Neurosurgery

Explaining the cerebral aneurysm's shape and timing of rupture – Unlocking the mystique using theoretical physics Ahmed Ansari, Yoko Kato Asian Journal of Neurosurgery 2020 15(4):799-799

Current role of laser interstitial thermal therapy in the treatment of intracranial tumors Farhan A Mirza, Rida Mitha, Muhammad Shahzad Shamim Asian Journal of Neurosurgery 2020 15(4):800-808 Laser interstitial thermal therapy (LITT) is gaining popularity in the treatment of both primary and secondary intracranial tumors. The goal of LITT is to deliver thermal energy in a predictable, controlled, and minimally invasive fashion. It can be particularly valuable in patients with recurrent tumors who, due to previous radiation or surgery, may have a potentially higher risk of wound breakdown or infection with repeat craniotomy. Deep-seated lesions that are often inaccessible through open approaches (thalamus, hypothalamus, mesial basal temporal lobe, brainstem) may also be suitable targets. The experience and data published thus far on this modality is limited but growing. This review highlights the use of LITT as a primary treatment method in a variety of intracranial tumors, as well as its application as an adjunct to established surgical techniques.

Management of mild brain trauma in the elderly: Literature review Federica Marrone, Luca Zavatto, Mario Allevi, Hambra Di Vitantonio, Daniele Francesco Millimaggi, Soheila Raysi Dehcordi, Alessandro Ricci, Graziano Taddei Asian Journal of Neurosurgery 2020 15(4):809-820 Purpose: The world population is aging. As direct consequence, geriatric trauma is increasing both in absolute number and in the proportion of annual admissions causing a challenge for the health-care system worldwide. The aim of this review is to delineate the specific and practice rules for the management of mild brain trauma in the elderly. Methods: Systematic review of the last 15 years literature on mild traumatic brain injury (nTBI) in elderly patients. Results: A total of 68 articles met all eligibility criteria and were selected for the systematic review. We collected 29% high-quality studies and 71% low-quality studies. Conclusion: Clinical advices for a comprehensive management are provided. Current outcome data from mTBIs in the elderly show a condition that cannot be sustained in the future by families, society, and health-care systems. There is a strong need for more research on geriatric mild brain trauma addressed to prevent falls, to reduce the impact of polypharmacy, and to define specific management strategies.

Stent-assisted coiling of unruptured intracranial aneurysms with wide neck Filippos Papadopoulos, Constantine Nikolaos Antonopoulos, George Geroulakos Asian Journal of Neurosurgery 2020 15(4):821-827 Objective: Morbidity and mortality in patients experiencing the rupture of intracranial aneurysm ruptures are high. We conducted a systematic review and meta-analysis to investigate the role of stent-assisted coiling (SAC) for unruptured intracranial aneurysms (UIAs) with wide neck. Materials and Methods: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled proportions with 95% confidence intervals (CIs) of ten outcomes of interest were calculated. Results: We finally reviewed 13 studies, including 976 patients. The technical success of the method was 98.43% (95% CI: 95.62–99.95). Early outcomes included total periprocedural obliteration with a rate of 50.20% (95% CI: 36.09–64.30) and periprocedural rupture with zero rate. During the follow-up period, ranging from 6 months to 2 years, the total postprocedural obliteration rate was 63.83% (95% CI: 45.80–80.18) and the overall late rupture rate was 0.41% (95% CI: 0.00–2.38). The pooled in-stent stenosis rate was calculated at 1.24% (95% CI: 0.02–3.63). We also estimated a pooled rate of 0.02% (95% CI: 0.00–0.51) and 4.33% (95% CI: 2.03–7.23) for total mortality and overall neurological complications, respectively. A pooled rate of 3.94% (95% CI: 1.48–7.33) was found for stroke. Finally, the recanalization rate was recorded at 7.07% (95% CI: 4.35–10.26). Conclusions: SAC of UIAs with wide neck seems to be a safe and acceptable alternative to surgical clipping. Although early results concerning total periprocedural obliteration may be modest, follow-up outcomes may be indicative of adequate occlusion of treated UIAs.

Women in Neurosurgery (WIN): Barriers to progress, world WIN directory and the way forward Sneha Chitra Balasubramanian, Dhivya Palanisamy, Souad Bakhti, Najia El Abbadi, Nelci Zanon Collange, Claire Karekezi, Boon Seng Liew, Yoko Kato Asian Journal of Neurosurgery 2020 15(4):828-832 Women in Neurosurgery (WIN) have come a long way and are making inroads in every neurosurgical subspecialty. There has been a worldwide increase in the number of female neurosurgeons both in the training and practice. Although this is a welcome trend, gender equality at work in terms of opportunities, promotions, and pay scales are yet to be attained. This is more apparent in the developing and underdeveloped nations. Barriers for a female neurosurgeon exist in every phase before entering residency, during training, and at workplace. In the neurosurgical specialty, only a few women are in chief academic and leadership positions, and this situation needs to improve. WIN should be motivated to pursue fellowships, sub-specialty training, research, and academic activities. Furthermore, men should come forward to mentor women, only then the gender debates will disappear and true excellence in neurosurgery can be attained. This article reviews the issues that are relevant in the present era focusing on the barriers faced by female neurosurgeons in the developing and underdeveloped countries and the possible solutions to achieve gender equality in neurosurgery. The authors also present the data from the World WIN Directory collected as a part of Asian Congress of Neurological Surgeons-WINS project 2019. These numbers are expected to grow as the WIN progress and add value to the neurosurgical community at large.

