Τετάρτη, 27 Μαρτίου 2019

Hamdan Medical Journal (Hamdan Med J)

Management of Alzheimer's disease
Michael Rainer, Hermann A M. Mucke

Hamdan Medical Journal 2019 12(2):37-46

Despite a huge amount of research investiment during the past three decades there is still no cure or disease-modifying therapy of any kind for Alzheimer's disease, and only very limited progress has been made since the millenium. This review provides a perspective on how Alzheimer's disease symptoms are currently treated with pharmacological and non-pharmacological approaches, and what the evidence for each is. In the absence of new drugs, it is remarkable how well medical foods and behavioural interventions fare in comparison, although much research is still required. A true causal therapy of Alzheimer's disease will have to await the unvailing of its ultimate cause. 

Updates on the role of imaging in the assessment of crohn's disease
Mohamed Walaaeldin Elfaal

Hamdan Medical Journal 2019 12(2):47-51

As initial studies reported that magnetic resonance imaging (MRI) was useful for the evaluation of the small intestine, this modality has become increasingly important in the diagnosis, assessment and exclusion of small bowel disease. The use of MRI for the assessment of inflammatory bowel disease is increasing, at the expense of the current primary imaging modality and computed tomography (CT) enterography. MRI has many advantages over CT, including a lack of radiation exposure, lower prevalence of adverse events, availability of dynamic information, higher resolution and better soft-tissue contrast. New MRI techniques, including diffusion-weighted imaging, spectroscopy, motility study, positron-emission tomography-MRI and molecular imaging, are currently under investigation to improve the diagnosis, follow-up and management of the disease. 

Anaesthetic challenges in complicated labour: Unruptured intracranial aneurysm
Ira Shrivastava

Hamdan Medical Journal 2019 12(2):52-56

Intracranial aneurysms are uncommon during pregnancy. Haemodynamic stress during pregnancy is a key factor in the multifactorial pathogenesis of cerebral aneurysm, contributing to the risk of aneurysm formation, progression and rupture. Successful management requires multidisciplinary care; anaesthetists require knowledge of obstetric anaesthesia, neuro-anaesthesia and critical care. The incidence of subarachnoid haemorrhage in pregnancy is 0.01%—0.05%, with a maternal mortality rate of 11% in treated cases and a foetal mortality rate of 5% in treated cases.[1] Definitive treatment involves either open neurosurgical clipping or endovascular therapy, maintaining stable transmural pressure in the aneurysm to prevent rupture. Very few cases have been reported in the literature, and guidelines for the management of intracranial aneurysm during pregnancy and evidence-based recommendations for obstetric anaesthesia in patients with unruptured intracranial aneurysm during labour do not exist. A review of the literature reveals varying results, differing on a case-by-case basis, for the treatment of intracranial aneurysms during pregnancy and labour. Reducing risks associated with intracranial aneurysm must focus on both mother and child. This review encourages the establishment of formal guidelines for an algorithmic approach to manage the intracranial aneurysm during pregnancy and labour. 

Study of fourier transform infrared of adding metallic nanofillers on heat cure acrylic resin treated by microwave
Makarem M Abdulkareem, Amer A Taqa, Nadira A Hatim

Hamdan Medical Journal 2019 12(2):57-64

Background: Polymethylmethacrylate (PMMA) has been the most popular material for the construction of denture bases since 1937. This is largely due to its favourable although not ideal characteristics. Aims of the study: To study the structural characterisation using Fourier transform infrared (FTIR) of adding aluminium oxide (Al2O3) and silver nanofillers on heat cure acrylic powder treated with microwave radiation and microwave-treated PMMA powder ground by micronizer. Materials and Methods: PMMA powder was treated with microwave radiation at a power level of 360 watt for ¾ h. The obtained PMMA powder was then grinded using a domestic blender group (V). The next step is particle size reduction of the microwave-treated PMMA powder using micronizer group (M). Two concentrations of Al2O3and Ag nanoparticles (NPs) were added separately into untreated PMMA powder group (P) and microwave-treated PMMA powder group (V and M) compared with the control group. The structural characterisations of all experimental groups are determined by FTIR. The samples were divided into 15 groups, one sample for each group. Results: The FTIR analysis has confirmed that the structural behaviour of both microwave and micronizer groups showed that there were no changes in the regions of the band locations for C=C and C=O when compared with the control one. The infrared spectra of all acrylic groups with (Al2O3and Ag) NPs additives showed all of the unique peaks attributed to the PMMA. These bands appeared in the same regions of the acrylic except the carbon double bond carbon (C=C) were absent in the infrared spectrometer chart. Conclusion: The FTIR test charts provide strong evidence that there are no chemical changes in all experimental groups. Except for the C=C band from the methacrylate group did not appear in samples containing NPs, which in turn indicates that the residual monomer of these groups is remarkably decreased. 

Streptozotocin-induced molecular and metabolic targets in pancreatic beta-cell toxicity
Arwa Munassar Thabet Al-Nahdi, Annie John, Haider Raza

Hamdan Medical Journal 2019 12(2):65-71

Background/Aim: The prevalence of diabetes is on the rise globally causing excessive burden on the health systems. Pancreatic beta-cell mass destruction/neogenesis/proliferation (seen in type1diabetes) and/or malfunction (type 2 diabetes) have been implicated in the aetiology, pathology, progression as well as in responses towards therapies and disease managements. Oxidative stress and alterations in mitochondrial energy metabolism play important roles in diabetes-induced cellular complications. Several studies, including our own, have suggested that Rin-5F pancreatic beta cells are extremely susceptible to oxidative stress due to excessive production of endogenous and exogenous reactive oxygen/nitrogen species (ROS/RNS) and low antioxidant defences, particularly, associated with GSH metabolism. Our aim was to investigate the molecular mechanism of streptozotocin (STZ), a beta cell-specific antibiotic, cytotoxicity in pancreatic cells. Methods: Rin-5F cells were treated with STZ under varying conditions to study oxidative stress-related changes. Results: Our studies have suggested that treatment of Rin-5F cells with STZ, inhibits cell survival and induces cytotoxicity by altering cellular survival and apoptotic signalling and gene expressions. Increased oxidative stress with increased DNA fragmentation and oxidative protein carbonylation were seen in STZ-treated cells. We also observed that beta cells treated with high glucose (up to 25mM) exhibited enhanced cytotoxicity. Cells exposed to conditions mimicking diabetes (hyperglycaemia) were under elevated oxidative stress and showed increased apoptosis and altered redox homeostasis leading to increased cytotoxicity. N-acetyl cysteine (NAC) treatment attenuated these changes in STZ-treated cells. Conclusion: These results may have implications in understanding the mechanism of beta cell survival/death in response to potential therapeutics/managements as well as in the aetiology and pathophysiology of diabetes. 

Outcome of pregnancy among women with threatened miscarriage in Latifa Hospital-Dubai
Bedaya Amro, Salma Almahdi

Hamdan Medical Journal 2019 12(2):72-79

Aim: The aim of this study was to investigate the outcome of pregnancy among women with threatened miscarriage, and the risk factors that can affect it and to determine the effect of bed rest and progestogen therapy on that outcome. Materials and Methods: This is a retrospective study that involved all pregnant women who attended the Early Pregnancy Assessment Unit in Latifa Hospital in Dubai with an intrauterine pregnancy and vaginal bleeding up to 14 weeks of gestation. The study was done in the period from March 2010 to March 2011. The main outcome measures included gestational age, baby weight at delivery and placental outcome. Results: A total of 129 pregnant women who met the inclusion criteria were analysed. The early foetal loss rate was 37.2%. Of the remaining, 62.8% who had continued their pregnancy, 23.4% of them had pre-term delivery and 9.9% had placental abruption. Regarding the baby outcome, 35.8% of women delivered low-birth-weight (LBW) babies (<2.5 kg). There was a statistically significant effect of increasing maternal age, increasing gravidity and increasing number of previous miscarriages on increasing the risk of miscarriage in current pregnancy (P < 0.05). No significant difference was found in using bed rest for the management of threatened miscarriage. On the other hand, using progestogen therapy significantly reduced the rate of miscarriage and the rate of LBW babies (P < 0.05). However, we found it had no significant effect on reducing pre-term delivery. Conclusions: Vaginal bleeding in early pregnancy (i.e. threatened miscarriage) is an important risk factor for adverse pregnancy outcomes, which should be taken into consideration when deciding on antenatal surveillance and counselling after a bleeding event. Overall, the results showed the positive effect of using progestogen therapy on pregnancy outcome. However, strong meta-analyses of prospective studies with good methodological quality are still needed to support its routine use in threatened miscarriage management. 

