9 score of the respondents was 8.10 (SD = 4.9), indicating mild depression severity. A statistically significant association was revealed between gender and severity of depression (P = 0.03), as well as between students’ origin and severity of depression (P = 0.02). Conclusion: The findings indicated high prevalence of depression among undergraduate health sciences students. While providing significant information to students’ affairs department, the study findings suggest the necessity to address depressive disorder in health sciences university students in Malaysia. Future research is needed to confirm these results in larger samples.

Wound-healing effect of honey gel and film Febriyenti Febriyenti, Henny Lucida, Almahdy Almahdy, Istianah Alfikriyah, Muhammad Hanif Journal of Pharmacy And Bioallied Sciences 2019 11(2):176-180 Background: Honey has been formulated into gel and film dosage forms for burn wound as previously reported. Aims: In this study, we evaluated the ability of honey gel and film to promote the healing of burns and incision wounds on the skin of Sprague-Dawley female white rats. Materials and Methods: Twenty-four female rats were divided into four groups, which were treatment groups (for honey gel or film), negative control, and positive control (treated with marketed product “B”), respectively. Burn and incision wound were created by the method previously reported with slight modification. Parameters such as the percentage of wound closure and the tensile strength of the incision wound were determined. Results: The experimental results showed that honey film has a greater effectiveness to accelerate the healing for burns and incision wound in comparison to the negative control. Conclusions: Two-way analysis of variance indicates the type of treatment group, and time has a significant effect on the burn wound (P < 0.05). Honey film shows the significant difference (P < 0.05) with other group on the incision wound.