Endoscopic microvascular decompression for hemifacial spasm Maruf Matmusaev, R Senthil Kumar, Yasuhiro Yamada, Tetsuya Nagatani, Tsukasa Kawase, Riki Tanaka, Miyatani Kyosuke, Yoko Kato Asian Journal of Neurosurgery 2020 15(4):833-838 Introduction and Objective: Hemifacial spasm (HFS) is a condition, characterized by painless, involuntary unilateral tonic or clonic contractions of the facial muscles innervated by the ipsilateral facial nerve. HFS starts with contractions in the orbicularis oculi muscle with subsequent eyelid closure and/or eyebrow elevation, but may spread to involve muscles of the frontalis, platysma, and orbicularis oris muscles. Microvascular decompression (MVD) is reliable and accepted surgical treatment for HFS. MVD is the standard surgical technique now for HFS treatment with long-term success rates. Materials and Methods: We performed fully endoscopic MVD technique for 1 patient with HFS (a 83-year-old female) at our institution. HFS was diagnosed based on the clinical history and presentation, a neurologic examination, and additional imaging findings. Respectively, the durations of HFS were 3 years, respectively. The patient had been previously treated with repeated botulinum toxin injections. Preoperative evaluation was done with magnetic resonance imaging; three-dimensional computed tomography fusion images examinations had identified the anterior inferior cerebellar artery (AICA) as the offending vessel in this patient. Results: The patient with HFS was treated by fully endoscopic MVD technique. The AICA, which had been identified as the offending vessel by preoperative magnetic resonance imaging, was successfully decompressed. No surgery-related complications occurred and had excellent outcomes with the complete resolution of HFS immediately after the operation. Conclusions: Endoscopic surgery can provide a more panoramic surgical view than conventional microscopic surgery. Fully endoscopic MVD is both safe and effective in the treatment of HFS. This method minimizes the risks of brain retraction and extensive dissection often required for microscopic exposure. Endoscopic MVD is safe and has advantage over microscope in terms of visualization of structure, identification of neurovascular conflict, but it has a learning curve and technically challenging.

Modified transclavicular-transmanubrial approach to cervicothoracic spine: Revisiting and Renovating the Path – Lessons learned TS Vasan, Raghavendra M Rao Asian Journal of Neurosurgery 2020 15(4):839-845 Introduction: A thorough knowledge of the vital structures adds to the safety in approaching the cervicothoracic spine junction. The best described method to reach the spine is via viscero-neurovascular space. We present our experience of 10 cases operated at our institute using the modified transclavicular transmanubrial approach to the cervicothoracic spine pathology.As we gained experience we have used various corridors to the operating field and used a new space to approach the lower cervicothoracic junction spine. Methods: Between February 2011 to August 2015, 10 patients with disease in upper thoracic vertebral body were admitted and evaluated clinically and radiologically. Neurological status in all cases was graded according to Frankel grading system.Patients were followed up with Histopathological reports and treated accordingly. Results: All patients(except metastasis) improved by 1 or 2 grade in post op period. Metastasis patients remained in same grade. Conclusion: Anterior approach with its modifications are the better suited biomechanically for exploring the pathology of cervicothoracic spine,its decompression and stabilization. Also it preserves the stability of shoulder girdle with good neurological and cosmetic outcome.

Endoscopic transcortical transventricular management of cystic craniopharyngioma: Outcome analysis of 32 cases at a tertiary care center Somil Jaiswal, Manish Jaiswal, Pooja Jaiswal, Ankur Bajaj, Chhitij Srivastava, Anil Chandra, Bal Krishna Ojha, Janu Vikas, Awadhesh Yadav Asian Journal of Neurosurgery 2020 15(4):846-855 Background: Microsurgical resection has been considered the gold standard treatment of craniopharyngioma, but lately, it has found less favor due to its morbidity and is being replaced by minimally invasive cyst drainage procedures. We present our experience of transventricular endoscopy and cyst drainage along with its technique and have analyzed its results. Materials and Methods: Clinical and radiological data of all cystic craniopharyngioma patients treated by transventricular endoscopic cyst drainage and Ommaya placement were retrieved and analyzed Results: Thirty-two patients underwent endoscopic cyst drainage during the study period. All patients had immediate clinical and radiological improvement. No significant complications were seen. All patients underwent adjuvant radiotherapy and six patients (18.7%) showed recurrence. Three patients died in the follow-up period. Conclusions: Endoscopic transcortical transventricular cyst drainage with Ommaya reservoir along with adjuvant radiotherapy is a simple, safe, and effective treatment modality.

Clinico-radiological outcome of single-level and hybrid total disc replacement with spineart Baguera®-C for cervical myeloradiculopathy: Minimum 2-year follow-up study in Indian population Jeevan Kumar Sharma, Tarush Rustagi, Nandan Marathe, Abhinandan Reddy Mallepally, Rajat Mahajan, Harvinder Singh Chhabra, Kalidutta Das Asian Journal of Neurosurgery 2020 15(4):856-862 Context: Cervical radiculopathy and myelopathy is one of the most frequent ailments encountered by spine surgeon. Motion-preserving surgeries in cervical spine is a standard of care due to its certain advantages such as biomechanical anatomical conformity, reduced chances of adjacent segment degeneration, and revision surgeries. While there is abundant data from some centers, data from developing countries are still limited. Aims: The aim was to study the clinico-radiological outcome of single-level and hybrid total disc replacement (TDR) with Spineart Baguera®-C cervical prosthesis for cervical myeloradiculopathy. Settings and Design: Retrospective study. Materials and Methods: Retrospective analysis of the 29 consecutive patient undergoing single level TDR and hybrid fixation (i.e., TDR with anterior cervical discectomy and fusion) with Spineart Baguera®-C cervical prosthesis for myeloradiculopathy from January 1, 2014 to December 31, 2017, was done. Radiological features and outcome were studied from data collected on Insta-picture archiving and communication system. Statistical Analysis Used: SAS 9.4 was used for all computations. Results on continuous measurements were presented as mean and standard deviation (min-max) and results on categorical measurements were presented as numbers (n) and percentages. Results: Twenty-nine patients were included in the study. The mean age was 43.31 ± 9.04 years with 14 males and 15 females. The most common level of TDR was C5-C6 (72.41%). The mean follow-up duration was 3.14 years ± 1.13 years (2–5 years). The mean hospital stay was 4.93 ± 2.12 days. The mean neck disability index (NDI) at admission was 27.24 ± 7.66 which decreased to 6.41 ± 4.29 at final follow-up. Conclusions: Two-year data on treatment with Spineart Baguera®-C cervical prosthesis shows significantly improved NDI, visual analog scale (arm) with maintenance of movement of the prosthesis.