Congenital cytomegalovirus infection-related diaphragmatic dysfunction: A case study
Yasmin A Gad, MN Khalaf, N Sujay

Hamdan Medical Journal 2019 12(2):80-82

Congenital cytomegalovirus (CMV) infection is a common disorder that can lead to multiple developmental sequelae. This case study reports a newborn with respiratory distress syndrome (RDS) associated with diaphragmatic dysfunction due to congenital CMV infection. In newborns with unexplained RDS, CMV infection-related diaphragmatic dysfunction is a potential underlying pathological mechanism. 

Haemophagocytic lymphohistiocytosis and the challenge of early diagnosis
Hoda Mohamed Hammoda, Mahmoud Mohamed Marashi, Hesham Abdalla Mohamed Abdalla, Mahmod El Shahat Awad Makhlof, Manal Sayed Rezzek

Hamdan Medical Journal 2019 12(2):83-85

Haemophagocytic lymphohistiocytosis (HLH) is an uncommon, life-threatening hyperinflammatory syndrome in which abnormal, ineffective energising of the immune system causes excessive activation of lymphocytes and macrophages, which can lead to hypercytokinaemia and massive tissue destruction. A high index of suspicion is necessary for early diagnosis. We report a case of HLH in a 66-year-old woman who presented with fever, pancytopenia and hepatosplenomegaly. 

Hepatolithiasis: A case report and literature review
Noor Amar, Labib Al-Ozaibi, Faisal Badri

Hamdan Medical Journal 2019 12(2):86-89

Hepatolithiasis (HL) is defined as calculi in the biliary ducts proximal to the joining of the right and left hepatic ducts regardless of the presence of concurrent gallstones in either the gallbladder or common bile duct. Most HL cases are asymptomatic. When patients do present with symptoms, they are usually features of cholangitis. 43 year old Bengali male presented to the emergency department with signs of cholangitis and a past surgical history of recurrent cholangitis and multiple ERCPs. He was febrile with scleral icterus and right upper quadrant abdominal tenderness with a positive Murphy's sign. His labs showed and elevated white blood cell count, alkaline phosphatase, total bilirubin, and C-reactive protein. Computed tomography of the abdomen revealed multiple intrahepatic stones occluding the left hepatic biliary duct causing proximal dilation of the hepatic duct [Figure 1] and [Figure 2]. The patient was diagnosed with acute ascending cholangitis and a left hepatectomy was done. The post-operative period was uneventful. Hepatolithiasis is a rare disease found mostly in East Asia. The gold standard for its diagnosis is ERCP and PTC. The current options for treating HL include non-surgical endoscopic approaches and hepatectomy. Indications for its surgical management include presence of stones in one lobe (especially left-sided), multiple large stones that cannot be treated by other methods, complications secondary to cholangitis and suspicion of cholangiocarcinoma. 

Social Psychiatry

The concept of "Stalking" and its relevance to the existing phenomena of internet and social media
Abhijit R Rozatkar, Nitin Gupta

Indian Journal of Social Psychiatry 2019 35(1):1-3

Social psychiatry in India: Current changes and challenges
Rajiv Gupta

Indian Journal of Social Psychiatry 2019 35(1):4-9

Effect of marriage on pre-existing psychoses
Prakash B Behere

Indian Journal of Social Psychiatry 2019 35(1):10-12

The relationship between marriage and mental illness is very complicated, and this issue commonly arises in psychotic illnesses. Psychosis is usually diagnosed at late adolescent and early adulthood. Being a disease of the age at which decision of marriage is taken, the question of whether to marry or not and whether marriage will lead to improvement or deterioration in psychoses is equally faced by patients, their family members, and treating psychiatrists. Mental disorders and problems in marriage are closely linked although there is a controversy about the sequence. In India, marriages are usually arranged by parents and are influenced by a number of factors such as astrological compatibility, caste regulation, geographic proximity, and expectations of dowry. We have worked for two decades in this area. The work summarizes as “Effect of marriage on clinical outcome of persons with bipolar affective disorder: A case–control study.” Married persons had experienced more episodes of illness and for longer duration. Males are more prone for illness than females in both groups (married and never married). Marriage did not influence the severity of illness in persons with bipolar affective disorder. The effects of marriage on women with schizophrenia are as follows: This study concluded that most of the patients and relatives were of the opinion that marriage can cure mental illness. Child birth was found to be a protective factor for decreasing separation in cases. Severity of mental illness was slightly higher in cases than comparison group. It was observed that with increasing severity of illness marital adjustment deteriorates with antagonistic interaction among members. 

Substance use disorders: Need for public health initiatives
Rakesh Kumar Chadda

Indian Journal of Social Psychiatry 2019 35(1):13-18

Substance use disorders (SUDs) are associated with substantial contribution to the global burden of disease due to high prevalence, early age of onset, and chronic course. The associated physical health complications such as HIV, hepatitis B and C, and opportunist infections, stigma, myths and misconceptions, and a huge treatment gap further increase the problem. Thus, there is a strong need to take public health initiatives. Conventionally, common substances of abuse include licit substances such as tobacco and alcohol and illicit substances such as opioids, cannabis products, cocaine, barbiturates, amphetamines, and prescription drugs. The new psychoactive substances have brought a new challenge. Conventionally, the three approaches of supply reduction, demand reduction and harm reduction have been used to deal with the problem of SUDs. Preventive strategies encompassing primary, secondary, and tertiary methods need to be formally planned to meet this massive challenge. Creating awareness about the problem in the community and targeting myths and misconceptions are important to reduce the treatment gap. There is need to ensure availability and accessibility of affordable and acceptable treatment facilities, provide evidence-based treatment, and ensure ethical standards in care including coordination between health, social, and legal agencies. Relapse prevention and rehabilitation also need to be an important component of the public health policy. A well-planned public health approach involving all stakeholders is likely to be the most appropriate method to deal with the challenges imposed by the SUDs. 

Therapeutic relationship: Riding on a bumpy road and steering through to the destination
Abhishek Ghosh

Indian Journal of Social Psychiatry 2019 35(1):19-23

Therapeutic relationship runs a dynamic course; it usually grows and intensifies with time, but there could be unforeseeable twists and disruptions. The course, to no small extent, is contributed by the therapist's dispositions and expertise on a particular theoretical orientation. Expertise is dependent on experience, level, and quality of training. Disruptions, although unwanted, give an opportunity to reflect upon the shortcomings and are an impetus for a course correction, which more often than not gives a desirable result. In this case discussion, I shall describe the highs and lows in a therapeutic relationship. After the initial euphoria, the therapist's inexperience, limited skills, and a wrong decision would contribute to significant disruption. However, the therapist's awareness of his/her limitations, a motivation to learn, and active help from mentors and colleagues would provide momentum in the second half of the therapy, which finally would see the daylight of success. 

Comparative survey of factors associated with illness-related knowledge among patients with severe mental illness and their caregivers
Snehil Gupta, Mamta Sood, Rohit Verma, Jawahar Singh

Indian Journal of Social Psychiatry 2019 35(1):24-31

Background: Knowledge about the illness and treatment is important for treatment adherence and positive outcomes in patients with severe mental illnesses (SMIs) and their caregivers. The current study aimed at comparing the knowledge of the patients with SMI and their caregivers, and its relationship with their sociodemographic characteristics. Methodology: A cross-sectional, observational study conducted in the outpatient department of a tertiary care general hospital and comprised 50 dyads of patients with SMIs and their caregivers. Information was collected by a semi-structured questionnaire. Comparison of knowledge between groups was performed using the Chi-square test, and the relationship of knowledge with their sociodemographic variables was analyzed using logistic regression test. Results: There was a lack of knowledge among participating dyads for most of the illness- and treatment-related variables. A significant difference was observed between the two groups in regard to their knowledge about the name of the illness, how medical comorbidity and comorbid substance use affect psychiatric illness, brand name of the medicine, adverse effect, duration of treatment, role of investigation in diagnosis and treatment, and psychosocial rehabilitation (P < 0.001). The difference in knowledge was also observed regarding the formulation of medicine other than tablets and mechanism of its action (P < 0.05). Dyads with higher socioeconomic status had more knowledge about some but not all aspects of their illness. Conclusion: The patients and their caregivers lacked knowledge about many important illnesses-related variables. It is important to psychoeducate in routine clinical practice. 

