Cancer Research and Therapeutics

Effectiveness of mouthrinses in prevention and treatment of radiation induced mucositis: A systematic review Varsha Manoharan, Nusrath Fareed, Hemant Battur, Sanjeev Khanagar, Jaseela Praveena Journal of Cancer Research and Therapeutics 2020 16(8):1-10 Mucositis is a frequent, severe consequence of radiation therapy among patients undergoing radiotherapy for the head-and-neck cancer, often requiring hospitalization and even breaks or discontinuity in treatment. Mouth rinsing with various agents has demonstrated effectiveness in the prevention and treatment of radiation-induced mucositis (OM), but evidence for the same is lacking. This systematic review is therefore conducted with the aim of assessing the evidence for the effectiveness of mouthrinses in prevention and treatment of OM. Joanna Briggs Institute guidelines were followed to conduct this review. Six databases were searched and a total of 25 randomized clinical trials published over a period of the past 31 years were included for qualitative synthesis. Analysis of 25 studies revealed that 1299 participants, aged 46–69 years were assigned to the test groups and control groups. A total of 16 different formulations were studied among patients over a duration of 6 days to 1 year in varying dosages. The overall preventive fraction ranged from 1.9% to 77.8% for a reduction in clinical grades of mucositis, 7.6%–83.3% for a reduction in pain and 20%–50% for a reduction in bacterial counts. Adverse effects such as mouth burning, altered taste, sore throat, have been reported, especially with chlorhexidine and benzydamine hydrochloride. Evidence for the included studies is IC and ID. Studies using herbal based products and tissue regenerating agents revealed comparatively better effectiveness with lesser side effects. However, the number of studies to support such a claim is very limited.

Thyroid paraganglioma: A case-based systematic review of literature Pritinanda Mishra, Somanath Padhi, Gayatri Behera Journal of Cancer Research and Therapeutics 2020 16(8):11-21 Thyroid paragangliomas are distinctly rare primary thyroid neoplasms with nearly 75 cases reported worldwide. Due to their similar embryological origin and cytohistomorphology with other thyroid neoplasms, they may pose great diagnostic challenges for pathologists, radiologists, endocrinologists, as well as surgeons leading to unnecessary aggressive therapy. With recent advances in molecular genetics, the prognostic significance of such seemingly innocuous thyroid neoplasms has been better understood. In this manuscript, we describe such a case and present a systematic review of all reported cases till date giving an update on our current knowledge regarding their diagnostic pitfalls, pathology, and molecular genetics.

The relevance of long noncoding RNAs in colorectal cancer biology and clinical settings Atefeh Talebi, Mazaher Azizpour, Shahram Agah, Mohsen Masoodi, Gholam Reza Mobini, Abolfazl Akbari Journal of Cancer Research and Therapeutics 2020 16(8):22-33 Colorectal cancer (CRC) is one of the most frequent causes of cancer-related death worldwide. The prognosis of the malignancy and patient survival is commonly poor. Therefore, the discovery of pertinent biomarkers is essential to provide an accurate diagnosis and effective therapy. Newly, a group of noncoding RNAs named long noncoding RNAs (lncRNAs) has been found to involve in CRC development and progression. In this review, we highlighted the biological function of lncRNAs and reviewed their potentials as clinical tools in the CRC. A literature search of PubMed, EMBASE, MEDLINE, Web of Science, Scopus, and Cochrane Library using the MeSH terms “CRC,” “long noncoding RNA,” “lncRNA,” and relevant was completed. The review included all articles that reported on the significance and role of lncRNAs in CRC development and clinical settings. All identified articles were cross-referenced for further articles, and any unavailable online were retrieved from hardcopy archive libraries. CRC-related lncRNAs could regulate a number of cellular processes, and their dysregulations have been suggested as potential biomarkers.

Predicting outcome of advanced head-and-neck cancer by measuring tumor blood perfusion in patients receiving neoadjuvant chemotherapy Kishore Singh, Rubu Sunku, Arun K Rathi, Gaurav S Pradhan Journal of Cancer Research and Therapeutics 2020 16(8):34-38 Purpose: The purpose of this study was to correlate treatment response with tumor blood perfusion in patient of advanced head-and-neck cancer undergoing neoadjuvant chemotherapy. Materials and Methods: A total of 40 patients of advanced head-and-neck cancer, who were planned for neoadjuvant chemotherapy, were included in the study. All patients underwent diagnostic computed tomography (CT) with perfusion study for staging and quantitative measurement of tumor volume as well as perfusion parameters (including tumor blood volume, blood flow, permeability, and time to peak enhancement), at baseline and after completion of neoadjuvant chemotherapy. Total 3 cycles of neoadjuvant chemotherapy with paclitaxel, cisplatin, and 5 fluorouracil were given. Tumor response was evaluated in terms of change in tumor volume and correlated with perfusion parameters. Results: Out of 40 patients, 22 patients had more than 50% reduction in tumor volume, who were grouped as responder and remaining 18 patients had <50% decrease in tumor volume, grouped as nonresponder. Both the groups were similar in terms of age, gender, performance status, stage, nodal status, or addiction. Baseline CT scan shows a significant difference in tumor blood flow (P = 0.048) and marginal difference in time to peak enhancement (P = 0.058) in two groups. However, there is no difference in tumor blood volume (P = 0.32) and permeability surface area (P = 0.07). Conclusions: Evaluation of tumor blood flow by perfusion CT is helpful in predicting chemotherapy outcome and deciding appropriate treatment modality, but further evaluation with more number of patients is required for validating the predictive role of each perfusion parameters.

Butyrylcholinesterase: An economical marker of disease activity in oral squamous cell carcinoma before and after therapy Shradha Gagan Jaiswal, Gagan Rajesh Jaiswal Journal of Cancer Research and Therapeutics 2020 16(8):39-42 Introduction: Biomarkers which can predict disease progression and serve as prognostic indicators are necessary for better management of oral cancer. Studies have shown that Cholinesterase plays an important role in cellular proliferation, differentiation and may have a possible involvement in tumor growth. Aim and Objective: The present study is aimed to determine the utility of serum Butyrylcholinesterase (BChe) levels as a marker for progression of oral squamous cell carcinoma (OSCC) in relation to the grade of the tumor and to determine if any variation occurred in the levels of BChe before and after therapy. Materials and Methods: A total of 120 patients were included in the study and divided into two groups as Group A-30 patients (healthy individuals) and Group B-90 cases of histopathologically diagnosed OSCC. The blood sample was collected before surgery, re-collected after the completion of radiotherapy (i.e., 3 and 6 months postsurgery) and analyzed biochemically for the concentration of BCh. Statistical Analysis: Paired t-test, ANOVA, and post hoc test (Bonferroni) were used for determining the statistical significance. Results: BChe levels were lower in OSCC (2940.32–1405.50 u/l when compared with controls (11149.60–11243.07 unit/l) and this difference was statistically significant. Postoperatively at 3 months, the serum BChe levels of OSCC patients increased almost two-fold compared to the preoperative values, and this difference was also statistically significant (P = 0.000) After 6 months, these levels further increased but did not reach those of controls. Conclusion: BChe can be used as an inexpensive, easy to use, noninvasive biomarker for the evaluation of disease-free survival in OSCC patients.

Good prognostic factor in patients with nonmetastatic nasopharyngeal carcinoma: Programmed death ligand-1 expression in tumor cells Hayriye Sahinli, Nalan Akyürek, Mukaddes Yılmaz, Olcay Kandemir, Ayşe Ocak Duran, Sezer Kulaçoǧlu, Gökhan Uçar, Elif Acar, Ahmet Özet, O Berna Ç. Öksüzoǧlu, Nuriye Y Özdemir Journal of Cancer Research and Therapeutics 2020 16(8):43-47 Purpose: Programmed death ligand-1 (PD-L1) is the main ligand for programmed death-1 (PD-1), and is one of the major targets for cancer immunotherapy. Only a few studies are available for the clinical significance of PD-1/PD-L1 in nasopharyngeal carcinoma (NPC). There is a controversial association between PD-L1 expression and survival in NPC. This study aimed at defining any potential association between PD-L1 expression in tumor cells (TCs) and prognosis in NPC. Patients and Methods: A total of seventy NPC patients treated between January 2008 and December 2016 were included in the study. PD-L1 expression was assessed by immunohistochemistry (IHC) in tumor specimens. The IHC assay was considered positive if ≥5% of TCs are stained. Clinicopathological variables were documented. Variables included in the analysis were PD-L1 expression, clinicopathological characteristics, and prognosis. Results: The estimated 5-year overall survival (OS) rate was 62%. Nearly 55.7% (n = 39) of the TCs tested positive for PD-L1 expression. No associations were found between the level of PD-L1 in TCs and clinicopathological characteristics. Comparisons between patients with PD-L1-positive tumors and PD-L1-negative tumors revealed that OS was statistically significantly longer in patients with PD-L1-positive tumors as assessed by the univariate Cox regression analysis (hazard ratio [HR], 0.378; 95% confidence interval, 0.158–0.905; P = 0.029) and Kaplan–Meier curves (P = 0.023). Conclusion: PD-L1 expression is an important prognostic factor in NPC. PD-L1 expression positively correlates with survival.