High-flow bypass with radial artery graft for cavernous carotid aneurysms: A case series Riki Tanaka, Boon Seng Liew, Kento Sasaki, Kyosuke Miyatani, Tsukasa Kawase, Yasuhiro Yamada, Yoko Kato, Akihiko Horiguchi Asian Journal of Neurosurgery 2020 15(4):863-869 Background: The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates. Objective: To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution. Materials and Methods: A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described. Results: All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 – 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae. Conclusion: The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Patient Safety and Infection Control

Audit on hand hygiene and use of personal protective equipment: Prevention of nosocomial transmission of COVID-19 Indranath Roy Journal of Patient Safety and Infection Control 2020 8(2):37-38

Attitude and beliefs about surgical safety checklist in a North Indian tertiary care hospital, a decade later of World Health Organisation checklist Lovenish Bains, Anurag Mishra, Daljit Kaur, Pawan Lal, Lalit Gupta, Vikas Malhotra Journal of Patient Safety and Infection Control 2020 8(2):39-47 Background: Avoidable surgical complications account for a large proportion of preventable medical injuries and deaths globally. Surgical safety checklist (SSCL) is evidence‑based, internationally accepted valid instrument, which has been found to reduce postoperative morbidity and mortality; the benefits of which are most striking in low and middle‑income countries (LMICs) Despite implementation in many hospitals throughout the country, there is still lack of awareness and concern in many LMICS health care facilities towards SSCL and its use, even after a decade of World Health Organisation (WHO) checklist. Methods: This was a single centre e-survey to assess the knowledge, attitudes and beliefs about the WHO‑surgical checklist, in which 65.4% (138) surgeons, 25.1% (53) anaesthetists and 9.5% (20) nurses participated. Results: Majority believed that the use of SSCL improves the safety of procedures, improves communication amongst theatre staff and will result in a reduction in errors in theatre, yet there was no commitment for the use of SSCL. Although all theatre personnel support implementation and use of SSCL; however, hierarchical issues, lack of administrative support, lack of training, logistics and timing, high patient volume and overburdened residents, lack of co‑ordinator or leadership role and shortage of workforce can be impediment to effective use. Discussion: Nurses and junior doctors play a crucial role. Commitment rather than compliance and teamwork will be the key, ably supported by education and training which should be mandatory for all operation theatre stakeholders. Therefore, any measure that can potentially improve patient safety should be embraced and benefits of SSCL be told to motivate them and enhance participation for patient safety. Committed leadership, knowledge sharing and periodic trainings, interdisciplinary communication, feedback and regular audits can define and determine effective implementation process.

Seroprevalence of hepatitis C infection in patients undergoing haemodialysis in a tertiary care centre Anjali Nair Vinayakumar, Reena John Journal of Patient Safety and Infection Control 2020 8(2):48-53 Introduction: Hepatitis C virus (HCV) infection is a major health problem among these patients in developing countries like India. This could be either due to a non-adherence to strict infection control measures or the unavailability of vaccine to prevent HCV infection. Objectives of the Study: This study aims to estimate the prevalence of HCV infection in patients undergoing haemodialysis and assess the major risk factors, the efficacy of infection control measures in the dialysis unit by studying the seroconversion rates from HCV negative to HCV positive and also formulate ways to prevent the nosocomial spread of HCV infection in the dialysis unit. Materials and Methods: This was a cross-sectional study carried out among 250 patients undergoing haemodialysis in the dialysis unit of a tertiary care centre. They were tested for the presence of anti-HCV antibody by enzyme linked immunosorbent assay. Results: The seroprevalence of HCV infection among the patients undergoing haemodialysis as per this study is 4.8%. The risk factors identified were age >50, prolonged duration of dialysis and multiple blood transfusions. One significant observation was of the probability of lateral spread of HCV infection within the dialysis unit. Conclusions: Although there is no consensus regarding machine dedication between HCV non-infected and HCV-infected patients, we found that using dedicated HD machines had an important role in reducing HCV transmission in our dialysis unit. However, risk prevails if any seronegative patient acts as HCV carrier.

Practice gaps and challenges to effective patient safety culture in a tertiary hospital in Nigeria Amaka Y Ezeuko, Chinomnso C Nnebue, Raymond C Okechukwu, Chigozie O Ifeadike Journal of Patient Safety and Infection Control 2020 8(2):54-59 Background: Knowledge and experiences of inefficiencies, odds and difficulties in patient safety culture (PSC) maintenance in health-care systems can facilitate the development and implementation of better strategies. Objective: The aim is to determine the practice gaps and challenges to effective PSC in Nnamdi Azikiwe University Teaching Hospital, (NAUTH) Nnewi, Nigeria. Materials and Methods: This was a cross-sectional survey conducted from June to November 2016 in NAUTH Nnewi, Nigeria. Data were collected through mixed methods:-self-administered structured questionnaire survey (QS), focus group discussions (FGD) and key informant interviews (KII). Stratified sampling technique was used for the QS, while the convenience sampling technique. was employed in the FGD and KII. Data were analysed using the Statistical Package for the Social Sciences version 22. Results: Challenges to the effective promotion of PSC each relate to gaps in either poor staff strength or punitive response to the error report. The challenges reported from the FGD are lack of training and re-training programmes (61%), poor team spirit and low staff capacity (56%). From the KII >80% reported non-availability of PSC unit, patient safety committee, patient safety guideline/policy, nor standard operation procedure while (61%) reported that management effort to provide enabling patient safety environment was adequate. Conclusions: This study found challenges to effective PSCsuch as poor training, staff strength, team spirit cum communication, excessive work hours and fear of punitive response to the error report. This buttresses the need for urgent attention to these areas of weakness through awareness and educational programmes on PSC, adequate staffing and prompt information dissemination.