Relationship between illness disability in patients with first-episode schizophrenia with caregivers' perception of their needs
Ragul Ganesh, Rohit Verma, Rachna Bhargava, Mamta Sood

Indian Journal of Social Psychiatry 2019 35(1):32-39

Introduction: The humanistic burden of schizophrenia is levied mostly upon the families in India which act as the primary source of caregiving. Studies have found that symptomatic patients with schizophrenia suffer from significant disability compared to those patients with minimal symptoms. Studies have reported positive correlation between patient's disability and higher number of needs perceived by caregivers of schizophrenia. There has been no evaluation of this aspect in first-episode schizophrenia (FES). Objective: The objective of this study was to evaluate the disability in patients with FES and find the relationship with the caregivers' perception of their needs. Methodology: This cross-sectional study included symptomatic patients with FES (Group 1; n = 30) along with their caregivers and patients with FES having minimal or no symptoms (Group 2; n = 30) along with their caregivers. The assessment was done using the World Health Organization Disability Assessment Schedule 2.0 for patients and Camberwell Assessment of Need-Short Appraisal Schedule for caregivers. The correlation was done among the level of disability in patients, patients' needs as perceived by their caregivers, sociodemographic, and clinical variables. Multiple regression analysis was done with needs as the dependent variable and other variables as independent predictors. Results: Among the patients with FES, Group 1 had higher disability scores than the Group 2 (t = 23.22, P < 0.01). Total needs of the patients as perceived by their caregivers were similar in both the groups. The unmet needs were more for Group 1 as compared to Group 2 (t = 16.45, P < 0.01). The former had more met needs compared to the latter (t = −13.23, P < 0.01). Disability in patients was positively correlated to illness duration (r = 0.65), unmet needs (r = 0.96), and total needs (r = 0.71). Sociodemographic parameters are not related to illness-related disability or caregivers' perception of the needs. Patients' disability, alogia, and asociality were the significant positive predictors of the unmet needs as perceived by caregivers in Group 1. Conclusion: Symptomatic patients with FES have more disability and more unmet patients' needs as perceived by their caregivers as compared to FES with minimal or no symptoms. 

Psychometric properties of the Hindi-translated version of the "Assessment of Recovery Capital" scale at a tertiary level de-addiction center in North India
Aniruddha Basu, Surendra Kumar Mattoo, Debasish Basu, BN Subodh, Suresh Kumar Sharma, Fazl E Roub

Indian Journal of Social Psychiatry 2019 35(1):40-46

Background/Objectives: The concept of “recovery capital” with regard to substance use draws upon the personal, social, cultural, and human resources in an individual to undergo recovery. However, lack of any structured instrument for its assessment in the local context necessitated the translation of the English self-assessment version of “Assessment of Recovery Capital” (ARC) scale to Hindi and the study of its psychometric properties. Methodology: In a cross-sectional study at a tertiary-level de-addiction center in Northwestern India, in the initial phase, forward translation to Hindi followed by expert panel back-translation, pretesting and cognitive interviewing were done. Thereafter, it was administered on 200 respondents of whom 100 were active alcohol-dependent or other illicit/pharmaceutical opioid-dependent users and another 100 dependent respondents were abstinent from such substances for the last 1 year. Results: Cognitive interviewing determined its face validity, whereas principal component analysis established a single-factor structure. It was shown to have good internal consistency (Cronbach's alpha = 0.86) and test-retest reliability (rho = 0.93, P < 0.001). Concurrent validity was established by comparing with the World Health Organization quality of life-BREF (P < 0.01), whereas predictive validity by significant area under the curve value of 82% and optimum cutoff of 41.5 (sensitivity: 81%, specificity: 71%) in the receiver operator characteristic curve. Divergent validity was established by lack of any significant positive correlation with the Addiction Severity Index (version 5.0). Conclusion: Hindi ARC has acceptable psychometric properties as a monitoring instrument for “recovery-oriented” de-addiction services. However, this needs to be studied in different settings with different substances longitudinally for its final validation. 

Trajectory of perinatal mental health in India
GT Harsha, Mithun Sadashiva Acharya

Indian Journal of Social Psychiatry 2019 35(1):47-54

The global burden of psychiatric disorders in women is on the rise, especially in the perinatal period. Despite this, the recognition of the need and delivery of health care in women of reproductive age group is scarce and still met by unscientific treatment modalities. Such a scenario is luring in India as well. We have focused on discussing the impact of culture on the treatment practices, different challenges faced, nosological status, and management principles of different perinatal psychiatric disorders. We mainly employed the Google Scholar search engine to look into articles of all sorts (review articles, case reports, expert opinions, newspaper extracts, and Indian government websites) and reviewed them. We also acknowledged the information extracted from these articles which were highly valuable and enlightening. The perspective of the health-care delivery in the perinatal group of population has been changing over the years, but still there is lot to change. A holistic, scientific, evidence-based approach is a definite need toward attaining this goal. 

Perinatal (Mother-infant) psychiatry in India: Now is the right time to talk
Balaji Bharadwaj

Indian Journal of Social Psychiatry 2019 35(1):55-56

Brain Circulation

The endocannabinoid system and stroke: A focused review
Bradley Kolb, Hamidreza Saber, Hassan Fadel, Gary Rajah

Brain Circulation 2019 5(1):1-7

Stroke is an important cause of morbidity and mortality worldwide. Development of novel neuroprotectants is of paramount importance. This review seeks to summarize the recent evidence for the role of the endocannabinoid signaling system in stroke pathophysiology, as well as the evidence from preclinical studies regarding the efficacy of cannabinoids as neuroprotective therapies in the treatment of stroke. Recent evidence from rodent models implicating cannabinoid 1 receptor (CB1R), cannabinoid 2 receptor (CB2R), and CB1R and CB2R co-antagonism as neuroprotective strategies in stroke are reviewed. Rodent evidence for the therapeutic role of the endocannabinoid system in treating poststroke depression is reviewed. Finally, evidence for the role of cannabidiol, a publicly available cannabinoid that does not bind directly to known endocannabinoid receptors, as a stroke neuroprotectant is also reviewed. The review closes with a consideration of the role of human cannabinoid abuse in stroke and considers future directions for research on endocannabinoid-based stroke therapeutics.

Treatment for ischemic stroke: From thrombolysis to thrombectomy and remaining challenges
Tiandong Leng, Zhi-Gang Xiong

Brain Circulation 2019 5(1):8-11

Stroke is a leading cause of death and long-term disabilities. Despite decades of extensive efforts in search of brain injury mechanisms and therapeutic interventions, pharmacological treatment is limited to the use of thrombolytic agent tissue plasminogen activator, which has limited therapeutic time window and potential side effect of intracranial hemorrhage. Over the past few years, endovascular thrombectomy with stent-retriever devices combined with advanced imaging modalities has transformed the standard of stroke care, offering an opportunity to improve the outcome in selected patients as late as 24 h after the onset of stroke. This mini-review summarizes the advancement in the treatment of ischemic stroke, from thrombolysis to thrombectomy and remaining challenges in the field.

Effect of remote ischemic preconditioning on cerebral vasospasm and biomarkers of cerebral ischemia in aneurysmal subarachnoid hemorrhage (ERVAS): A protocol for a randomized, controlled pilot trial
RP Sangeetha, VJ Ramesh, Sriganesh Kamath, Rita Christopher, Dhananjaya I Bhat, HR Arvinda, Dhritiman Chakrabarti

Brain Circulation 2019 5(1):12-18

INTRODUCTION: Cerebral vasospasm is a dreaded complication of aneurysmal subarachnoid hemorrhage (aSAH) predisposing to delayed cerebral ischemia. We intend to study the cerebroprotective effects of remote ischemic preconditioning (RIPC) in patients with aSAH. MATERIALS AND METHODS: This is a single-center, prospective, parallel group, randomized, pilot trial, approved by the Institutional Ethics Committee. Patients with aSAH admitted to our hospital for surgical clipping; fulfilling the trial inclusion criteria will be randomized to true RIPC (n = 12) (inflating upper extremity blood pressure cuff thrice for 5 min to 30 mmHg above systolic blood pressure) or sham RIPC (n = 12) (inflating blood pressure cuff thrice for 5 min to 30 mmHg) in 1:1 allocation ratio using a computerized random allocation sequence and block randomization. RESULTS: Our primary outcome measure is vasospasm on cerebral angiography and transcranial Doppler study, and concentration of serum S100B and neuron-specific enolase at 24 h after RIPC and on day 7 of ictus. Our secondary outcomes are safety of RIPC, cerebral oxygen saturation, and Glasgow coma score, and extended Glasgow outcome scale scores at discharge and at 1, 3, and 6 months following discharge. Outcome measures will be assessed by an observer blinded to the study intervention. CONCLUSION: If our preliminary results demonstrate a beneficial effect of RIPC, this would serve as a clinically applicable and safe preemptive method of protection against cerebral ischemia.

Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis
Evan A Katz, Seana B Katz, Curtis A Fedorchuk, Douglas F Lightstone, Chris J Banach, Jessica D Podoll

Brain Circulation 2019 5(1):19-26

CONTEXT: Loss of cervical lordosis is associated with decreased vertebral artery hemodynamics. AIM: The aim of this study is to evaluate cerebral blood flow changes on brain magnetic resonance angiogram (MRA) in patients with loss of cervical lordosis before and following correction of cervical lordosis. SETTINGS AND DESIGN: This study is a retrospective consecutive case series of patients in a private practice. MATERIALS AND METHODS: Cervical lordosis of seven patients (five females and two males, 28–58 years) was measured on lateral cervical radiographs ranging from −13.1° to 19.0° (ideal is −42.0°). Brain MRAs were analyzed for pixel intensities representing blood flow. Pixel intensity of the cerebral vasculature was quantified, and percentage change was determined. STATISTICAL ANALYSIS USED: A Student's t-test established significance of the percentage change in cerebral blood flow between pre- and postcervical lordosis adjustment images. Regression analysis was performed. An a priori analysis determined correlation between cervical lordosis and change in MRA pixel intensity. The statistician was blinded to the cervical lordosis. RESULTS: Pixel intensity increased 23.0%–225.9%, and a Student's t-test determined that the increase was significant (P < 0.001). Regression analysis of the change in pixel intensity versus the cervical lordosis showed that as the deviation from a normal cervical lordosis increases, percentage change in pixel intensity on MRA decreases. CONCLUSION: These results indicate that correction of cervical lordosis may be associated with an immediate increase in cerebral blood flow. Further studies are needed to confirm these findings and understand clinical implications.

Commentary on "Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis"
Kenneth I Maynard

Brain Circulation 2019 5(1):26-26

Early signs of middle cerebral artery infarction on multidetector computed tomography: Review of 20 cases
Sultan Alshoabi, Ramzi Alnajmani, Mohamed Shamsuddin, Moawia Gameraddin

Brain Circulation 2019 5(1):27-31

OBJECTIVE: This study intended to assess the occurrence of early signs of middle cerebral artery (MCA) on multidetector computed tomography (MDCT) in correlation with duration of the clinical features of stroke. PATIENTS AND METHODS: This retrospective study analyzed the electronic records of 20 patients with MCA infarction. The detected signs studied according to the onset of the clinical features of stroke to the time of CT imaging. RESULTS: Out of 20 patients with MCA infarction included in this study, the results revealed a significant relationship between the presence of insular ribbon sign and/or subtle hypodensity and hyperacute infarction (P < 0.001 and 0.003, respectively). Results revealed significant relationship between the occurrence of hypodense area, effacement of the cortical sulci, and compression of the ipsilateral lateral ventricle with acute infarction (6–72 h), (P = 0.006, 0.007, and 0.002) (odds ratio = 0.047, 0.050 and 0.028) and (95% confidence interval = 0.004–0.552, 0.004–0.597 and 0.002–0.367) respectively. CONCLUSION: MDCT can detect nearly half of MCA infarctions in the first 6 h. Insular ribbon sign and subtle hypodensity were the most significant findings in the first 6 h of stroke. Hypodense area was a significant sign after 6 h. Diabetes mellitus and ischemic heart disease were the most common risk factors. Hemiparesis was the most common clinical finding in MCA infarction.

Utilization and safety of extracranial–intracranial bypass surgery in symptomatic steno-occlusive disorders
Hamidreza Saber, Gary Rajah, Mohan Palla, Sunil A Sheth

Brain Circulation 2019 5(1):32-35

OBJECTIVE: The objective of this study was to investigate patterns of utilization and safety of extracranial–intracranial (EC-IC) bypass in patients with symptomatic cerebrovascular steno-occlusive disorders. METHODS: Patients with one of the steno-occlusive conditions (defined as symptomatic intracranial stenosis, extracranial stenosis, and moyamoya disease) were identified using all nonfederal hospitalizations in New York (2005–2014) and Florida (2005–2015). EC-IC bypass surgery was defined using the corresponding procedure codes. Patients were included if there was a prior history of ischemic stroke or transient ischemic attack. Patients were excluded for any preceding diagnosis of cerebral hemorrhage, aneurysm, or trauma. The primary outcome was perioperative ischemic stroke, cerebral hemorrhage, or mortality occurring within 30 days of surgery. We also determined yearly trends for the volume of EC-IC bypass procedures in the study period. RESULTS: Among 346 patients with steno-occlusive disease treated with EC-IC bypass, median age was 52.5 years and 52.5% were female. Rates of EC-IC bypass surgery procedure increased until 2011 and then decreased coinciding with the publication of the Carotid Occlusion Surgery Study trial. Thirty-day event rates of stroke, hemorrhage, or death decreased in patients treated with EC-IC bypass (odds ratio: 0.2, confidence interval: 0.0.4–0.99; P = 0.03) over the 10-year study period. CONCLUSIONS: Overall utilization of EC-IC bypass procedure is relatively low, whereas the 30-day complication rates for patients with steno-occlusive conditions appear to be relatively low and improving. Further research is needed to confirm these findings and to determine the subset of patients who would most likely benefit from this intervention.

Snuff box radial access: A technical note on distal radial access for neuroendovascular procedures
Gary Rajah, Richard Justin Garling, Miles Hudson, Ali Luqman

Brain Circulation 2019 5(1):36-40

Prevention of traumatic brain injury-related death using the brain-gut axis
Usama Khan, Yuchuan Ding

Brain Circulation 2019 5(1):41-42

Family Medicine and Primary Care

Physicians and healthcare professionals in the era of #Metoo
Jagdish Khubchandani, Raman Kumar, Sharon L Bowman

Journal of Family Medicine and Primary Care 2019 8(3):771-774

Gender Based Violence is and has been a pervasive problem in our societies and communities. In recent times, there has been a renewed emphasis on the problem given the #MeToo movement and social activism. In this editorial, we discuss healthcare professions and gender-based violence in light of the #MeToo movement. Also, three major types of exchanges in the healthcare field have been described in relation to gender-based violence. Implications for practice and prevention of gender-based violence in healthcare systems worldwide have been discussed. Healthcare industry is one of the biggest and most prominent enterprises worldwide with lives at stake. Safety of providers and patients and violence free healthcare workplaces can significantly improve health outcomes. The #MeToo movement reminds us of our responsibilities and professional codes of conduct and demands that we always keep at the forefront—the rights of those we serve or interact with. 

Public health crisis of road traffic accidents in India: Risk factor assessment and recommendations on prevention on the behalf of the Academy of Family Physicians of India
Ranabir Pal, Amrita Ghosh, Raman Kumar, Sagar Galwankar, Swapan Kumar Paul, Shrayan Pal, Debashis Sinha, AK Jaiswal, Luis Rafael Moscote-Salazar, Amit Agrawal

Journal of Family Medicine and Primary Care 2019 8(3):775-783

Roads are considered a sign of development bringing colossal benefits to community as socioeconomic and logistic facilitator. Yet, growth of road network has brought road crashes leading to civic pain from premature deaths of productive age group. In 2017, 16 citizens were killed and 53 injured every hour on Indian roads as per officially reported data, while a fair number go unreported. This is unacceptably high when compared with international standards. Risk correlates of road traffic injuries (RTIs) need to be redefined so as to form a continuum with other confounding factors that impact to take lives on road. Risk factors impacting RTIs vary from human components to the roles and responsibilities of healthcare stakeholders. We should have made roads safer for all citizens because a large percentage of population – children, pedestrians, cyclists, motorcyclists, and the elderly – are most vulnerable. A taskforce was set up by the Academy of Family Physicians of India to scientifically analyze the literature available to assess risks and put forward appropriate recommendations. 