Eyelid carcinoma: An experience from a tertiary cancer center Shivakumar Thiagarajan, Ameya Bahani, Devendra Chaukar, Anil K Dcruz Journal of Cancer Research and Therapeutics 2020 16(8):48-52 Context: Eyelid carcinoma is rare tumors of the head and neck. They are rarely lethal but can be associated with significant morbidity if not treated early and appropriately. There are limited data available from world over and in particular the Indian subcontinent regarding eyelid carcinoma and its prognostic factors influencing treatment outcomes. Setting and Design:Retrospective study of patients treated in a tertiary cancer center between 2005 and 2016. Methodology: In this study, 51 patients with eyelid carcinoma treated at single tertiary cancer center were included. The demographic, clinical data, which includes the treatment received, histopathology report and follow–up, were recorded. All the relevant variables influencing disease-free survival (DFS) were analyzed. Results: Sebaceous carcinoma was the most common eyelid carcinoma followed by squamous cell carcinoma and basal cell carcinoma in descending order in this series. Lower eyelid was involved most often. The incidence of nodal metastasis was low (14%). Multivariate analysis revealed that margin status influenced the DFS (P= 0.001) (hazard ratios = 15.9 [95% confidence interval: 1.8–135.2]). The 5 years' DFS was 70%. Conclusion: Eyelid tumors are less common cancer with good prognosis if treated appropriately. The morbidity associated with treatment can be reduced if treated early.

Cytopathology-histopathology correlation and the effect of nodule diameter on diagnostic performance in patients undergoing thyroid fine-needle aspiration biopsy Nusret Yilmaz, Guven Baris Cansu, Serap Toru, Ramazan Sari, Guzide Gokhan Ocak, Cumhur Arici, Hasan Ali Altunbas, Mustafa Kemal Balci Journal of Cancer Research and Therapeutics 2020 16(8):53-58 Introduction: Although thyroid fine-needle aspiration biopsy (FNAB) is established to have a good overall sensitivity and specificity, various outcomes have been reported on its performance in large nodules. The aim of the study was to evaluate the diagnostic performance of FNAB and the effect of the nodule diameter on its diagnostic performance. Materials and Methods: The outcomes of a total of 7319 patients who underwent FNAB over the course of 5 years were analyzed retrospectively and 648 patients who had undergone post-FNAB thyroidectomy or lobectomy were included in the study. FNAB results were classified according to the Bethesda system. After evaluating the compatibility between cytology and pathology results, all-nodules and diameter-based (<4 cm and ≥4 cm) sensitivity, specificity, false positivity, false negativity, and accuracy rates of FNAB were calculated. Results: Sensitivity of FNAB was 85.4% for all nodules, 88.3% for nodules <4 cm, and 75.8% for nodules >4 cm (P < 0.001). Specificity was 58.4% for all nodules, 49.3% for nodules <4 cm, and 75.1% for nodules >4cm (P < 0.001). While false positivity was 41.6% for all nodules, it was 50.7% for nodules smaller than 4 cm and was 24.9% for nodules larger than 4 cm (P < 0.001). False negativity was 14.6% for all nodules and was 11.7% for nodules smaller than 4 cm and 24.2% for nodules larger than 4 cm (P < 0.001). Finally, among the entire set of nodules, the accuracy was 64.4%, which was 59.2% in nodules smaller than 4 cm, and 75.2% in nodules larger than 4 cm (P < 0.001). Conclusion: Despite a higher rate of false negativity, FNAB has higher specificity and accuracy in large nodules than those in the small nodules. Nodule diameter should not be used alone as a criterion to recommend thyroidectomy to the patient.

The radioprotective effect of melatonin against radiation-induced DNA double-strand breaks in radiology Farid Esmaely, Aziz Mahmoudzadeh, Mohsen Cheki, Alireza Shirazi Journal of Cancer Research and Therapeutics 2020 16(8):59-63 Objective: The objective of this study is to observe the effect of 100-mg melatonin in reducing the levels of double-strand breaks (DSB) induced by 10 mGy and 100 mGy X-ray in peripheral lymphocyte applying H2AX immunofluorescence microscopy and comparing the different efficacies of melatonin ingestion 1 and 2 h before irradiation. Materials and Methods: Informed consent was obtained from five healthy males, nonathlete, and nonsmoking human volunteers aged between 25 and 35 years. Each volunteer was given a single oral dose of 100 mg melatonin at 9 a.m. Blood samples were collected in vacutainer tubes (without any preservative to separate the serum, and with heparin as an anticoagulant for separating leukocytes for in vitro exposure to gamma radiation) 5–10 min before then 1 and 2 h after melatonin ingestion. Afterward, each sample was subdivided into nonirradiated and irradiated groups (10 mGy and 100 mGy). After irradiation, lymphocytes of samples were separated. The isolated lymphocytes in each group were permeabilized for DSB assessment and stained against the phosphorylated histone variant γH2AX. Results: Melatonin ingestion 1 and 2 h before irradiation caused a significant reduction in γH2AX foci. Results further indicate that the change in ingestion of melatonin from 1 to 2 h before exposure had no significant effect. In addition, melatonin administration showed no side effects. Conclusion: The present study showed that melatonin will prove effective in radioprotection against ionizing radiation (IR)-induced DNA damage in human lymphocytes. Our results suggest ingestion of 100-mg melatonin by patients before exposure to IR in radiology.

Estimation of cancer risk due to radiation exposure for some daily consumption of foods Akbar Abbasi, Vali Bashiry Journal of Cancer Research and Therapeutics 2020 16(8):64-67 Aims: Considering the increasing concern about the cancer risk caused by environmental radiological effects related to the food consumption, the study was carried out evaluate the activity concentrations and cancer risk assessments of 226 Ra,232 Th, and 40 K in 72 food samples collected from different suppliers in Tehran Province of Iran. Subjects and Methods: The specific activity concentration was determined by means of a high-resolution high-purity germanium gamma-spectroscopy system. The collected various sample groups were wheat, rice, meat, milk, and mushroom. Results: The maximum concentration of 226 Ra and 232 Th was found in the wheat sample, equal to 0.7862 Bq/kg and 0.968 Bq/kg, respectively, whereas for 40 K, it was 598.35 Bq/kg in the milk sample. The annual effective dose rate ranged from 2.47 μSv/y in mushroom to 64.66 μSv/y in rice. The average excess lifetime cancer risk (ELCR) was varied from 1.60 × 10–5 for mushroom to 4.20 × 10–4 for milk, with the total ELCR value from main daily diets 1.37 × 10–3, which was a little more than the acceptable ELCR limit of 10–3. Conclusions: The ELCR due to five main daily diets was a little more than the acceptable ELCR limit of 10–3 for radiological risk in general.

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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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Neurological Sciences and Neurophysiology

Neuroinflammation in Alzheimer's disease continuum Aslihan Taskiran-Sag, Müge Yemişçi Neurological Sciences and Neurophysiology 2020 37(4):155-163 Aging population brings an ever-increasing global burden of dementia, and Alzheimer's disease (AD) is the most frequent type worldwide. Many years of research have introduced characteristic cerebral histopathological and molecular changes in this disease. However, all attempts to establish an effective treatment have failed. In this review, we aim to address the basic evidence regarding the role of inflammatory mediators in AD and their link to the other pathogenetic pathways. Novel findings based on advanced biotechnology and bioinformatics are covered briefly, as well.

Long latency reflexes in patients with postural instability and ataxia Ersin Deneri, Nesibe Tilek, Aysel Çoban, Cengiz Tataroğlu Neurological Sciences and Neurophysiology 2020 37(4):164-169 Objectives: Distal electrical stimulation of an upper extremity mixed nerve can generate a reflex response from the trapezius muscle. This reflex response may have a central neural pathway and can be affected by postural changes. Materials and Methods: In this study, long latency reflexes (LLRs) from both distal and trapezius muscle were evaluated in patients with Parkinson's disease (PD) with and without postural dysfunction and in patients with cerebellar ataxias. Thirty-three patients with PD, 10 patients with degenerative cerebellar ataxia and 22 healthy volunteers were included in the study. LLRs were recorded from ipsilateral thenar and trapezius muscles. Latencies and amplitudes of LLRs obtained from thenar (thenar LLR) and trapezius (trapezius LLR) muscles were analyzed. Results: In patients with PD, thenar LLRs showed significant shortening in the onset latencies and significant increase in the amplitudes in comparison with healthy controls. Trapezius LLRs did not show any significant difference in latencies or amplitudes; however, these responses showed a significant absence in one or two components in patients with Parkinson's disease with postural dysfunction. Additionally, this reflex was not recorded in patients with cerebellar ataxia. Conclusion: Trapezius LLRs can give some information regarding the physiology of neural circuits responsible for postural arrangement. Cerebellar connections may have a major role in the generation of trapezius LLRs.