Applying patient safety principles in public safety in the COVID-19 scenario Thanjavur S Ravikumar, Aravindakshan Rajeev, Shikha Yadav Journal of Patient Safety and Infection Control 2020 8(2):60-63 COVID-19 has overwhelmed the health systems all over the world. Using a methodology for finding excess deaths due to illnesses, we estimated the statistics for the countries which had their first case of coronavirus infection in January 2020. For illustration, the avoidable harm in the USA was 160,988 and that of the UK was 38,857 until the 2nd week of August 2020. Geographic distribution of excess deaths was plotted on GeoDa® shaded map. Spatial error model showed that early and vigorous testing reduced the mortality load. Strategy has to be worked out to contain the pandemic using the appropriate public health tools.

Nasal carriage of methicillin-resistant Staphylococcus aureus amongst healthcare workers of intensive care unit of a tertiary care centre in South India: An observational cross-sectional study Abhishek Thanuja Jayadhar, Ashish Jitendranath, Amalu Ann Thomas, GS Sarika Journal of Patient Safety and Infection Control 2020 8(2):64-67 Staphylococcus aureus is one of the dangerous pathogens causing infections in both community level and hospital setting. This study aims to find the carrier rate of S. aureus and a resistant strain of the bacterium–methicillin-resistant S. aureus (MRSA). Sterile cotton swabs (saline moistened) were used to collect the nasal samples from the healthcare workers (HCWs) of different intensive care units. The isolation S. aureus was done by standard bacteriological procedures. Antibiotic susceptibility testing of all isolates was performed by modified Kirby–Bauer disc diffusion method. Methicillin resistance of S. aureus was identified using cefoxitin disc diffusion test. One hundred and forty-one nasal swabs were processed (104 nurses, 27 doctors and 10 non-medical staff). Amongst the 141 nasal swabs processed, 18.4% of HCWs were carriers of S. aureus, out of which 9.9% tested positive for MRSA. To prevent the colonisation of HCWs by S. aureus and avoid cross infection amongst patients, proper hand hygiene practices are vital. Creating an awareness and periodic screening is yet another task needed to tackle this crisis.

Impact of COVID-19 in non-COVID hospitals: Do we need a pandemic to augment healthcare worker and patient safety? Areena Hoda Siddiqui, HN Tripathi, R Harsvardhan Journal of Patient Safety and Infection Control 2020 8(2):68-69

A virtual birth companion! – Yet another application of virtual reality during the COVID-19 pandemic Vijayan Sharmila, Thirunavukkarasu Arun Babu Journal of Patient Safety and Infection Control 2020 8(2):70-71

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Interdisciplinary Dentistry

Webinars-boon or bane Mahalaxmi Sekar, Monisha P Khatri Journal of Interdisciplinary Dentistry 2020 10(3):95-96

Detection and comparison of spirochetes in periodontal health and disease by microscopy and polymerase chain reaction techniques: A microbiological study Reshma Naik, SP Pushpa, Kishore Bhat, Sanjeevini Hattarki Journal of Interdisciplinary Dentistry 2020 10(3):97-104 Background: Periodontitis is caused by specific microorganisms or group of specific microorganisms. Spirochetes have been implicated to play a role in the pathogenesis of the periodontal disease. Objectives: The aim is to detect the prevalence of total spirochetes in patients with healthy periodontium, gingivitis, and periodontitis using microscopy and polymerase chain reaction (PCR) techniques. And to compare microscopy (silver nitrate staining) technique and PCR technique in the detection of spirochetes. Subjects and Methods: A total of 150 patients were selected and divided into healthy, gingivitis, and periodontitis groups with 50 patients in each group. Subgingival plaque samples were collected using sterile Gracey curettes. The plaque samples were analyzed for the presence of spirochetes using microscopy and PCR techniques. Statistical analysis for the prevalence of spirochetes was performed using the Chi-square test. The sensitivity and specificity of the microscopy and PCR techniques were compared. Results: The prevalence of spirochetes increased from healthy to gingivitis to periodontitis patients. The prevalence of spirochetes was statistically significantly higher in the periodontitis group as compared to the healthy and gingivitis group. PCR was more sensitive in detecting spirochetes than microscopy, but that microscopy showed slightly greater specificity than PCR. Conclusion: There is a strong association between the presence of spirochetes with periodontal disease as well as its severity. The microscopic method by silver nitrate staining can be a very useful, simple, and rapid screening method for the evaluation of oral spirochetes, but PCR technique may serve as more sensitive indicator of subjects at risk for periodontal disease, thus allowing preventive measures.

Comparison of tensile and tear strength of three silicone materials for maxillofacial prosthesis in Indian climatic condition Vibha Shetty, Anoop Sharma, Sweekriti Mishra Journal of Interdisciplinary Dentistry 2020 10(3):105-110 Aims: The aim of the study was to evaluate and compare physical properties such as tensile strength and tear strength of three commonly used silicone maxillofacial materials in Indian climatic condition. Settings and Design: An in vitro study was conducted to compare the tensile and tear strength using a universal testing machine with 100 N load at a speed of 20 mm/min. Specimens were prepared from three commercially available silicones, i.e., medical grade silicone (control group), prosthetic grade silicone (test Group 1), and a locally available medical grade silicone (test Group 2). One-way analysis of variance was carried out to test any significant difference between the mean values of tensile and tear strength between the tested materials. Post hoc test of Tukey was used to find which of the two groups' means shows a significant difference. Results: Prosthetic grade silicone showed the highest tensile strength with a P< 0.001* among the two tested materials. Tear strength and mean elongation was highest in control showing statistically significant results (<0.001*). Locally available medical grade silicone showed the least favorable properties among all the tested materials, though tensile strength was within acceptable range. Conclusions: Tensile strength of prosthetic silicone was highest followed by medical grade, whereas tear strength and elongation were maximum in medical grade silicone. Locally available medical grade silicone showed the least favorable properties.