Fixing accountabilities and finding solutions to tackle acute (communicable) diseases viewed as collateral damage due to errors of omission and commission in primary care
Sudip Bhattacharya, Amarjeet Singh

Journal of Family Medicine and Primary Care 2019 8(3):784-787

Out-patient coverage: Private sector insurance in India
Ramandeep S Gambhir, Ravneet Malhi, Saru Khosla, Rina Singh, Arvind Bhardwaj, Mandeep Kumar

Journal of Family Medicine and Primary Care 2019 8(3):788-792

Background: There has been a growth of 25% in the health insurance business in India during the last few years with the expansion of the private health insurance sector. The share of the private health insurance companies has increased considerably, despite the fact that from the patients' point of view, health insurance is not a good deal. Aim: To provide information and assess the current status of private sector insurance with regard to out-patient coverage in India. Materials and Methods: The present review was conducted after doing extensive literature search of peer review journals in Pubmed and various search engines like Google. Data of Indian private health insurance companies was also utilized. No limitation in terms of publication date and language was considered. The main focus of the present review would be on the private health insurance sector with a spotlight on the out-patient coverage and various obstacles faced by the private health insurance sector. Results: Out-patient (OPD) coverage is one of the important emerging trends in the private sector health insurance. OPD cover assists the insured to claim expenses other than that incurred during hospitalization. However, it is still not a full-fledged offering under health insurance and major insurance companies are providing this cover for an additional premium. Conclusion: Private is strongly being advocated and receiving growing consideration by our country's policy makers that can deal with alarming health care challenges in India. However, it is not the only option. 

Pulse therapy: Opening new vistas in treatment of pemphigus
Subhasish Mustafi, Rupam Sinha, Samhita Hore, Suman Sen, Subhadeep Maity, Pritha Ghosh

Journal of Family Medicine and Primary Care 2019 8(3):793-798

Pemphigus is comprised of a group of life-threatening autoimmune diseases that is characterized by circulating IgG antibodies targeting several types of keratinocyte antigens. After introduction of systemic steroids, survival has improved dramatically. However, mortality and morbidity were still very high due to side effects of steroids. Pulse therapy is defined as discontinuous/intermittent intravenous infusion of very high doses of corticosteroids along with certain immunosuppressive agents over a short period. This therapy was introduced to minimize the side effects of conventional corticosteroid therapy. The target is to achieve a faster response and stronger efficacy and to decrease the need for long-term use of systemic corticosteroids. As a result, this therapy has gained its popularity since three decades. The purpose of this article is to review the various available pulse therapy regimens with dosage, indications and contraindications and side effects. 

The relationship between gender, age, anxiety, depression, and academic achievement among teenagers
Mahnaz F Khesht-Masjedi, Somayeh Shokrgozar, Elahe Abdollahi, Bahareh Habibi, Tahereh Asghari, Reyhaneh Saber Ofoghi, Sabra Pazhooman

Journal of Family Medicine and Primary Care 2019 8(3):799-804

Background: Researchers have shown that the anxiety and depression have an important role in academic achievement. Objectives: This study is designed to identify the impact of anxiety and depression on academic achievement in students living in North of Iran. Patients and Methods: In this study 666 secondary school students (13–19 years old) were involved in North of Iran, were involved in this study. We used two instruments for data collection, The Beck Anxiety Inventory and The Beck Depression Inventory. Results: The results indicate that girls with 21.8% were more anxious than boys with 11.6% (F = 21.448, t = 5.420), while boys with 29.5% are more depressed than girls with 17.8% (F = 25.530, t = 4.847). Additionally, there were a significantly negative correlation between academic achievement with anxiety and depression. There was no statistically significant difference in the mean of anxiety and age between teenagers, but a significant depression level of respondents who are 18 and 19 years old was significantly different from other ages. Conclusions: It is recommended that along with academic performance, mental health be developed in school settings using support strategies such as educational guidance and counseling, teaching life skill programs, and psychotherapy. It was concluded that there is an urgent need to pay more attention to the anxiety and depression of adolescents in Iran. The findings of the study will be useful in assisting educators, counselors, and psychologists to develop strategies to enhance students' psychological well-being. 

Parent's knowledge, attitude, and practice about children car seats at Unaizah city, KSA
Ghadah A AlSallum, Alshamoos A Alwassel, Abdullah M Alshushan, Abdulrahman K Abaalkhail, Mohammad A Alhasoon, Abdullah S Aldamigh

Journal of Family Medicine and Primary Care 2019 8(3):805-811

Background: Motor vehicle collision (MVC) is a major cause of death in children worldwide. Using children car seats will stabilize them during accidents and decrease the morbidity and mortality from MVC dramatically. There is no study in Saudi Arabia about car seat use and relationship between using it and children morbidity and mortality following a car accident. Objectives: To assess knowledge, attitude, and practice of children car seats among parents at Unaizah city, KSA, to assess the level of awareness regarding the children car safety system, to determine the parent level of education, socioeconomic status, and other factors affecting their behavior regarding car seats, to determine the prevalence of car seat use among parents in Unaizah city, and to assess the effectiveness of car seat policies on parents' behavior. Design: Cross-sectional study. Settings: Public and private pediatric clinics at Unaizah city in Qassim region. Materials and Methods: The study was conducted from May to June 2018, among parents with child ≤7 years old. Anyone who could not complete the questionnaire for any reason was excluded from our study. SPSS version 20 has been used to analyze all data. Main Outcome Measures: To assess knowledge, attitude, and practice of children car seats among parents at Unaizah city, KSA. Sample Size: 350. Results: There were 350 participants who were included in this study of which females were dominant 77.1%. The age range of parents was 25–35 years old. Most of them complied with the seatbelt policy (56.7%). Among these numbers, 130 participants use a seatbelt for security reason while others were to protect from irregularities. More parents do not put baby seat in the car (57.3%) while 57 participants use child seat every time the child rides in the car. Conclusion: The overall knowledge, attitude, and practices toward children car safety seat in this study was relatively low. This signifies the need of parents to step up their awareness to safe guard their children while on the road. Limitations: Small sample size and limited to pediatrics clinics visitors. 

Knowledge and awareness toward anterior cruciate ligament (ACL) injury among population of Aseer region, Saudi Arabia
Alsheri Shaker, Mohammed Sultan M. Alshehri, Fayez Saeed Alshehri, Mazen Mohammed Alshahrani, Meshary Safar Alshahrani, Omar Mohammed Alamri

Journal of Family Medicine and Primary Care 2019 8(3):812-817

Purpose: The aim of this article is to determine the knowledge and awareness of population toward anterior cruciate ligament (ACL) injury in Aseer region, and to determine the extent of knowledge about what does a person with ACL injury suffer from, and thus investigate the main sources of information that public obtained their medical information about sport injury from. Materials and Methods: This is a cross-sectional study based on a questionnaire distributed to the participants either in malls, campuses, or campaigns and filled by them in Aseer region. A sample of 576 participants was successfully interviewed. Convenience sampling method was used. Results: Nearly all of the participants considered this injury as a multi-factorial incident resulting from a combination of any of the following risk factors: sports, high body weight, heavy housework, and car accidents. Regarding mechanisms responsible about occurrence of ACL injuries during playing sports, the majority (60.8%) proposed a combination of two or more incorrect technical movements: lack of self-protection awareness, insufficient preparation, and overload of exercise. Regarding the participant's information about methods that could decrease pain of ACL injury, about three quarters of all participants (72.2%) stated that resting could alleviate pain. Moreover, most of individuals with previous ACL injury confirmed this. In addition, those with pervious ACL injury supported the role of ice significantly more than the remainder (53.6% vs. 48.1%). Prescription pain medications were selected by 47.3% of all participants. In all, 53.8% of all participants considered Internet as a main source of information about ACL injury. Conclusion: Findings indicated reasonable awareness of the general population in Aseer region about the seriousness of ACL injury, but there was a lack of information about risk factors other than sports, that is, dangerous actions that increase incidence of ACL injuries and their characteristic symptoms. 