The role of vestibular evoked myogenic potential and the video head impulse test in patients with multiple sclerosis without radiologic findings Reyhan Surmeli, Mehmet Sürmeli, Gözde Günay, Ayşe Destina Yalçın, Ayşe Aslı Şahin Yılmaz, Fatma Kulalı Neurological Sciences and Neurophysiology 2020 37(4):170-175 Objective: The aim is to evaluate the vestibular system using the video head impulse test (vHIT) and vestibular evoked myogenic potentials (VEMP) in patients with multiple sclerosis (MS) without central vestibular involvement in magnetic resonance imaging (MRI), and to determine whether there was subclinical vestibular system impairment. Materials and Methods: The study comprised 27 patients with MS and 26 healthy participants. The participants had no lesions in the central vestibular system in an MRI taken in the past 3 months. Detailed neuro-otologic and neuro-ophthalmologic examinations were performed on all participants. Then, the Dizziness Handicap Inventory (DHI) was completed for subjective vestibular system evaluation. In addition, vHIT and cervical VEMP (cVEMP) were performed for objective vestibular system evaluation. The results were analyzed statistically. Results: The mean age of the patients in the MS group was 39.3 ± 11.4 years and 42.7 ± 9.7 years in the control group. The median DHI score was 4 (range, 0–8) in the MS group and 2 (range, 0–6) in the control group. There were no statistically significant differences between the DHI score averages of the groups. The mean vestibulo ocular reflex (VOR) gain in vHIT was 0.76 ± 0.21 in the MS group and 0.99 ± 0.13 in the control group. VOR gain was statistically significantly lower in patients with MS. The VOR gain cut-off level was considered as 0.8. Gain level was below the cut-off level in 53.7% of patients with MS. There was no cVEMP response in 31.5% of patients with MS. In addition, patients with MS had prolonged P1 and N1 latencies and decreased P1-N1 peak-to-peak amplitudes. Conclusion: We found subclinical involvement in electrophysiologic tests (vHIT and cVEMP) in patients with MS without MRI lesions and without subjective vestibular system symptoms. We believe that vHIT and cVEMP can be used for subclinical evaluation in patients with MS without central vestibular system involvement in MRI.

The association between causes and electrophysiology in myoclonus: When and why electrophysiology? Meral E Kiziltan, Aysegül Gündüz, M Hazal Ser, S Naz Yeni, Çigdem Özkara, Veysi Demirbilek, Cengiz Yalçınkaya, Günes Kızıltan Neurological Sciences and Neurophysiology 2020 37(4):176-182 Objective: We aimed to identify the possible causes of myoclonus and related electrophysiological features in a cohort of young patients. Patients and Methods: We performed a retrospective analysis of all clinical and electrophysiological recordings of patients who had myoclonus and were under 60 years between 2005 and 2018. The clinical data included age at examination, gender, age at onset, and main neurological or systemic findings, underlying cause and electrophysiological features constituted surface electromyogram, long-loop reflexes, electroencephalography, and somatosensory-evoked potentials. Results: In the study period, we identified 155 patients with myoclonus. Myoclonus was most commonly related with epilepsy and movement disorders. Myoclonus with epilepsy was the leading cause between 10 and 30 years, whereas myoclonus with movement disorders was more common after 30 years. In our country, SSPE was an important cause of myoclonus under the 20 years of age. We identified cortico-subcortical subtype followed by cortical, cortical reflex, subcortical-basal ganglia, subcortical-brainstem and propriospinal subtypes, and correlated these subtypes with relevant disorders. Conclusion: The electrophysiological classification provides anatomical subtyping, which is favorable in diagnosing certain cases such as brainstem and propriospinal myoclonus. Certain characteristics such as reflex nature of myoclonus and accompanying features narrow the list of differentials and help in making the diagnosis.

Sleep disorders in a shift worker population sample in Turkey Duygu Kurt Gok, İlker Ünal, Kezban Aslan Neurological Sciences and Neurophysiology 2020 37(4):183-189 Aims: This study aims to determine the sleep quality of night-shift workers, determine the prevalence and characteristics of sleep disorders related to shift work, and compare sleep characteristics between shift workers and day workers. Subjects and Methods: The study included 1473 individuals employed in three different areas (health, security, and labor) as shift (78.5%) or day (21.5%) workers in the city of Adana, Turkey. Data were collected using a structured questionnaire consisting of 132 questions. The questionnaire included demographic data, education level, socioeconomic status, shift schedule, accompanying health problems, sleep disorders and sleeping habits, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, the Berlin Questionnaire, and the Restless Legs Syndrome (RLS) scale. Statistical Analysis Used: The SPSS for Windows 20.00 software package was used for statistical analyses. Results: Day workers and shift workers exhibited excessive daytime sleepiness in 17.1% and 24.9% (P = 0.004), poor sleep quality in 41.5% and 44.3% (P = 0.374), chronic insomnia in 8% and 16.2% (P < 0.001), RLS in 4.7% and 5.3% (P = 0.818), and sleep-disordered breathing in 7.3% and 7% (P = 0.864), respectively. Conclusions: Shift work significantly compromises sleep quality. In particular, fixed night shifts or rotating shift workers experience relatively higher rates of decline in subjective sleep quality, excessive daytime sleepiness, and chronic insomnia compared with day workers.

The ratios of estradiol and progesterone to testosterone influence the severity of facioscapulohumeral muscular dystrophy Ceren Hangul, Selen Bozkurt, Ugur Bilge, Sebahat Ozdem, Hasan Altunbas, Hilmi Uysal, Filiz Koc, Sibel Berker Karauzum Neurological Sciences and Neurophysiology 2020 37(4):190-196 Background: Facioscapulohumeral muscular dystrophy (FSHD) occurs as a consequence of genetic deletion of D4Z4 repeats on chromosome 4q35. Onset of FSHD is earlier in males, suggesting that testosterone may trigger the disease. In accordance, the rapid progression of disease in women after menopause suggests a protective role for estrogen and progesterone. No studies have examined levels of all these hormones in relation with the severity of FSHD. Aims: To evaluate the possible correlation between the severity of FSHD with sex hormones, age, and genetic deletion on chromosome 4q35. Subjects and Methods: D4Z4 repeat units were investigated in 33 patients (19 males/14 females) with FSHD. In the blood samples, luteinizing hormone, follicle-stimulating hormone, free estriol, estradiol, free testosterone and total testosterone, progesterone, 17-OH progesterone, prolactin, albumin, and fibrinogen were measured. The severity of FSHD was identified using a Clinical Severity Score (CSS) scaling system. Spearman's correlation and regression analyses were performed as statistical analyses. Results: Age (P = 0.001, r = 0.541) and total testosterone (P = 0.045, r = 0.351) were positively correlated, and the progesterone/total testosterone (P = 0.025, r = −0.390) and estradiol/total testosterone ratios (P = 0.025, r = −0.389) were negatively correlated with the severity of FSHD. Conclusions: Our results indicate that age, total testosterone, ratios of estradiol and progesterone to total testosterone, but not deletion on chromosome 4q35, have a significant relation with the severity of FSHD. Given that both estrogen and testosterone treatment are considered in therapy, our results suggest that estrogen and progesterone but not testosterone are likely to be more effective on the severity of FSHD.

Botulinum toxin injections for neurological disorders: Experience between 1994 and 2019 Cem Boluk, Yesim Gökçe, Aysegül Gündüz, Nurten Uzun Adatepe, Feray Karaali Savrun, Asim Kaytaz, Meral E Kızıltan Neurological Sciences and Neurophysiology 2020 37(4):197-202 Aim: Reported results of botulinum toxin (BoNT) injections vary widely in different studies and in different neurological disorders. The aim of this study was to investigate the efficacy and safety of BoNT injections for each neurological disorder and to report our experience in this area since 1994. Materials and Methods: All patients who were injected with BoNT since 1994 were included in this retrospective study. Age, gender, etiology, specific diagnosis, time from first symptom to first injection, type of BoNT (onabotulinum toxin-abobotulinum toxin), doses, treatment response, and complications were extracted from patient files. Etiologies were classified into five main groups: hyperkinetic movement disorders, focal spasticity, painful conditions, sialorrhea, and hyperhidrosis. Positive treatment response was defined as any objective clinical improvement determined by the attending physician and declared by the patient. Results: We determined that 1792 patients were considered for BoNT injections. Among them, 341 were not found to be suitable for injections or did not accept to have the procedure done. In total, 1451 different patients were included in the study. The most common indications for BoNT injection were hyperkinetic movement disorders (72.3%) and focal spasticity (15.2%). Other disorders included painful conditions, hyperhidrosis, and sialorrhea. In 74.3% of the patients, the only injected toxin was onabotulinum toxin, whereas 10.2% of the patients were injected only with abobotulinum toxin. In 14.7% of the patients, the injection type was changed from one to the other, due to ineffectiveness or unavailability. Response rates were 95.4% for focal spasticity, 92.6% for hyperkinetic movement disorders, 81.1% for painful conditions, 66.7% for hyperhidrosis, and 63.1% for sialorrhea. Severe complications were seen in 0.6% of the patients. Conclusion: BoNT injections seem to be effective in all of the neurological disorders which we investigated. Except for mild cosmetic complications, BoNT is generally safe in experienced hands.