Effect of probiotics on Candida in diabetic and nondiabetic complete denture wearers – An In vivo study Bonda Rajasekhar, Anil Kumar Gujjari, Ranjitha Shankaregowda, Karteek Durbakula Journal of Interdisciplinary Dentistry 2020 10(3):111-116 Aim: To evaluate the effectiveness of probiotics on Candida albicans in diabetic and nondiabetic complete denture wearers. Study Design: Twenty complete denture wearers with dentures aging more than 6 months were selected randomly and divided into two groups (controlled diabetic and nondiabetic) based on their blood glucose levels and medical history. Materials and Methods: Probiotics were prescribed for all the subjects for the duration of 30 days. Microbial swab was collected from their dentures at 0, 15th, and 30th days and incubated in Sabouraud's dextrose agar broth. C. albicans colony-forming units (CFU/ml) were counted. Statistical Analysis: The candidial CFUs were compared using statistical analyses such as descriptive statistics, paired samples t-test, independent samples t-test, and repeated-measures ANOVA test and P < 0.05 was considered as statistically significant. Results: C. albicans count reduced in both the groups during the usage of probiotics, but the reduction was more in controlled diabetic subjects which showed statistically significant results. Conclusion: Probiotics can be used as an alternative therapy for the management of oral candidiasis in denture wearers particularly in controlled diabetic patients.

Management of a velopharyngeal defect with hollow speech bulb prosthesis Snehal Jaiswal, Mohit Kheur, Tabrez Lakha Journal of Interdisciplinary Dentistry 2020 10(3):117-121 Velopharyngeal (VP) insufficiency is an anatomic defect of the soft palate which renders the palatopharyngeal sphincter incomplete. In cases where a surgically repaired soft palate is too short to contact the pharyngeal walls during function, speech aid prosthesis or speech bulbs are optimum choices of treatment. This case report elaborates the correction of hypernasality of speech associated with VP insufficiency, by means of speech bulb prosthesis. This speech bulb is a combination of cast partial denture with extension into the defect area to hold heat cure acrylic material. This retentive component was embedded in heat cure acrylic resin material to aid in retention. This improved the hypernasality, speech, comfort, retention, and overall patient acceptance.

Rehabilitation of dentition affected by stage IV periodontitis through an interdisciplinary approach Abin Sam Abraham, Jimmy George, Deepak Thomas, Babu Cherian Journal of Interdisciplinary Dentistry 2020 10(3):122-125 Rehabilitation of periodontally compromised dentitions is always challenging in order to restore the masticatory function as well as to prevent future disease progression. This case report discusses an interdisciplinary approach for managing a case of Stage IV periodontitis in a female patient who presented with multiple mobile furcations involved posterior teeth. By a combined endo-perio-prosthetic effort, the retention and rehabilitation of majority of her teeth was achieved.

Rehabilitating a maxillectomy patient by interdisciplinary alveolar bone preservation technique using submergence of teeth roots C Femil Jilta, RS Sreeraj, R Ravichandran, K Harsha Kumar Journal of Interdisciplinary Dentistry 2020 10(3):126-131 Retention for edentulous maxillary obturator is always challenging. Although implants offer good retention in edentulous patients, lack of tissue beds, less predictable integration, economic constraints may preclude implantation. Therefore, the preservation of residual alveolar ridge is mandatory to enhance the retention, support, and stability of the removable obturator prosthesis. Retaining roots through “Root submergence technique” maintains the attachment apparatus and aids in decreasing the resorptive pattern, thereby preserving the residual ridge to some extent. Here, we report a case in which nonvital root submergence is carried out in a partial maxillectomy patient to prevent alveolar ridge resorption adhering to DeVan's dictum “Perpetual preservation” of what remains is more important than the meticulous replacement of what is missing.

Managing esthetics by immediately placed immediately loaded implants: A case report Amitabh Srivastava, Shivam Yadav, Anshdha Shah, Sajid Husain Journal of Interdisciplinary Dentistry 2020 10(3):132-136 \Immediate implants offer a suitable treatment modality as treatment time is reduced, and postextraction bone loss can be avoided. Temporization of implants in the anterior region is becoming much needed for esthetics as well as helps to avoid the second-stage surgical procedure. A 23-year-old female presented with mobility in lower anterior teeth and radiographic bone loss extending to the apical third. The patient was treated with postextraction immediate implants, and immediate nonfunctional prosthesis was given after evaluation of implant stability quotient by radiofrequency analysis using the Ostell® device. A 7-month follow-up presented successful temporization and osseointegration.

Management of a nonvital discolored tooth associated with radicular cyst: A multidisciplinary approach Richa Gupta, Nilav Bhagabati, Gaurav Jain, Jyoti Ahlawat Journal of Interdisciplinary Dentistry 2020 10(3):137-140 The radicular cyst arises from proliferated epithelial cell rests of malassez when they get stimulated by an inflammatory process originating from pulpal necrosis of a nonvital tooth. The associated tooth is usually asymptomatic and may result in swelling of the soft tissues and mobility of the teeth involved. The typical radiographic description of the lesion is a round or oval, well-circumscribed radiolucency involving the apex of the tooth. Radicular cysts can be managed either surgically or nonsurgically. The nonvital, discolored anterior tooth associated with the lesion is a common esthetic concern for patients. It can effect their self-confidence and employability. Discolored nonvital teeth are frequently compromised due to root canal treatment, previous trauma, or caries. Invasive treatment options like crowns or veneers further weaken the tooth structure. This case report presents the successful surgical management of a radicular cyst associated with a nonvital discolored anterior tooth. This will also include the technicalities involved in the inside/outside nonvital bleaching technique.