Prevalence of splenic vein thrombosis and risk of gastrointestinal bleeding in chronic pancreatitis patients attending a tertiary hospital in western India
Vikas Pandey, Mallangoud Patil, Ruchir Patel, Alisha Chaubal, Meghraj Ingle, Akash Shukla

Journal of Family Medicine and Primary Care 2019 8(3):818-822

Background: Splenic vein thrombosis (SVT) is most commonly caused by acute and chronic pancreatitis (CP). Variceal gastrointestinal (GI) bleeding is a potentially life-threatening event in such patients. The aim of this study was to determine the prevalence of SVT in CP patients and the risk of variceal GI bleeding. Materials and Methods: A total of 187 consecutive patients with a diagnosis of CP were assessed for the presence of SVT at the gastroenterology department of a tertiary care hospital. Thirty seven patients had evidence of SVT. Patients with portal vein thrombosis or cirrhosis were excluded. Potential factors associated with SVT were assessed. Results: Of the 187 CP patients assessed, 37 patients (19.8%) (male 33; female 4; mean age 41.9 years) had evidence of SVT. Among patients with SVT, most common etiology of CP was alcohol abuse (70.3%). Seven patients (18.9%) with SVT presented with clinically significant upper GI bleeding. The source of GI bleeding was gastric varices in three patients (8.1%) and non-variceal source in four patients (10.8%). All three patients with gastric varices were managed by splenectomy. There were no new variceal bleeding episodes in other 33 patients (89.2%) during mean follow-up of 16.4 months. On comparison of patients with and without SVT, the factors associated with significantly higher incidence of SVT were smoking (P = 0.019, odds ratio 3.021, 95% confidence interval 1.195–7.633) and presence of pseudocyst (P = 0.008, odds ratio 3.743, 95% confidence interval 1.403–9.983). Complete resolution of SVT was seen in three patients (8.1%) after resolution of underlying pseudocyst. Conclusion: SVT is a common complication of CP, particularly in patients with pseudocysts and history of smoking. Most patients remain asymptomatic and the risk of variceal bleeding is low. Splenectomy is the treatment of choice in patients with variceal bleeding. Conservative approach is preferred in other patients. Resolution of pseudocysts may lead to resolution of SVT in some patients. 

Beneficial effects of gluten free diet on IgA tissue transglutaminase levels and various growth parameters in celiac disease patients
Dayanand Hota, Kapil Bhalla, Sanjiv Nanda, Ashish Gupta, Shuchi Mehra

Journal of Family Medicine and Primary Care 2019 8(3):823-827

Context: In the resource poor country like India it is difficult to get HLA screening and EMA testing in patients with celiac disease in small centres. Aims: To study the effect of gluten free diet on IgA tissue transglutaminase levels and various growth parameters in patients with celiac disease. Settings and Design: This was a prospective study conducted in the department of paediatrics of a tertiary referral hospital in north India in 3 stages viz. on presentation, after 3 months and 6 months of initial presentation. Materials and Methods: 392 patients with symptoms suggestive of celiac disease were screened for IgA tTG levels more than 10 folds of upper limit of normal. 50 cases (who followed up for 6 months regularly) were enrolled in the study. Spectrum of various growth and clinical parameters were also studied. Statistical analysis used: Statistical analysis was performed by the SPSS version 20.0. Data were checked for normality before statistical analysis. p value less than 0.05 was considered statistically significant. Results: 50 cases were enrolled in study. After initiation of gluten free diet, improvements were seen in various growth factors like height (12.71%) and weight (3.47 cm) after 6 months. Serum tTG(IgA) levels decreased to 94.88±55.35 U/mL from baseline level of 202±83.96 U/mL after 6 months. Conclusions: Gluten free diet has major role in improvement in growth parameters as well as anemia. So, early detection of celiac disease is an important step in prevention of morbidity associated with this chronic disease. 

Tropical Medicine

SARS and its treatment strategies
Chun-Song Hu, Tengiz Tkebuchava

Asian Pacific Journal of Tropical Medicine 2019 12(3):95-97

This paper briefly review severe acute respiratory syndrome, a devastating disease which broke out 15 years ago, and its treatment strategies. With the newly discovered SARSr-CoV strain in Yunnan, China, and the help of new technologies such as RNA interference, DNA vaccines, CRISPR technology and base editing, and intervention of RT-ABCDEF (iRT-ABCDEF), a standardized comprehensive program, people can better fight severe acute respiratory syndrome and other major virus-communicable diseases like highly pathogenic avian influenza and dengue fever with these powerful tools in the future. 

Phyllanthus acidus (L.) Skeels and Rhinacanthus nasutus (L.) Kurz leaf extracts suppress melanogenesis in normal human epidermal melanocytes and reconstitutive skin culture
Moragot Chatatikun, Takeshi Yamauchi, Kenshi Yamasaki, Anchalee Chiabchalard, Setsuya Aiba

Asian Pacific Journal of Tropical Medicine 2019 12(3):98-105

Objective: To determine the effect of extracts from Phyllanthus acidus (P. acidus) (L.) Skeels and Rhinacanthus nasutus (R. nasutus) (L.) Kurz leaves on melanogenesis and the underlying mechanism in normal human epidermal melanocytes (NHEM) and a reconstitutive skin model. Methods: NHEM and a reconstitutive skin model were stimulated with ethanol extracts of P. acidus (L.) Skeels and R. nasutus (L.) Kurz leaves. mRNA expression of microphthalmia-associated transcription factor (MITF), tyrosinase (TYR), tyrosinase-related protein 1 (TYRP1) and dopachrome tautomerase (DCT) were examined by real-time PCR. The melanin content in NHEM was also measured. Moreover, protein levels of tyrosinase were determined using western blot analysis. Results: In NHEM and the reconstitutive skin model, ethanol extracts from P. acidus (at 12.5 and 25.0 μg/mL) and R. nasutus (at 6.25 and 12.50 μg/mL) significantly diminished mRNA expression of MITF, TYR, TYRP1 and DCT in a concentration-dependent manner. P. acidus and R. nasutus extracts also reduced the amount of melanin in α-MSH-stimulated NHEM. Moreover, P. acidus and R. nasutus extracts markedly suppressed tyrosinase at the translational level in the reconstitutive skin model. Conclusions: P. acidus and R. nasutus extracts significantly reduced melanogenesis in NHEM and the reconstitutive skin model, suggesting that P. acidus and R. nasutus extracts can inhibit melanin synthesis through downregulation of MITF, TYR, TYRP1 and DCT. Therefore, the ethanol extracts of P. acidus and R. nasutus contain compounds that have the potential for development as a skin lightening agent for the treatment of hyperpigmentation disorder or melasma. 

Antihydatic and immunomodulatory effects of Algerian propolis ethanolic extract: In vitro and in vivo study
Nahla Deghbar, Dalila Mezioug, Touri Kahina, Yacine-Miloud Medjdoub, Chafia Touil- Boukoffa

Asian Pacific Journal of Tropical Medicine 2019 12(3):106-116

Objective: To evaluate the in vitro and in vivo effect of the Algerian propolis ethanolic extract (EEP) against Echinococcus granulosus (E. granulosus) infection. Methods: In vitro scolicidal activity of EEP was investigated on the protoscolices of hydatid cyst. This in vitro study was conducted by using an in vivo assay. BALB/c mice were inoculated with E. granulosus and treated with propolis for three months. Hydatid cysts development was assessed. Nitric oxide (NO), tumor necrosis factor alpha (TNF-α) production and inducible NO synthase, NF-κB, and TNF-α spleen expression were estimated by Griess method and immunofluorescence respectively. Results: Our study revealed that EEP has a high scolicidal activity against E. granulosus. Oral administration of EEP decreased TNF-α, NF-κB and inducible NO synthase expression in the spleen tissues in the CE+EEP group, in comparison with the CE group. Concomitantly, EEP treatment caused an important systemic decrease in NO and TNF-α levels. These findings are associated with the reduction of CE development. Conclusions: This is the first report demonstrating with interest the antihydatic and immunomodulatory effects of the Algerian EEP, suggesting its therapeutic potential for the hydatid disease treatment. 

Chemical composition of Mentha suaveolens and Pinus halepensis essential oils and their antibacterial and antioxidant activities
Abdelhakim Bouyahya, Omar Belmehdi, Jamal Abrini, Nadia Dakka, Youssef Bakri

Asian Pacific Journal of Tropical Medicine 2019 12(3):117-122

Objective: To determin the chemical compounds of Mentha suaveolens (M. suaveolens) and Pinus halepensis (P. halepensis) essential oils (Eos) and evaluate their antioxidant and antibacterial activities. Methods: The chemical composition of P. halepensis and M. suaveolens EOs was determined by GC-MS analysis. The antioxidant activity was evaluated using DPPH, ABTS and FRAP assays. The antibacterial effect was tested against 6 bacterial strains using the well diffusion method and micro-dilution assay. Results: The major components of P. halepensis EOs were β-caryophyllene (28.04%), myrcene (23.81%) and α-pinene (12.02%). However, piperitenone oxid (56.28%), piperitenone (11.64%) and pulegone (6.16%) were the major components of M. suaveolens EOs. M. suaveolens EOs showed remarkable antioxidant activities compared with P. halepensis EOs, showing antioxidant capacity values of IC50=(64.76±2.24) μg/mL, IC50=(82.73±3.34) μg/mL, and IC50=(93.35±4.45) μg/mL, revealed by DPPH, ABTS and FRAP assays, respectively. However, P. halepensis EOs showed interesting antibacterial effects against all bacterial strains. The most sensible strains to P. halepensis EOs were Staphylococcus aureus [(34.00±0.50) mm], Listeria monocytogenes [(31.00±1.50)] mm and Proteus mirabilis [(29.00±2.25)mm]. Furthermore, the lowest minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) values were revealed by P. halepensis EOs against Staphylococcus aureus [MIC=MBC=0.125% (v/v)] and Listeria monocytogenes [MIC=MBC=0.25% (v/v)]. Conclusions: P. halepensis and M. suaveolens EOs contain bioactive compounds that could have potential applications against bacterial infections and oxidative stress related diseases as well as for food conservation. However, further investigations are necessary to isolate and investigate the action mechanisms of these bioactive compounds. 