Agomelatine is superior to melatonin in pain suppression: An experimental study Ali Okan Yucel, Devrim Demir-Dora, Mehmet Ferit İsbir, Babür Dora Neurological Sciences and Neurophysiology 2020 37(4):203-207 Objective: Agomelatine is a synthetic analog of melatonin with selective agonist action on melatonin MT1 and MT2 receptors and antagonistic effect on serotonin 5HT2c receptors. Similar to melatonin, it also has antinociceptive properties. There are only a few studies comparing the antinociceptive effects of agomelatine to melatonin. Methods: Male Wistar albino rats were grouped into seven treatment groups and a control group (8 animals each). Treatment groups received intraperitoneal injections of agomelatine 25 mg/kg, 35 mg/kg and 50 mg/kg; agomelatine 35 mg/kg + luzindole 10 mg/kg; melatonin 60 mg/kg and 90 mg/kg and melatonin 60 mg/kg + sertraline 10 mg/kg. Animals were placed on a hot plate and time to pain avoidance behavior was measured. Results: Agomelatine 25 mg/kg, 35 mg/kg and 50 mg/kg were significantly superior to placebo (all p < 0. 0001); agomelatine 35 mg/kg and 50 mg/kg were significantly superior to melatonin 60 mg/kg (p < 0.05 and p < 0.01, respectively) and melatonin 90 mg/kg (p < 0.001 and p < 0.001, respectively) in prolonging reaction times. Agomelatine 50 mg/kg was superior to melatonin 60 mg/kg + sertraline 10 mg/kg (p < 0,05); on the contrary; agomelatine 25 mg/kg was significantly inferior to this combination in prolonging reaction times (p = 0,041). Melatonin 90 mg/kg but not 60 mg/kg was significantly superior to placebo in prolonging reaction times (p < 0.0001). Both agomelatine 50 mg/kg and 35 mg/kg were superior to agomelatine 25 mg/kg (p < 0.0001 and p = 0.002, respectively), but the difference between agomelatine 50 mg/kg and 35 mg/kg was not significant. Conclusions: We demonstrated that agomelatine is superior to melatonin on pain behavior in a dose -dependent manner using an experimental pain model. The a ddition of a serotonergic agent increased the antinociceptive effect of melatonin in regard to agomelatine, but high doses of agomelatine were still more effective, suggesting a dose -dependent effect of agomelatine on 5-HT2c receptors.

Management of hardware infections in deep-brain stimulation: A 4-year, single-center experience Vural Hamzaoglu, Hakan Özalp, Okan Doğu, Nevra Öksüz, Sabri Aydın, Tolga Akbıyık, Ahmet Dağtekin, Emel Avcı, Celal Bağdatoğlu Neurological Sciences and Neurophysiology 2020 37(4):208-214 Objectives: The introduction of deep-brain stimulation (DBS) was a milestone in the treatment of movement disorders, intractable epilepsy, and severe psychiatric disorders. We aimed to identify risk factors for hardware infection in patients with these conditions who underwent DBS at our center over a 4-year period. Materials and Methods: Bilateral DBS was performed in seventy patients by the Department of Neurosurgery at the Mersin University School of Medicine between April 2016 and January 2020. The surgical indication was Parkinson's disease in 48 patients, dystonia in 11 patients (10 primary generalized and 1 secondary), and tremor in 11 patients (10 essential tremor and 1 other). Results: Infection was detected in eight patients (11.4%). There were no hardware complications other than infection or postoperative intracerebral hematomas. The entire device was explanted in four (50%) patients with infection; device explantation occurred at 3, 13, 19, and 42 months after surgery. The other 4 (50%) patients who developed infection were successfully treated with antibiotics without complication. A patient with primary dystonia who underwent bilateral globus pallidus interna DBS sustained a severe acute subdural hematoma due to trauma 45 days after electrode implantation but prior to stimulation. We elected not to explant the device after hematoma evacuation; delayed stimulation programming was successful. Conclusion: DBS surgeries are susceptible to complications related to the anatomic target, hardware, and the procedure itself. Infection is the most common complication; however, there is no established protocol for its treatment. Antibiotics and partial removal of the device may be a rational approach.

Craniopharyngiomas: Analysis of 68 surgical cases Emrah Akcay, Hakan Yılmaz, Hüseyin Berk Benek, Alper Tabanlı, Alaettin Yurt Neurological Sciences and Neurophysiology 2020 37(4):215-220 Objective: Although craniopharyngiomas are benign pathologies, they have surgical challenges due to their locations, infiltrations, and potential for neuroendocrine problems. We evaluated the surgical outcomes, complications, the neuroendocrine problems in patients who underwent total or subtotal resection, and to reveal the ideal treatment regimen. Materials and Methods: We retrospectively reviewed 68 patients who received pathologic results of craniopharyngioma between 1999 and 2019 in our neurosurgery clinic. The demographic characteristics, hormone levels, resection ratio (total/subtotal), residue and recurrence rate, and the complications after surgery were used in the analysis. Results: Twenty-six (38.2%) patients underwent total tumor removal, and 42 (61.8%) had subtotal removal. Fifteen (22%) patients had recurrence. Of the total tumor removal group, only one patient was determined as having recurrence. We detected hypothalamic–pituitary system deficiency in 15 patients with total removal and nine patients with subtotal removal. Of the 37 patients who had lesions smaller than 4 cm, only one died and 30 were in good health after surgery. Of the 31 patients who had lesions larger than 4 cm, five died and 15 were in poor or moderate health. Conclusion: Tumor size is one of the most important factors affecting surgical results. Subtotal tumor removal is associated with tumor recurrence and total removal with serious hypothalamic deficiency symptoms.

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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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Preventive and Clinical Dental Research

Effect of titanium oxide and zirconium oxide nanoparticle incorporation on the flexural strength of heat-activated polymethyl methacrylate denture base resins – An in vitro experimental study Prasanth Viswambharan, AR Adhershitha International Journal of Preventive and Clinical Dental Research 2020 7(4):91-95 Introduction: Flexural strength is one of the most important properties which determine the clinical success of dentures. Even though titanium oxide nanoparticles (nano-TiO2) and zirconium oxide nanoparticles (nano-ZrO2) are extensively used to modify the properties of polymethyl methacrylate (PMMA) resin, there is negligible documentation in the literature comparing these two. Aim: The aim of the study is to find out and compare the effect of incorporation of 1 weight % nano-TiO2 and nano-ZrO2 on the flexural strength of heat-activated PMMA resin. Materials and Methods: 1 weight % of TiO2 and ZrO2 nanoparticles were weighed using a digital weighing balance and mixed with PMMA resin powder using the geometric dilution method. Sixty “35 mm × 10 mm × 3 mm” rectangular-shaped specimens fabricated were divided into three different groups, each containing twenty samples each. The specimens were loaded to failure at a crosshead speed of 1 mm/min and with 500 N load cell in a Universal Instron Testing Machine, Model 3345. Flexural strength was registered by the machine with 0.001 MPa precision. Results: PMMA with nano-TiO2 group had the maximum flexural strength, load at maximum flexure, and load at break followed by unreinforced PMMA and PMMA with nano-ZrO2. Statistically significant difference was noted between the three groups (P < 0.001). Post hoc analysis using Tukey's post hoc test showed a statistically significant difference for all three pair-wise comparison. Conclusions: Within the limitations of this study, it can be concluded that nano-TiO2 greatly enhanced the flexural strength, load at maximum flexure load, and load at break of PMMA resin, whereas nano-ZrO2 significantly reduced these properties of PMMA.

Prevalence of periodontal diseases in orthodontic patients Ujjwal Priyadarsi, Mohammad Shahbaz Alam, Abid Hussain, Farrukh Azam, Priyanka Kumari, Md Abu Nafe International Journal of Preventive and Clinical Dental Research 2020 7(4):96-98 Objective: The objective was to investigate the association between orthodontic treatment and periodontitis in a representative sample of Jharkhand. Methodology: The clinical examinations at six sites per tooth were assessed using visible plaque index (VPI), gingival bleeding index (GBI), bleeding on probing (BOP), periodontal probing depth (PPD), and clinical attachment loss (CAL). A manual Williams probe (Neumar, São Paulo, Brazil) was used, except for the VPI. Data analysis was done. Results: The median percentage values of sites positive for VPI, GBI, and BOP were calculated for each group and compared using a Mann–Whitney test and the mean values for PPD and CAL with a Student's t-test. Intragroup comparisons between teeth were performed with Tukey's analysis of variance. The level of significance was set at 5%. Conclusion: The use of orthodontic appliances is not necessarily related to worsening periodontal conditions. The results of the present study reinforce the importance of susceptibility to periodontal disease independent of the presence of a well-known retentive plaque factor, i.e., orthodontic appliances and/or bands.