Salvaging a tooth with radisection: A case report with 3-year long-term follow-up Monisha P Khatri, Anupama Biradar, Shruti Paradkar, Sachin Shivanaikar Journal of Interdisciplinary Dentistry 2020 10(3):141-144 The successful management of endodontically involved teeth depends on adequate biomechanical preparation and obturation in adherence to a satisfactory coronal seal. However, challenges such as extensive carious involvement, periodontal attachment loss, and iatrogenic mishaps which include ledges, blocked canals, and instrument separation compromise the salvation of the teeth. Treatment options for such mishaps in multirooted teeth can range from endodontic treatment alone, combined endodontic-periodontic treatment, or extraction in cases with poor prognosis. One such treatment in case of file fracture or extensive periodontal involvement in maxillary molars could be root resection, also known as radisection. This procedure offers an economically viable treatment option for the patient to preserve the natural tooth. This article highlights a case report of root resection in maxillary molar with endodontic, periodontic, and prosthetic management with resultant successful oral rehabilitation along with a follow-up of 3 years.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Neurosurgical Anesthesiology

Correlation Between Invasive and Noninvasive Technique of Intracranial Pressure Measurement in Children With Traumatic Brain Injury: An Observational Study Background: Direct measurement of intracranial pressure (ICP) is an invasive technique with potential complications, which has prompted the development of alternative, noninvasive, methods of ICP assessment. The aim of this study was to determine the relationship between noninvasive ultrasound-based measurement of optic nerve sheath diameter (ONSD), transcranial Doppler-derived pulsatility index (PI), and invasive ICP measurements in children with traumatic brain injury (TBI). Methods: Children aged 1 to 18 years undergoing invasive ICP monitoring following TBI were included in the study. Noninvasive ONSD and PI measurements were compared with simultaneous invasive ICP. Results: In all, 406 measurements of ONSD and PI were obtained in 18 patients. ONSD and PI correlated with ICP (r=0.76 and 0.79, respectively), combining ONSD and PI resulted in an even stronger correlation with ICP (r=0.99). Formulas were derived from mixed-effect models that best fitted the data for noninvasive ICP estimation. A combination of ONSD and PI had the highest ability to detect ICP >20 mm Hg (area under the receiver operating characteristic curve=0.99, 95% confidence interval: 0.99-1.00). Optimal cutoff values for the prediction of intracranial hypertension were 5.95 mm for ONSD (sensitivity, 92%; specificity, 76%) and 1.065 for PI (sensitivity, 92%; specificity, 87%). Conclusions: In children with TBI, a combination of ONSD and PI strongly correlates with invasive ICP and has potential to screen for intracranial hypertension noninvasively. ONSD and PI may be useful tools for assessing ICP where invasive monitoring is unavailable or contraindicated. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Gyaninder P. Singh, DM. E-mail: drsingh_gp@yahoo.co.in. Received August 2, 2020 Accepted November 20, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Kratschmer Reflex During Transnasal Endoscopic Pituitary Surgery No abstract available