Isolation and structural elucidation of antifungal compounds from Curcuma amada
Jesmin Akter, Kensaku Takara, Md. Zahorul Islam, Md. Amzad Hossain, Ayako Sano, De-Xing Hou

Asian Pacific Journal of Tropical Medicine 2019 12(3):123-129

Objective: To isolate and identify the antifungal compounds from Curcuma amada. Methods: The antifungal activity was measured by the diameter of colonies grown on Petri dish, microscopic observation, and CLSI microdilution methods. The antifungal compounds were isolated through bioactivity guided purification by using silica gel and high-performance liquid chromatography. Structural identification of the antifungal compounds was conducted using 1H NMR, 13C NMR, and liquid chromatography-tandem mass spectrometry. Results: The purified antifungal compounds were zederone and furanodienone. These two compounds showed dose-dependent antifungal activity against Fusarium solani sensu lato. The concentration required for 50% growth inhibition (IC50) of FSSL ranged from 115 to 129 μM and 82 to 91 μM for zederone and furanodienone, respectively. Conclusion: This study suggested that the isolated compounds from Curcuma amada could be promising natural antifungal agents to control the diseases caused by Fusarium solani sensu lato. 

Status of intestinal parasitic infections among rural and urban populations, southwestern Iran
Molouk Beiromvand, Esmat Panabad, Abdollah Rafiei

Asian Pacific Journal of Tropical Medicine 2019 12(3):130-136

Objective: To evaluate the prevalence and risk factors of intestinal parasitic infections in the urban and rural areas of Shushtar County, southwest Iran. Methods: A total of 1 008 fecal samples were analyzed by direct smear examination, formalin-ether concentration, and Ziehl-Neelsen and trichrome staining; furthermore, PCR was used to distinguish Trichostrongylus and hookworm species based on 28S rRNA gene. Results: Totally, 16.0% cases tested positive, either with a pathogenic or a non-pathogenic parasite. Protozoa were detected in 14.0%, helminths in 1.0%, protozoa and helminth co-infections were detected in 0.3%, and co-infections of two protozoa were detected in 0.7% of cases. The most common protozoa and helminths were Giardia duodenalis (7.7%) and Trichostrongylus spp. (0.5%), respectively. Among five microscopy Trichostrongylus positive cases, Trichostrongylus culbriformis was successfully identified in three isolates by sequencing. In the rural areas, the prevalence of parasitic infection was higher (9.8%) than that in the urban areas (6.2%). A significant association was found between educational level, type of drinking water, animals contact, hand-washing, and clinical symptoms. Conclusions: This study indicates that intestinal parasitic infections remain as a public health priority in Shushtar County. It seems that drinking water and environmental sanitation are the main risk factors of parasitic infections in rural areas. 

X-linked Toll-like receptor 7 polymorphism associated with susceptibility to Chikungunya Fever
Daniela M Rauseo, Mercedes Fernández-Mestre

Asian Pacific Journal of Tropical Medicine 2019 12(3):137-141

Objective: To investigate the association between TLR3 and TLR7 polymorphisms with susceptibility and clinical manifestations of Chikungunya Fever. Methods: A total of 177 individuals were studied: 73 patients with a confirmed diagnosis for Chikungunya virus and 104 non-infected individuals. Polymorphisms were determined by Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP). Results: Our analysis showed an increased CC genotype frequency of the TLR7 rs3853839 polymorphism in male patients compared to control (29% versus 2%, respectively; OR=20.69; 95 % CI= 2.55-167.36; P<0.001). Furthermore, arthritis (acute and chronic) was frequently found in CC male patients. On the contrary, 65% of CG carriers were no-infected males (29% versus 65%, respectively; OR=0.23, 95% CI=0.48-3.04; P=0.002). Finally, we observed a higher frequency of lymphopenia in CG male patients (CG=666.86±233.77, GG=1,314.27±752.29 cells/mm3, P=0.047). Conclusions: Our results suggest the TLR7 rs3853839 polymorphism is associated with lymphopenia and increased susceptibility to Chikungunya Fever in males. 

Occurrence of Escherichia coli virulence genes in feces of wild birds from Central Italy
Fabrizio Bertelloni, Errica Lunardo, Guido Rocchigiani, Renato Ceccherelli, Valentina Viginia Ebani

Asian Pacific Journal of Tropical Medicine 2019 12(3):142-146

Objective: To investigate the potential role of wild birds as fecal spreaders of enteropathogenic, enterohemorrhagic and Shiga-toxins producing Escherichia coli (E. coli), enteropathogenic E. coli, enterohemorrhagic E. coli and Shiga toxin-producing E. coli strains. Methods: Fecal samples collected from 121 wild birds of different orders and species were submitted to molecular analyses. In particular, eaeA encoding intimin, hlyA encoding for hemolysin, stx1 and stx2 genes encoding Shiga-toxins 1 and 2, respectively, were investigated. Results: Overall, 21(17.35%) fecal samples resulted positive for at least one of the investigated genes. In detail, 12(9.91%) samples were positive for eaeA, 10(8.26%) for stx1, 4(3.31%) for hylA and 1(0.83%) for stx2. An owl (Athene noctua) positive for the four investigated genes suggesting that it harbored a STEC strain. However, virulence genes characterizing EPEC, and EHEC strains were mainly found among seagulls, waterfowl and feral pigeons. Conclusions: Seagulls, waterfowl and feral pigeons, which frequently reach and contaminate rural, urban and peri-urban areas with their droppings, may be important sources of E. coli infection for other animals and humans. 

Plastic Surgery

Traction vasculogenesis: Experimental vessel elongation by traction in rat model
Cagil Meric Erenoglu, Yigit Ozer Tiftikcioglu, Yigit Uyanikgil, Turker Cavusoglu

Turkish Journal of Plastic Surgery 2019 27(2):44-48

Background: Microsurgeons may face inadequate vessel length in traumatic or post-resection vascular defects and flap surgery. As tissue regeneration by mechanical forces is possible like in tissue expansion and distraction osteogenesis, we questioned the effect of traction forces on isolated vessels, generated by an internal maxillary distraction device to overcome such problem. Methods: 30 Wistar-Albino rats were randomized in two groups as control and traction. By an internal maxillary distraction device placed subcutaneously to abdominal region, femoral artery and vein of traction group were applied daily traction for 10 days perpendicular to their course. Control group received the same procedure but no traction was applied. Vessel length, blood flow and histologic and microangiographic changes were evaluated on postoperative 11th day. Results: Final length of vessels was found to be higher in the traction group (21.93 mm) compared to control group (12.86 mm). (P = 0.000) Blood-flow patency rate of artery and vein was found 100 % in control group (n = 15) and 80 % in experiment group (n = 12). Microangiographic study showed patent blood flow in both control and traction groups. Histologic evaluation showed vascular wall thickening, perivascular adipocyte and neutrophil infiltration and vein lumen enlargement compared to control group. Conclusion: The preliminary “traction vasculogenesis” technique is found to be a promising technique to gain vessel length in vascular shortness problems. With further studies and refinements this technique may be carried to clinical applications in cases of vascular inadequacy. 