Awareness and attitude toward COVID-19 among the students of a rural tertiary care center and dental college: A cross-sectional study AR Adhershitha, Prasanth Viswambharan, Sheela Virginia Rodrigues International Journal of Preventive and Clinical Dental Research 2020 7(4):99-103 Introduction: Awareness, attitude, and practice play a major role in containing any infectious disease. Coronavirus disease 2019 (COVID-19) has no definitive treatment or vaccines; hence, it is momentous to spread awareness regarding the prevention strategies. It is crucial for the government and concerned authorities to understand the students' perception and attitude in the time of the current pandemic. Aim: The aim of this study is to assess the level of awareness among the students of Government Dental College Alappuzha, a rural tertiary care center and Dental College in Kerala, India, regarding COVID-19 and their attitude toward the pandemic. Methodology: Questionnaire which included 21 items was used for the research. Observed data were coded, tabulated, and analyzed using IBM SPSS Statistics for Windows (Version 20.0. Armonk, NY, USA: IBM Corp.). The total awareness score calculated was 20. Comparison between gender (males/females) and study groups (preclinical students/clinical students) was made using the Chi-square test. Comparison of total awareness scores between study groups was made using independent t-test. Results: Most of the study participants across study groups regularly kept track of the latest news on COVID-19 and perceived it to be of moderate or very dangerous risk though they were quite optimistic of its control. About 96% of males and 82% of females felt it is necessary to get mental health help if one panics in lieu of the pandemic situation. The mean total awareness score (out of 20) was 15.16 ± 1.81. There was no significant difference in total awareness score based on gender (15.23 ± 2.24 for males and 15.15 ± 1.71 for females) and also among the category of students (14.88 ± 1.94 for preclinical students and 15.35 ± 1.69 among clinical students). Conclusions: Attempts should be made for increasing the awareness regarding the preferred method of hand hygiene, protocol for performing aerosol-generating procedures, and airborne infection isolation room.

Knowledge attitude and practice of school personnel on COTPA Dhwani Desai, Dhvani Desai International Journal of Preventive and Clinical Dental Research 2020 7(4):104-106 Background: The “Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COTPA)” has been formulated to control the Tobacco epidemic in India. School personnel serve as role models for students and have daily interaction with students, while college students may be under the influence of adolescent behavior and cigarettes is easier to procure. Materials and Methods: A cross-sectional questionnaire-based study carried out on a convenience sample of 100 school personnel aged 18–60 years, participated in the study. Five schools were undertaken in this study on the basis of convenience sampling. All the school personnel preseent on the day of conduction of survey were included in the study. Results: The awareness of school personnel in relation to COTPA ranges between 21% and 79% whereas least awareness (80%) was seen in relation to loose cigarettes not to be sold. Conclusion: The present study indicates that participants have lesser and inappropriate knowledge and attitude toward COTPA and majority of not taken any step to implement COTPA in their work place

Trends in the patterns of maxillofacial fractures in Kolkata Gourab Das, Dhritiman Pathak, Bharat Shukla, Ruchira Shukla, Dazy Patel, Krishna Mondal International Journal of Preventive and Clinical Dental Research 2020 7(4):107-110 Background:- The maxillofacial skeleton is commonly fractured due to its prominent position. Maxillofacial fractures lead to cosmetic disfigurement as well as problems in oral functioning. Aim: The aim of this study was to determine the incidence, etiology, mode, and the pattern of fractures in the maxillofacial region. Methods: A retrospective study of maxillofacial injuries at ESIC Medical College and Hospital, Joka (Kolkata) between Feb 2018 to April 2019 was conducted and data extracted from patients who were either treated in emergency room or in outpatient department. Results and Conclusion: The study concluded that better road safety laws need to be enforced along with the improvement of the education and socio-economic setup.

Temporomandibular disorders: An updated review M Nazargi Mahabob International Journal of Preventive and Clinical Dental Research 2020 7(4):111-114 A group of conditions related to temporomandibular joint (TMJ) is called as “temporomandibular disorder” (TMD). Several attempts were made to classify TMD based on the frequency of occurrence, etiology, and anatomy, but they have had some shortfalls, and one mostly accepted is diagnostic criteria/TMD classification. TMD is a group of clinical problems; it involves either TMJ or its associated structures separately or combination. Any factor that affects one part of the system is likely to have an impact on the other parts also, so it is essential to approach carefully when considering likely signs and symptoms of TMD. About 20%–30% of the adult populations are affected to some degree of TMD, and it is predominately affected young and middle-aged adults. The prevalence rate of TMD problems twice common in females than the males. The etiology of TMD is inconclusive, and now, it has been accepted that multiple factors play a role in TMD. Since it is multifactorial, treatment should be planned according to that and varies patient to patient. Majority of the patients having mild-to-moderate TMD and conservative treatment approach over surgery results in satisfactory outcomes. The aim of this review is to evaluate the recent updates and propose solutions for patients with TMD.

Prosthodontic rehabilitation of an edentulous hemimandibulectomy patient Saumil Chetan Sampat, Mistry Saloni, Banga Parmeet, Dole Vinay, Dubey Amol International Journal of Preventive and Clinical Dental Research 2020 7(4):115-118 Edentulous patients with lateral discontinuity defects of the mandible pose a challenge for the prosthodontist. With variable degrees of bony and soft-tissue resection, the prosthodontic prognosis is dependent on a number of complex factors. Complete dentures in such patients are primarily given for improvement of esthetics. In a selected few patients, however, such prosthesis may improve speech and masticatory function. This case report describes the use of two rows of nonanatomic teeth (in the maxillary denture) on the unresected side to broaden the occlusal table, thus fulfilling the patient's needs and requirements.

Apexification in primary central incisor Nandita Mohan, Shriyam Sharan, Supreeya Patel, Divya Nigam, Aarti Kumari, Silpi Chatterjee International Journal of Preventive and Clinical Dental Research 2020 7(4):119-121 The upper deciduous incisors are frequently the teeth most commonly affected either by dental caries or due to the impact of trauma. In such cases, there may be complete coronary destruction of teeth. As they erupt around 7½–9 months of age and the roots only complete at approximately 18–24 months, pulp involvement may occur even before the end of this process. Hereby, we highlight the case of a 15-month-old male patient who reported with a history of trauma. Treatment plan of apexification was made after confirming with multiple radiographs. Root-end closure was obtained after a period of 7 months.

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Medical Journal

Reliability of international hip dysplasia institute classification for the developmental dysplasia of the hip among different medical personnel in Iraq Jagar Omar Doski Mustansiriya Medical Journal 2020 19(2):41-44 Background: The international hip dysplasia institute (IHDI) classification is a new method for quantifying the severity of the developmental dysplasia of the hip (DDH). Objectives: This study aimed to compare the reliability of this classification between different medical personnel such as pediatricians, general practitioners, and family doctors in addition to orthopedic surgeons and radiologists. Methods: Hundred pelvic radiographic films (with 200 hips) were randomly selected from the files of children already diagnosed and treated as DDH cases. These films were analyzed by 12 independent observers of four different specialties: three orthopedic surgeons (Ortho Group), three radiologists (Radio Group), three pediatricians (Pediat Group), and three general practitioners (GP Group). Results: The average measures (Cronbach's alpha) for the intraclass correlation coefficient (ICC) for absolute agreement between all observers was 0.874 (with 95% confidence intervals between 0.780 and 0.925). This was considered as having a good level of reliability and agreement between all observers. The ICC for agreement between the observers of radio group showed the highest score (0.904) while that between those of GP Group had the lowest one (0.826). However, during the comparison between the mean score of each group with that of the other groups by the one-way ANOVA method, there was no statistically significant difference between all groups (P values were 0.563, 0.415, 0.399, and 0.291 respectively). Conclusion: The IHDI classification method for cases of DDH has a good level of reliability among different medical personnel regardless of their specialties.