Genome-wide Association Study of Postoperative Cognitive Dysfunction in Older Surgical Patients Background: Postoperative cognitive dysfunction (POCD) is a common neurocognitive disorder after surgery and anesthesia, particularly in elderly patients. Various studies have suggested genetic risk factors for POCD. The study aimed to detect genome-wide associations of POCD in older patients. Methods: In this prospective observational cohort study, participants aged 65 years and above completed a set of neuropsychological tests before, at 1 week, and 3 months after major noncardiac surgery. Test variables were converted into standard scores (z-scores) based on demographic characteristics. POCD was diagnosed if the decline was >1 SD in ≥2 of the 15 variables in the assessment battery. A genome-wide association study (GWAS) was performed to determine potential alleles that are linked to the POCD phenotype. In addition, candidate genes for POCD were identified in a literature search for further analysis. Results: Sixty-three patients with blood samples were included in the study. POCD was diagnosed in 47.6% of patients at 1 week and in 34.2% of patients at 3 months after surgery. Insufficient sample quality led to exclusion of 26 patients. In the remaining 37 patients, a GWAS was performed, but no association (P<5×10−8) with POCD was found. The subsequent gene set enrichment analysis of 34 candidate genes did not reveal any significant associations. Conclusion: In this patient cohort, a GWAS did not reveal an association between specific genetic alleles and POCD at 1 week and 3 months after surgery. Future genetic analysis should focus on specific candidate genes for POCD. Preliminary data in this manuscript were presented at the Euroanaesthesia Congress, Vienna, Austria, June 1–3, 2019, as well as at the European Society of Human Genetics Conference, June 6–9, 2020. This research was supported by departmental sources and a grant no. 32003B-121956 from the Swiss National Science Foundation. L.A.S. has received speaker honoraria from Medtronic Schweiz (Münchenbuchsee, Switzerland), Covidien (Neuhausen am Rheinfall, Switzerland) MSD, (Luzern, Switzerland), Hamilton Medical (Bonaduz, Switzerland), Lilly (Vernier, Switzerland), and Orion Pharma (Zug, Switzerland). N.G. has received consultancy fees from PIPRA AG (Zug, Switzerland). None of these fees were related to this study. The remaining authors have no conflicts of interest to disclose. Address correspondence to: Nicolai Goettel, MD. E-mail: nicolai.goettel@usb.ch. Received September 21, 2020 Accepted October 27, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Management of Endovascular Treatment for Acute Ischemic Stroke During the COVID-19 Pandemic at a Single Institution in Beijing, China: A Brief Report Background: The coronavirus disease (COVID-19) pandemic is currently a major challenge for health care systems around the world. For a time-sensitive emergency such as acute ischemic stroke (AIS), streamlined workflow times are essential to ensure good clinical outcomes. Methods: The aim of this single-center, retrospective, observational study was to describe changes in stroke workflow patterns and clinical care during the COVID-19 pandemic. Data from AIS patients undergoing emergent endovascular treatment (EVT) between 23 January and 8 April 2020 were retrospectively collected and compared with data from patients admitted during a similar period in 2019. The primary outcome was difference in time from symptom onset to recanalization. Secondary outcomes included workflow times, clinical management, discharge outcomes, and health-economic data. Results: In all, 21 AIS patients were admitted for emergent EVT during the 77-day study period, compared with 42 cases in 2019. Median time from symptom onset to recanalization was 132 minutes longer during the pandemic compared with the previous year (672 vs. 540 min, P=0.049). Patients admitted during the pandemic had a higher likelihood of endotracheal intubation (84.6% vs. 42.4%, P<0.05) and a higher incidence of delayed extubation after EVT (69.2% vs. 45.5%, P<0.05). National Institutes of Health Stroke Scale at hospital discharge was similar in the 2 cohorts, whereas neurointensive care unit stay was longer in patients admitted during the pandemic (10 vs. 7 days, P=0.013) and hospitalization costs were higher (123.9 vs. 95.2 thousand Chinese Yuan, P=0.052). Conclusion: Disruptions to medical services during the COVID-19 pandemic has particularly impacted AIS patients undergoing emergent EVT, resulting in increased workflow times. A structured and multidisciplinary protocol should be implemented to minimize treatment delays and maximize patient outcomes. This study was supported by the Beijing Municipal Science and Technology Commission (Z191100006619068) and Beijing Municipal Administration of Hospitals (DFL20180502). The study investigators did not receive compensation for participating in the study. No funding agencies had any role in the design or conduction of the study, study management, data collection, analysis, interpretation, decision to publish, or preparation of the manuscript. S.L. and M.Z. contributed equally to the manuscript as co-first authors. Y.P. and R.H. contributed equally to the manuscript. R.H. is a member of the Editorial Board of Journal of Neurosurgical Anesthesiology. The remaining authors have no conflicts of interest to disclose. Address correspondence to: Yuming Peng, MD, PhD, E-mail: florapym766@163.com. Received June 20, 2020 Accepted October 25, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Early Lymphopenia and Infections in Nontraumatic Subarachnoid Hemorrhage Patients Introduction: Subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. A certain degree of immunodepression has been reported during critical illness, and lymphopenia identified as an independent predictor of poor outcome; no data are available for critically ill SAH patients. We aimed to evaluate the prevalence of lymphopenia among SAH patients and its association with hospital-acquired infection. Methods: Retrospective cohort study of adult patients admitted to an intensive care unit with nontraumatic SAH between January 2011 and May 2016. Lymphocyte count was obtained daily for the first 5 days; lymphopenia was defined as lymphocyte count <1000/mm3. The occurrence of infection during the first 21 days after hospital admission, hospital mortality, and unfavorable neurological outcome (Glasgow Outcome Scale score 1 to 3 at 3 mo) were recorded. Results: Data from 270 patients were analyzed (median age 54 y; male 45%); 121 (45%) patients had lymphopenia and 62 (23%) patients developed infections. Median (25th to 75th percentiles) lymphocyte count at hospital admission was 1280 (890 to 1977)/mm3. Lymphopenia patients had more episodes of infection (38/121, 31% vs. 24/139, 17%; P=0.003) than nonlymphopenia patients, while mortality and unfavorable outcome were similar. Lymphopenia was not independently associated with the development of infection, unfavorable neurological outcome or with mortality. Conclusions: Early lymphopenia is common after SAH, but is not significantly associated with the development of infections or with poor outcome. This study was present as an e-poster at LIVES congress—ESICM, September 28th to October 2nd, Berlin, Germany. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Elisa Gouvêa Bogossian, MD, MSc. E-mail: elisagobog@gmail.com. Received August 5, 2020 Accepted October 6, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Utility and Predictive Value of CHIIDA Score in Pediatric Traumatic Brain Injury: A Prospective Observational Study Background: The Children's Intracranial Injury Decision Aid (CHIIDA) is a tool designed to stratify children with mild traumatic brain injury (mTBI). The aim of this study was to assess the utility and predictive value of CHIIDA in the assessment of the need for intensive care unit (ICU) admission in pediatric patients with mTBI. Methods: This prospective observational study included 425 children below 18 years of age admitted to the ICU of a tertiary care hospital with mTBI (Glasgow Coma Scale 13 to 15). The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Sensitivity, specificity, predictive values and likelihood ratios were calculated at CHIIDA scores 0 and 2. Results: Among 425 children with mTBI, 210 (49%) had a CHIIDA score 0, 16 (4%) scored 2 points, and 199 (47%) scored more than 2 points. Thirty-six (8.47%) patients experienced the primary outcome, and there were 3 deaths. A cutoff CHIIDA >0 to admit to ICU had a sensitivity of 97.22% (95% confidence interval [CI], 97.05%-97.39%) and a negative predictive value of 99.54% (95% CI, 99.50%-99.56%). A cutoff of score >2 had a sensitivity of 97.22% (95% CI, 97.05%-97.39%), and negative predictive value of 99.56% (95% CI, 99.54%-99.59%). The post-test probability at cutoff score of 0 and 2 was 16.65% and 16.27%, respectively. Conclusions: CHIIDA score does not serve as reliable triage tool for identifying children with TBI who do not require ICU admission. The pilot data of this study has been presented at the 19th annual conference of the Indian Society of Neuroanaesthesiology and Critical Care (ISNACC) 2018 and published as an abstract in the conference proceedings in the Journal of Neuroanaesthesiology and Critical Care 2018. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Ruchi A. Jain, MD, DNB, PDFC. E-mail: ruchiajain@gmail.com. Received July 5, 2020 Accepted September 29, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Hemoglobin Concentration May Influence the Incidence of Postoperative Transient Neurological Events in Patients With Moyamoya After Extracranial-intracranial Arterial Bypass: A Retrospective Single Center Experience Background: Moyamoya is a rare condition characterized by cerebral angiographic findings of intracranial carotid artery stenosis with abnormal net-like vessels in the brain, and often presents as transient ischemic attacks or intracranial hemorrhage. Revascularization in the form of extracranial-intracranial (EC-IC) artery bypass has demonstrated efficacy in preventing ischemic attacks and intracranial hemorrhage, although it is associated with a relatively high rate of perioperative ischemic and hemorrhagic stroke. This retrospective analysis aims to evaluate the possible association between postoperative hemoglobin (Hgb) concentration and early postoperative transient neurological events (TNEs) experienced at our center. Methods: Consecutive patients undergoing EC-IC bypass between January 1, 2017 and August 31, 2019 were identified, resulting in a study population of 24 patients with 34 individual cases for different cerebral hemispheres. Postoperative Hgb level was evaluated upon arrival to the intensive care unit (ICU) and the primary outcome was the occurrence of TNEs within 24-hours after surgery. Results: The incidence of TNEs within 24 hours postoperatively was 12% (n=4). Statistically significant differences were demonstrated between patients who did and did not experience TNEs in the postoperative period: total Hgb value (mean 9.4 vs. 11.3 g/dL, respectively; P=0.012) and percentage of patients with Hgb <10 g/dL (75% vs. 20%, respectively; P=0.048). Patients with a postoperative Hgb value <10 g/dL upon arrival to the ICU were significantly more likely to experience TNEs (odds ratio, 12; 95% confidence interval, 1.053-136.794; P=0.045). Conclusions: This study reports a possible association between postoperative Hgb level and the occurrence of TNEs within the first 24 hours after surgery in patients undergoing EC-IC for moyamoya. Present address: Nicholas V. Mendez, MD, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA. Catherine Chen, MD, Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH. Angela M. Richardson, MD, PhD, Department of Neurological Surgery, University of Wisconsin-Madison, Madison, WI. Previous presentations: (1) Online abstract for the Annual Meeting of the Florida Society of Anesthesiologists; 2020 June; Palm Beach, FL. (2) Online abstract for the Annual Meeting of the International Anesthesia Research Society; 2020 May; San Francisco, CA. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Nicholas V. Mendez, MD. E-mail: nckmendez@gmail.com. Received June 22, 2020 Accepted September 28, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved

Transcranial Ultrasound as a Useful Tool in Early Detection and Follow-up of Hydrocephalus in Acute Subarachnoid Hemorrhage No abstract available

Stellate Ganglion Block Effects on Cerebral Vascular Tone: A Missing Piece of the Puzzle No abstract available

Facemask as Eye Cover: Think Beyond Mask Ventilation No abstract available

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Fwd: Panafrican Medical Journal - Recently Published

Panafrican Medical Journal 

Authors are invited to submit original articles for consideration  The special issue will run for a period of one year and articles will be published continuously. The PAMJ will expedite the publication and PubMed Central indexation of accepted articles. Article Processing Charges will be waived for accepted submissions. Submit Now!                               Recently Published in PAMJ, 14-21 December 2020 RESEARCH Prevalence and associated factors of alcohol use patterns among university students in Uganda Louis Henry Kamulegeya et al. The harmful use of alcohol is a serious global health burden causing both acute and chronic health problems and adverse social consequences are common when they are associated with alcohol consumption. Every year, the harmful use of alcohol kills 2.5 million people, including 320,000 young people between 15 and 29 years of age. It is the third leading risk factor for poor health globally and harmful use of alcohol was responsible for almost 4% of all deaths in the world, according to the estimates for 2018. READ MORE   Compared efficacy and tolerance of the neuromuscular blockade induced by brand-name (Nimbex®) and generic (Cisatrex®) of cisatracurium in mechanically ventilated critically ill patients: a crossover double-blind randomized study Nesrine Fraj et al. Generic drugs are made to be chemically and therapeutically equivalent to the brand name ones. These equivalencies are obtained at lower costs making generic drugs use certainly appealing. Therefore, many payers/providers have encouraged substitution of brand name drugs with inexpensive bioequivalent generic versions. In the last 30 years, several controversies concerning generic drugs legislation have arisen. Recent literature reviews demonstrated that physicians, pharmacists and general population hold negative perceptions and knowledge of generic medicines. Neuromuscular Blocking Agents (NMBAs) are usually used in patients with altered respiratory mechanics properties such as Acute Respiratory Distress Syndrome (ARDS), status asthmaticus or severe acute exacerbation of COPD (AECOPD).  READ MORE  CASE REPORTS Concomitant in-situ and in transit right heart thrombi: a case report Najlaa Belharty et al. In absence of atrial fibrillation, right heart thrombi (RHT) mostly represent an embolus in transit originating from a deep venous thrombosis which has the propensity of distal embolization. They are uncommon but are associated with higher mortality (80-100%). Right atrial clots may also form in-situ and are mostly small and immobile. There is little if any consensus for the optimal management of RHT, thus being challenging, most importantly, when treating a combination of in transit and in-situ RHT. READ MORE 1p36 deletion syndrome: first case report in Morocco detected by fluorescence in situ hybridization (FISH): a case report Kenza Dafir et al.  1p36 deletion syndrome (OMIM: 607872) is a chromosomal abnormality characterized by intrauterine growth retardation, a characteristic facial dysmorphism made up of straight eyebrows, sunken eyes, wide and flat nasal bridge, upper floor middle of the hypoplastic face, a long philtrum, a pointed chin and a frequent delay in closing the anterior fontanel (>3cm at birth), microbrachycephaly, upturned ears of low implantation and malformed, brachydactyly, camptodactyly, short feet, hypotonia, developmental delay, intellectual deficit, seizures, heart defects and hearing and vision impairment. It is considered to be the most common terminal deletion in humans. It is estimated that the syndrome occurs in one in every 5,000 to 10,000 births without differentiation of sex or ethnicity READ MORE Do you want to submit fot the special issue on COVID-19?  Submit your manuscript through the PAMJ Manuscript Hut (https://www.manuscript-hut.panafrican-med-journal.com) Select Supplement - PAMJ COVID 19 Series as manuscript type and follow the instructions to upload your submission The submissions should comply to the PAMJ Instructions for Authors (http://www.panafrican-med-journal.com/instruction.php) We look forward to receiving your submission. Submit Manuscript Copyright © -2018- PAMJ-CEPHRI/ThePAMJ.org. Kenya: 3rd Floor, Park Suite Building, Parkland Road, Nairobi. PoBox 38583-00100, tel: +254 (0)20-520-4356 | Cameroon: Immeuble TechnoPark Essos, Yaounde, PoBox: 10020 Yaounde, tel: +237 (0)24-309-5880     Address queries to  editor@panafrican-med-journal.com. Add pamj.alert@panafrican-med-journal.com to your safe senders list in your e-mail address book. Doing so ensures that our e-mails reach your Inbox. Thank you. Terms and conditions | Privacy statement | Contact technical board

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