The effects of different amounts of thrombin application on fat graft viability in rats: An experimental study
Caner Kacmaz, Kaan Gideroglu, Emre Guvercin, Gaye Taylan Filinte, Mehmet Bozkurt, Deniz Filinte

Turkish Journal of Plastic Surgery 2019 27(2):49-55

Aims: The most important disadvantage of fat graft, which is also a late-term complication, is graft resorption. The aim of this study is to evaluate the effect of thrombin, which is reported to increase the tissue regeneration and angiogenesis in many areas, to viability of fat graft. Settings and Design: Twenty Wistar-Albino type adult male rats were used in the study. They were divided into four groups as one control group and three experimental group. Subjects and Methods: Inguinal fat pads were excised and reduced to 500 mg (±1 mg) in all animals. To obtain thrombin, 3 animals were sacrificed. One percent amount of 0.25 mg lidocaine hydrochloride was injected to the scapular regions of the animals. Afterward, subcutaneous cavities were formed there to place the fat tissue inside. After placing the graft, varying proportions of thrombin were injected to the animals in the experimental groups. No thrombin was not injected to the control group. After 90 days, the experimental animals were sacrificed, and the fat grafts were removed. Statistical Analysis Used: The data obtained from control and experimental groups were analyzed using SPSS software (version 20.0; SPSS Inc., Chicago, IL, USA). Normal fat ratio, cyst or vacuole development, inflammation, fibrosis, microvascular density, apoptosis, and weight score differences between groups were compared using Kruskal–Wallis test. To compare two groups with different scores, Mann–Whitney U test was used. The statistical significance level was accepted as 0.05 (P = 0.05). Results: Macroscopic, histological, and statistical evaluations showed that thrombin has reduced the weight and volume loss on fat graft, increased viable fat cell amount and reduced inflammation on receptive area. Conclusion: The positive effects of thrombin on the viability of fat graft have given us courage to use it in further studies. Longer follow-ups are necessary and more studies are required to use it in clinical practice in combination with fat grafts. 

Flap based reconstruction for the defects of Fournier's gangrene
Utku Can Dolen

Turkish Journal of Plastic Surgery 2019 27(2):56-61

Background: Fournier's gangrene is necrotizing fasciitis of the perineal area caused by mixed aerobic and anaerobic bacteria. It is a devastating disease that requires serial debridement besides intravenous antibiotic therapy. It often results with extensive and disfiguring soft tissue and skin loss. Plastic surgeons are always consulted for coverage of the defects. Wound coverage varies from simple wound care to free-flap reconstruction. Most of the cases require regional or distant flaps. Vacuum-assisted closure might be a good option until definitive coverage, but its application is quite difficult due to genital organs and anus. In this review article, flap-based reconstruction of the perineogenital area is discussed rather than the pathophysiology or primary treatment of the Fournier's gangrene. Methods: Literature review is performed on Pubmed and Google Scholar in Turkish, English, and French languages. Conclusion: Eradication of the infection and supportive patient care are the most important initial steps in the treatment of the Fournier's gangrene patient. This is followed by functional and aesthetic reconstruction of the resultant defect. The reconstructive ladder, from simple wound care to free-flap surgery, guides the reconstructive decision-making process. 

Radiofrequency: Review of literature
Metin Gorgu, Ali Gokkaya, Jehat Kizilkan, Ertugrul Karanfil, Ali Dogan

Turkish Journal of Plastic Surgery 2019 27(2):62-72

Background: Radiofrequency (RF) devices have widespread use in skin rejuvenation. Although they are used noninvasively, recently minimally invasive RF devices are being added to the inventory to increase their efficiency. Because RF devices do not operate on a light basis, their effects are independent of skin color and type. Therefore, they have a broader spectrum of patients compared to other noninvasive and minimally invasive devices. Skin rejuvenation with RF devices will continue to be important for plastic surgeons to pursue the nonsurgical operations. With RF application, heat is generated at different levels and different degrees under the skin. Methods: Shrinkage and denaturation of the collagen with temperature increase the likelihood of desired rejuvenation effects. The degree of temperature increase in RF applications depends on the frequency of the devices, the power of the devices used, and the characteristics of the headers. Today, different types of RF devices are offered by manufacturers. Heating with an RF device in a therapeutic dose of the skin is possible if appropriate frequency and adequate power are provided. When the therapeutic temperature is close to the complication limit, the user needs to know the device well, be aware of the skin structure at the application site and skin thickness, as well as can adjust the application doses well to get better therapeutic results. Conclusion: The wide variety of RF devices has led to the development of different application methods for users. In this article, RF devices, mechanisms of action, methods of use, clinical practice techniques, and results are reviewed. Even though the results are good, RF applications are not an alternative to a surgery. 

Does the patient satisfaction correlate with sensorial recovery after primary repair of digital nerves and flexor tendons?
Egemen Ayhan, Abdurrahman Ciftaslan, Melih Bagir, Metin M Eskandari

Turkish Journal of Plastic Surgery 2019 27(2):73-76

Background: We aimed to evaluate the correlation of patients' satisfaction with sensorial evaluation results after primary repair of digital nerves and flexor tendons. Materials and Methods: In total, 31 fingers of 25 patients that underwent primary repair for clear-cut digital nerve and flexor tendon injuries were included in this retrospective study. The mean age of the patients was 34.8 ± 9.4 years. Patients' gender, age at admission, trauma date, and injured finger were obtained from patients' folders. We called the patients for the last follow-up and used two-point discrimination (2PD) and Semmes–Weinstein monofilament (SWM) tests to evaluate sensorial recovery. Patients were interviewed for hand dominance, cold intolerance, and if they were satisfied. Visual analog scale (VAS) was used to evaluate the satisfaction of patients related to the injured finger. We analyzed correlations between VAS score and age, follow-up period, 2PD score, SWM score, cold intolerance score, gender, hand dominance, and the injured finger. Results: Patients' satisfaction was significantly correlated only with cold intolerance score. There was no significant correlation between patients' satisfaction and age, follow-up period, gender, hand dominance, injured finger, 2PD score, and SWM score. Conclusion: Our study revealed that patients' satisfaction was not only correlated with sensorial recovery scores but also significantly negatively correlated only with cold intolerance, and novel modalities to treat this phenomenon are required. Moreover, patients' satisfaction was not related to age, gender, hand dominance, and the injured finger; hence, surgeons should focus on meticulous repair of digital nerves in any age, for any gender, and any finger of patients. 

Herbo-medicinal formulation; Marham-e-raal: A potent ointment for acute and chronic wounds – A review
Waseem Ahmad, Saiyad Shah Alam, Zareena Aquil

Turkish Journal of Plastic Surgery 2019 27(2):77-83

The wound is a break in continuity of skin and mucus membrane. It may arise owing to multiple causes such as mechanical, chemical, and thermal injuries. There are number of treatments available for the acute and chronic wounds but each having its own drawback from the point of view of the reach of below poverty line and common people. Many of them are so much costly that it becomes difficult to adopt them as a mode of treatment, and few others have lesser potency in terms of cure. The aim of this review is to elaborate the properties, pharmacological actions, phytochemical studies, and mechanism of action of the contents of Marham-e-raal which is easily available and affordable. We have taken a deep insight into the Marham-e-raal by collecting and studying the meaningful and scientific data in favor of the same; and made an essential conclusion that it possesses antimicrobial, antiviral, antiseptic, rubefacient, and wound healing properties. 

A rare location and unusual development: Antecubital leiomyoma
Alper Ural, Fatma Bilgen, Mehmet Bekerecioglu, Sevgi Bakaris

Turkish Journal of Plastic Surgery 2019 27(2):84-86

Leiomyomas are benign soft tissue neoplasms which are originated from smooth muscle cells. Leiomyomas rarely occur in the upper extremity. To our knowledge, there have been no reports of a leiomyoma of the forearm which occured after intravenous catheterisation in Turkish literature. Herein, we report such a case of antecubital leiomyoma in a 52-year-old man. The case is presented due to its rarity and the risk of tumor misdiagnosis. Leiomyomas should be considered in the differential diagnosis of solitary masses of the extremities. 

Congenital deficiency of the medial crus
Suphan Tunc, Oguz Kayiran

Turkish Journal of Plastic Surgery 2019 27(2):87-90

Congenital deficiency of lower lateral cartilages is rarely observed. Moreover, congenital lack of medial and/or lateral crus is extremely rare. Here, a case having nasal tip asymmetry with lack of nasal tip support, hence, the atrophy of medial crus is presented. Reconstruction of the medial crus was appropriately established with a septal cartilage graft. Supportive grafts were also used to enforce the tip and columella. The patient was extremely satisfied from the surgery. The practitioners must be aware of the deformities and deficiencies of the nasal cartilages as well as suitable reconstructions. 

Sinuses: Another diagnostic marker of malignant transforming pressure ulcer
BA Ramesh, Satish Kumar Jayaraman, J Mohan

Turkish Journal of Plastic Surgery 2019 27(2):91-92

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