Management of florid diabetic retinopathy Faiz I Shakarchi, Ahmed F Shakarchi, Shadha A Al-Bayati Mustansiriya Medical Journal 2020 19(2):45-48 Background: Florid diabetic retinopathy (FDR) is a severe form of proliferative diabetic retinopathy associated with high risk of blindness. Aim: The aim of this study is to evaluate the efficacy and safety of prompt intravitreal injection of bevacizumab followed by complete pan-retinal photocoagulation (PRP) for treating eyes with FDR. Setting and Design: Prospective, interventional case series. Patients and Methods: Patients with FDR were treated initially with intravitreal injections of bevacizumab 1.25 mg. One week after the injection, patients were sent for wide field fluorescein angiography (WFA), and PRP was performed in two sessions, 2 weeks apart. Patients were examined every 2–4 weeks to determine the status of new vessels (NVs). Additional laser burns were applied in cases with recurrence of NVs. Statistical Analysis: Numbers and percentages were calculated and reported. Results: Eleven patients (18 eyes) with FDR were included. All included patients had poorly controlled diabetes mellitus with mean glycated hemoglobin of 10.6%. One week after the injection, all eyes showed clinical regression of NVs. WFA showed extensive areas of peripheral retinal capillary nonperfusion. Eight weeks after the injection, three eyes (16.7%) showed recurrent increase in NVs, and additional laser therapy was performed for these eyes with special attention to ablating the areas of peripheral capillary non-perfusion. After 16 weeks from the primary treatment, 15 eyes (83.3%) had complete neovascular regression on clinical and angiographic assessment. Pars planavitrectomy was required for three eyes (16.7%) with tractional retinal detachment (2 eyes) or macular epi-retinal membranes (one eye). Conclusions: According to this study, most cases with FDR stabilized after prompt bevacizumab injection followed by complete PRP with special attention for ablating the peripheral capillary nonperfusion areas, guided by WFA images.

Male circumcision using bone cutter with thermal cautery Salih Abdul Kafi Hammoodi Al-Ani Mustansiriya Medical Journal 2020 19(2):49-53 Background: Bone cutter is a widely used procedure to cut the prepuce during circumcision. Aim of the study: The aim of the study was to assess the safety of circumcision of male using bone cutter with thermal cautery, including the operative time and healing time and the effect of dressing on rate of infection and bleeding. Materials and Methods: Over 20 years period from 1996 till 2015, six thousands of males were circumcised under local anesthesia (in form local infiltration of 1% plain lidocaine 5 min before circumcision and xylocaine spray after the procedure) using a bone cutter with thermal cautery, the first assistant is to fix the upper limbs, while the main assistant is to fix the knees in a fully extended position by the left hand, while the right hand used to elevate the two mosquitoes, then by using thermal cautery to cut the foreskin above the jaw of bone cutter and by using S-ring in certain situation to fix the bone cutter tightly. Results: Six thousands males were included in this study. The mean operative time was 1-2 minutes, healing time was 5-7 days, 387 cases (6.45%) developed early & late complications, 180 (3%) bleeding, 195 (3.25%) developed infection, 3 (0.05%) with mild glans injury need dressing only for 24-48 hours only 9 (0.15%) need re-circumcision later on in the same procedure. Conclusions: Bone cutter with thermal cautery circumcision is feasible with a relatively lower complications rate, shorter operative time, and short healing time.

Evaluation of maternal serum sestrin2 levels in preeclampsia and their relationship with the Disease severity Raghad Ahmed Fadhil, Lilyan W Sersam Mustansiriya Medical Journal 2020 19(2):54-58 Background: Preeclampsia (PE) is considered one of the major causes of both maternal and fetal mortality and morbidity. Advances have been made on understanding the pathophysiology of this pregnancy-specific disorder. Sestrin2 (SESN2) is a metabolic regulator protein, whose expression is induced in response to exposure to different adverse effects such as hypoxia, DNA damage, or oxidative stress, thus acting as cytoprotective. Objective: The objective of the study was to investigate the levels of maternal serum SESN2 in preeclamptic and uncomplicated pregnancies and their association with the disease severity. Patients and Methods: This was a case–control study conducted at the Department of Obstetrics and Gynecology at Al-Yarmouk Teaching Hospital in Iraq – Baghdad city from the first of March till the end of November 2019. The study included a total of 92 pregnant women, 27 with a healthy pregnancy, 33 with nonsevere PE, and another 32 having severe PE. From all participants, blood samples were collected for the evaluation of serum SESN2 levels using enzyme-linked immunosorbent assay. Results: The mean readings of SESN2 for normal pregnancies were 5.22 ± 1.71 ng/ml which was significantly lower than that for the nonsevere PE group (8.41 ± 1.42 ng/ml), while SESN2 levels were the highest among those with severe PE (16.92 ± 5.15 ng/ml). A negative correlation was found between each of GA at delivery, birth interval, and birth weight and the SESN2 level (P = 0.001); while mean arterial pressure positively correlated with SESN2 levels (P = 0.001), the cutoff value for the diagnosis of severe PE was 9.95 ng/ml (sensitivity of 93.8% and specificity of 98.8%). Conclusion: Maternal serum SESN2 levels are significantly higher in pregnancies complicated by severe PE than nonsevere PE and control groups. It could be a useful biomarker that can help in diagnosing severe PE.

Assessment of left ventricular longitudinal function in hypertensive patients without left ventricular hypertrophy by mitral annular plane systolic excursion Samara Mohammad Khider, Ghalib Al-Shareefi Mustansiriya Medical Journal 2020 19(2):59-65 Background: Hypertension is an important risk factor for many cardiovascular diseases worldwide. Assessment of left ventricular (LV) systolic function has a major diagnostic and prognostic importance in patients with hypertension. The use of mitral annular plane systolic excursion in the assessment of LV systolic dysfunction is helpful especially in cases of poor imaging quality, “since good imaging quality is needed for the modern echocardiographic techniques. Objectives: Detection of early subclinical LV longitudinal systolic dysfunction in hypertensive patients without LV hypertrophy (LVH) with preserved ejection fraction by mitral annular plane systolic excursion. Patients and Methods: A comparative case-control study which took place at Al-Yarmouk Teaching Hospital in Baghdad/Iraq from October 2018 to October 2019. The study population consisted of 60 patients without LVH and 60 healthy subjects considered as controls. Echocardiographic parameters for left ventricular systolic assessments were done for all subjects. Results: Mean peak annular systolic velocity was significantly lower in hypertensive patients without LVH compared to controls (P = 0.034). There was no significant difference between hypertensive patients without LVH and controls regarding mitral annular plane systolic excursion (P = 0.4). There was positive linear correlation between mitral annular plane systolic excursion and peak annular systolic velocity for hypertensive patients without LVH (r = 0.535, P = 0.015). Conclusion: Although there was a significant linear correlation between mitral annular plane systolic excursion and peak systolic velocity and both are considered as a surrogate for LV longitudinal systolic function, mitral annular plane systolic excursion cannot be used for assessment of LV longitudinal systolic function in patients with hypertension without LVH.

The portrayal of microbes in respiratory medicine M V Raghavendra Rao, Vijay K Chennamchetty, Dilip Mathai, Mahendra Kumar Verma, Tiara Calvo Leon, Pamphil Igman, Surekha Bhat, Mohammad Ismail Nizami, Sanjay Kumar Agarwal, Lakshmi Hitesh Billa, Abrar A Khan Mustansiriya Medical Journal 2020 19(2):66-72 Respiratory diseases caused by a number of infectious agents including Streptococcal pneumonia, streptococcal pyogenes, Klebsiella pneumonia H. influenzae, Legionella pneumophilia, Mycoplasma pneumonia, Coxiella Bunetii, chlamydia pisittaci. These microbes enter into the lungs and cause primary cases of pneumonia. The whole respiratory epithelium down to the internal bronchioles is ciliated. The cilia and the thin film of mucus covering them have the critical function of trapping foreign particles, including bacteria, and propelling them toward the pharynx. They contribute to the prevention of respiratory infection as they do the macrophages utilizing their secretory, phagocytic, and bactericidal activity. Despite the wonderful defense, the bacterium escapes and settles in the lungs to produce diseases. Pneumonia is the term used to describe inflammation of the lung. Pneumococcal pneumonia is characterized by homologous consolidation of one or more lobes or segments. Pneumococcal pneumonia occurs at all ages but most frequently in early and middle adult life. Pneumonia is characterized with the rise in body temperature 39-40oC, remain associated with painful cough initially dry, but later patient develops production of tenacious sputum, which is often rusty and occasionally bloodstained. Staphylococcal pneumonia is caused due to Streptococcus aureus, which may occur either as a primary respiratory infection or as a blood-borne infection from a staphylococcal lesion elsewhere in the body. Klebsiella pneumonia is caused due to K. pneumoniae, a rare disease with high mortality. There is usually massive consolidation and excavation of one or more lobes, with the upper lobes being most often involved and with large amounts of purulent sputum, sometimes characteristic red currant jelly sputum. Legionella pneumonia is caused by Gram-negative bacillus L. pneumophila, which is usually transmitted in water droplets from infected cisterns used to provide water for showers, particularly in warm climates. It is often a serious and occasionally a fatal illness. C. psittaci causes psittacosis (ornithosis), a systemic illness contracted from infected birds. Pneumonia associated with it may be extensive, with severe toxemia. M. pneumoniae is a pleomorphic bacterium; symptoms of mycoplasma pneumonia are mild compared to other cases of pneumonia (walking pneumonia). On the other hand, liver function test derangements and dyselectrolytemia are more common. It is susceptible to tetracyclines though a few strains are sensitive only to erythromycin.

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Otolaryngology & Head and Neck Surgery

Imaging-based navigation technologies in head and neck surgery Purpose of review Image guided navigation has had significant impact in head and neck surgery, and has been most prolific in endonasal surgeries. Although conventional image guidance involves static computed tomography (CT) images attained in the preoperative setting, the continual evolution of surgical navigation technologies is fast expanding to incorporate both real-time data and bioinformation that allows for improved precision in surgical guidance. With the rapid advances in technologies, this article allows for a timely review of the current and developing techniques in surgical navigation for head and neck surgery. Recent findings Current advances for cross-sectional-based image-guided surgery include fusion of CT with other imaging modalities (e.g., magnetic resonance imaging and positron emission tomography) as well as the uptake in intraoperative real-time 'on the table' imaging (e.g., cone-beam CT). These advances, together with the integration of virtual/augmented reality, enable potential enhancements in surgical navigation. In addition to the advances in radiological imaging, the development of optical modalities such as fluorescence and spectroscopy techniques further allows the assimilation of biological data to improve navigation particularly for head and neck surgery. Summary The steady development of radiological and optical imaging techniques shows great promise in changing the paradigm of head and neck surgery. Correspondence to Jonathan C. Irish, MD, Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, 200 Elizabeth St 8NU-882, Toronto, ON, Canada, M5G 2C4. Tel: +1 (416) 340 3113; e-mail: Jonathan.Irish@uhn.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Oral potentially malignant disorders: new insights for future treatment Purpose of review The purpose of this review is to define the issues regarding oral potentially malignant disorders (OPMDs) and provide an overview of currently available treatments and ongoing clinical trials for future opportunities. Recent findings Nowadays, the treatment of choice of OPMD is surgery, whose role in preventing malignant transformation is however limited because of the high rate of recurrence and field cancerization. There have been several attempts of combining systemic therapies with surgery to reduce risk of malignant transformation. The identification of biomarkers that could predict malignant transformation is crucial in better tailoring the risk profile and possible therapeutic approaches. Summary Loss of heterozygosity remains the most predictive marker of malignant transformation; however, role of specific microRNA and OPMD immune infiltration are emerging as potential biomarkers. Given the failure of previous trials with various chemopreventive strategies, new strategies should be defined to address the issue of systemic prevention of malignant transformation. Recent updates about immune infiltration and the immune-equilibrium concept for OPMD could shed light into new preventive approaches. Correspondence to Paolo Bossi, Department of Medical and Surgical Specialties, Medical Oncology, Radiological Sciences and Public Health University of Brescia, ASST-Spedali Civili, Piazzale Spedali Civili 1, 25123 Brescia, Italy. Tel: +39 0303998969; e-mail: paolo.bossi@unibs.it Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Therapeutic challenges in radiation-induced salivary gland cancers Purpose of review To give an overview of recent advances in therapeutic approaches of radiation-induced salivary gland cancers (ri-SGCs). Recent findings Reirradiation with protons and carbon ions demonstrated to be feasible, safe and to offer good local control rates, with the possibility of overcoming radioresistance and dosimetric issues in previously irradiated cancer patients. Chromosomal rearrangements, gene fusions and expression profiles are important to identify specific cancer subtypes and can guide tailored systemic therapy. Summary Ri-SGCs are rare and heterogeneous. Patients are often heavily pretreated and at risk of toxicities, and their management remain challenging. A multidisciplinary approach in referral centers is mandatory. Knowledge about SGCs cellular and molecular mechanisms is constantly evolving. In the last years, novel advances in therapeutic approaches, such as carbon ion radiotherapy, are emerging as safe and effective options in active treatment, but further efforts are needed to offer tailored personalized treatments and to improve survival. Correspondence to Sara Ronchi, MD, Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy. Tel: +39 0382078501; e-mail: sara.ronchi@cnao.it Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

A roadmap of six different pathways to improve survival in laryngeal cancer patients Purpose of review Laryngeal cancer continues to require improvement in earlier stage diagnosis and better imaging delineation of disease, and hence 'more evidence-based' selection of treatment, as recent evidence suggests that related mortality, in the last decades, has not significantly decreased worldwide. Even though the reasons are not fully understood, there persists an urgency for a review and development of future strategies to embrace such clinical and diagnostic challenges from a political, societal, as well as scientific and clinical points of view. Recent findings This review of the published literature suggests that survival improvement in laryngeal cancer may be achieved by fuelling and combining at least some or all of six targeted agendas: documentation of disease global incidence and national burden monitoring; development and implementation of high-quality cancer registries; education on risk factors and hazardous habits associated with laryngeal cancer for the general population; active modification of proven at-risk population lifestyles; centralization of treatment; and use of machine learning of gathered 'big data' and their integration into approaches for the optimization of prevention and treatments strategies. Summary Laryngeal cancer should be tackled on several fronts, commencing with disease monitoring and prevention, up to treatment optimisation. Available modern resources offer the possibility to generate significant advances in laryngeal cancer management. However, each nation needs to develop a comprehensive approach, which is an essential prerequisite to obtain meaningful improvement on results. Correspondence to Patrick J. Bradley, 10 Chartwell Grove, Mapperley Plains, Nottingham NG3 5RD, UK. E-mail: pjbradley@zoo.co.uk Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Immediate dental implant placement and restoration in the edentulous mandible in head and neck cancer patients: a systematic review and meta-analysis Purpose of review Oral rehabilitation with dental implants in head and neck cancer (HNC) patients is challenging. After tooth removal prior to radiotherapy, immediate placement of dental implants during panendoscopy or surgery is thought to reduce the oral rehabilitation time improving patients' quality of life. Recent findings There is lack of consensus on the timing of dental implant placement and loading protocols. The aim of this study was to perform a systematic review of the literature regarding the performance and survival rate of immediately inserted dental implants placed prior to radiotherapy. Of 1003 articles, 10 were finally included comparing immediate vs. delayed placement of implants and comparing the effect of radiotherapy on immediately placed implants. Meta-analysis demonstrated a slightly higher survival of immediately placed implants compared with postponed placed implants [risk ratio: 0.92, 95% confidence interval (95% CI): 0.48–1.78, P = 0.81, I2 = 0%]. The other meta-analysis comparing radiotherapy vs. nonradiotherapy showed a clearly better survival of immediately placed implants not having received radiotherapy (risk ratio: 5.02, 95% CI: 0.92–27.38, P = 0.10, I2  = 56%). Summary Guidelines are recommended for immediate dental implant placement in the edentulous mandible in HNC patients prior to radiotherapy to allow homogeneity regarding the treatment protocols and thus comparison of treatment outcomes. Correspondence to Frank K.J. Leusink, MD, PhD, Amsterdam UMC, location VUmc, Department of Oral and Maxillofacial Surgery, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands. Tel: +31 20 444 1023; fax: +31 20 444 1005; e-mail: f.leusink@amsterdamumc.nl Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.co-otolaryngology.com). This is an-open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Treatment of persistent/recurrent nodal disease in nasopharyngeal cancer Purpose of review Persistent or recurrent disease in the neck lymphatics is an unusual pattern of failure in nasopharyngeal carcinoma (NPC) after definitive radiotherapy or chemoradiotherapy. The purpose of this review is to critically synthesize the current knowledge regarding salvage treatment of this unique form of failure in NPC. Recent findings Surgery in the form of radical neck dissection has been established as the standard salvage treatment with 5-year regional control of 60--86%. Recent shift in paradigm has resulted in the use of modified or selective neck dissection as salvage surgery in some centers. Risk factors for poor survival outcome include recurrent nodal disease, number of involved lymph nodes, extracapsular extension, high lymph node ratio, and positive resection margin. There are no well controlled studies on the role of additional radiotherapy or chemotherapy to improve local control or survival after salvage neck dissection in this group of patients with regional failure. Summary There is limited literature regarding the extent of surgical dissection in treating nodal persistent or recurrent disease. Prospective studies are also needed to determine whether adjuvant therapy improves treatment outcomes. Correspondence to Wai-Tong Ng, Department of Clinical Oncology, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, China. Tel: +852 2255 4352; fax: +852 2872 6426; e-mail: ngwt1@hku.hk Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Orthopedic Disorders

Poncet's disease (tubercular rheumatism): a narrative review Ganesh Singh Dharmshaktu Clinical Trials in Orthopedic Disorders 2020 5(4):23-27 Poncet's disease or tubercular rheumatism is uncommon, and there are not many related studies. No consensus has been achieved with respect to its etiopathogenesis. The low prevalence of this Poncet's disease even in endemic regions suggests hidden mechanisms that require further research to fully comprehend this enigmatic disorder. Careful identification of primary focus of tubercular infection, clinical suspicion and knowledge of this disorder is crucial for prompt identification and treatment. This article aims to provide an overview of the recently published articles about Poncet's disease. The article attempts to highlight key features of the disease for better understanding of this peculiar disorder.

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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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Anesthesia & Analgesia

Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24–31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.

Efficiency Metrics at an Academic Freestanding Ambulatory Surgery Center: Analysis of the Impact on Scheduled End-Times BACKGROUND: Understanding the impact of key metrics on operating room (OR) efficiency is important to optimize utilization and reduce costs, particularly in freestanding ambulatory surgery centers. The aim of this study was to assess the association between commonly used efficiency metrics and scheduled end-time accuracy. METHODS: Data from patients who underwent surgery from May 2018 to June 2019 at an academic freestanding ambulatory surgery center was extracted from the medical record. Unique operating room days (ORDs) were analyzed to determine (1) duration of first case delays, (2) turnover times (TOT), and (3) scheduled case duration accuracies. Spearman's correlation coefficients and mixed-effects multivariable linear regression were used to assess the association of each metric with scheduled end-time accuracy. RESULTS: There were 1378 cases performed over 300 unique ORDs. There were 86 (28.7%) ORDs with a first case delay, mean (standard deviation [SD]) 11.2 minutes (15.1 minutes), range of 2–101 minutes; the overall mean (SD) TOT was 28.1 minutes (19.9 minutes), range of 6–83 minutes; there were 640 (46.4%) TOT >20 minutes; the overall mean (SD) case duration accuracy was −6.6 minutes (30.3 minutes), range of −114 to 176; and there were 389 (28.2%) case duration accuracies ≥30 minutes. The mean (SD) scheduled end-time accuracy was 6.9 minutes (68.3 minutes), range of −173 to 229 minutes; 48 (15.9%) ORDs ended ≥1 hour before scheduled end-time and 56 (18.6%) ORDs ended ≥1 hour after scheduled end-time. The total case duration accuracy was strongly correlated with the scheduled end-time accuracy (r = 0.87, 95% confidence interval [CI], 0.84-0.89, P < .0001), while the total first case delay minutes (r = 0.12, 95% CI, 0.01-0.21, P = .04) and total turnover time (r = −0.16, 95% CI, 0.21-0.05, P = .005) were less relevant. Case duration accuracy had the highest association with the dependent variable (0.95 minutes changed in the difference between actual and schedule end time per minute increase in case duration accuracy, 95% CI, 0.90-0.99, P < .0001), compared to turnover time (estimate = 0.87, 95% CI, 0.75-0.99, P < .0001) and first case delay time (estimate = 0.83, 95% CI, 0.56-1.11, P < .0001). CONCLUSIONS: Standard efficiency metrics are similarly associated with scheduled end-time accuracy, and addressing problems in each is requisite to having an efficient ambulatory surgery center. Pursuing methods to narrow the gap between scheduled and actual case duration may result in a more productive enterprise.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures BACKGROUND: Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration. METHODS: We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients. RESULTS: A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1–3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3–3.7], P < .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P = .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes. CONCLUSIONS: Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.

Intermittent Hypoxia and Effects on Early Learning/Memory: Exploring the Hippocampal Cellular Effects of Pediatric Obstructive Sleep Apnea This review provides an update on the neurocognitive phenotype of pediatric obstructive sleep apnea (OSA). Pediatric OSA is associated with neurocognitive deficits involving memory, learning, and executive functioning. Adenotonsillectomy (AT) is presently accepted as the first-line surgical treatment for pediatric OSA, but the executive function deficits do not resolve postsurgery, and the timeline for recovery remains unknown. This finding suggests that pediatric OSA potentially causes irreversible damage to multiple areas of the brain. The focus of this review is the hippocampus, 1 of the 2 major sites of postnatal neurogenesis, where new neurons are formed and integrated into existing circuitry and the mammalian center of learning/memory functions. Here, we review the clinical phenotype of pediatric OSA, and then discuss existing studies of OSA on different cell types in the hippocampus during critical periods of development. This will set the stage for future study using preclinical models to understand the pathogenesis of persistent neurocognitive dysfunction in pediatric OSA.

Development and Evaluation of a Risk-Adjusted Measure of Intraoperative Hypotension in Patients Having Nonemergent, Noncardiac Surgery BACKGROUND: Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts. METHODS: The measure we developed defines hypotension as a mean arterial pressure <65 mm Hg sustained for at least 15 cumulative minutes. Comparisons are based on whether clinicians have more or fewer cases of hypotension than expected over 12 months, given their patient mix. The measure was developed and evaluated with data from 225,389 surgeries in 5 hospitals. We assessed discrimination and calibration of the risk adjustment model, then calculated the distribution of clinician-level measure scores, and finally estimated the signal-to-noise reliability and predictive validity of the measure. RESULTS: The risk adjustment model showed acceptable calibration and discrimination (area under the curve was 0.72 and 0.73 in different validation samples). Clinician-level, risk-adjusted scores varied widely, and 36% of clinicians had significantly more cases of intraoperative hypotension than predicted. Clinician-level score distributions differed across hospitals, indicating substantial hospital-level variation. The mean signal-to-noise reliability estimate was 0.87 among all clinicians and 0.94 among clinicians with >30 cases during the 12-month measurement period. Kidney injury and in-hospital mortality were most common in patients whose anesthesia providers had worse scores. However, a sensitivity analysis in 1 hospital showed that score distributions differed markedly between anesthesiology fellows and attending anesthesiologists or certified registered nurse anesthetists; score distributions also varied as a function of the fraction of cases that were inpatients. CONCLUSIONS: Intraoperative hypotension was common and was associated with acute kidney injury and in-hospital mortality. There were substantial variations in clinician-level scores, and the measure score distribution suggests that there may be opportunity to reduce hypotension which may improve patient safety and outcomes. However, sensitivity analyses suggest that some portion of the variation results from limitations of risk adjustment. Future versions of the measure should risk adjust for important patient and procedural factors including comorbidities and surgical complexity, although this will require more consistent structured data capture in anesthesia information management systems. Including structured data on additional risk factors may improve hypotension risk prediction which is integral to the measure's validity.

Do Elderly Patients With Diastolic Dysfunction Require Higher Doses of Norepinephrine During General Anesthesia for Noncardiac Surgeries? A Prospective Observational Study BACKGROUND: Diastolic dysfunction is a risk factor for postoperative major cardiovascular events. During anesthesia, patients with diastolic dysfunction might experience impaired hemodynamic function and worsening of diastolic function, which in turn, might be associated with a higher incidence of postoperative complications. We aimed to investigate whether patients with diastolic dysfunction require higher doses of norepinephrine during general anesthesia. Furthermore, we aimed to examine the association between the grade of diastolic dysfunction and the E/e' ratio during anesthesia. A high E/e' ratio corresponds to elevated filling pressures and is an important measure of impaired diastolic function. METHODS: We conducted a prospective observational cohort study at a German university hospital from February 2017 to September 2018. Patients aged ≥60 years and undergoing general anesthesia (ie, propofol and sevoflurane) for elective noncardiac surgery were enrolled. Exclusion: mitral valve disease, atrial fibrillation, and implanted mechanical device. The primary outcome parameter was the administered dose of norepinephrine within 30 minutes after anesthesia induction (μg·kg−1 30 min−1). The secondary outcome parameter was the change of Doppler echocardiographic E/e' from ECHO1 (baseline) to ECHO2 (anesthesia). Linear models and linear mixed models were used for statistical evaluation. RESULTS: A total of 247 patients were enrolled, and 200 patients (75 female) were included in the final analysis. Diastolic dysfunction at baseline was not associated with a higher dose of norepinephrine during anesthesia (P = .6953). The grade of diastolic dysfunction at baseline was associated with a decrease of the E/e' ratio during anesthesia (P < .001). CONCLUSIONS: We did not find evidence for an association between diastolic dysfunction and impaired hemodynamic function, as expressed by high vasopressor support during anesthesia. Additionally, our findings suggest that diastolic function, as expressed by the E/e' ratio, does not worsen during anesthesia.

Fiber-Needle Swept-Source Optical Coherence Tomography for the Real-Time Visualization of the Transversus Abdominis Plane Block Procedure in a Swine Model BACKGROUND: Fascia blocks (eg, the transversus abdominis plane [TAP] block) target the intermuscular fascia layers. Ultrasound techniques have allowed peripheral blocks to be performed with accuracy and safety, however, with limitations. Optical coherence tomography (OCT) is based on low-coherence interferometry. In this study, we examined the ability of OCT to identify the TAP. METHODS: A swept-source OCT probe was placed in a 17-gauge needle to obtain imaging. The needle was inserted within 2 different angle ranges (0°–30° and 30°–60°) on a slice of pork belly to assess imaging characteristics. A series of real-time OCT imaging of the muscle, fascia, and interfascial space was obtained. The tissue location of the needle tip was identified using near-infrared (NIR) imaging. In vivo OCT imaging was further done on 3 female 6-month-old native Chinese Landrance Duroc pigs. Real-time images of tissue layers were obtained with needle insertion. Ultrasound imaging of the OCT needle probe was also performed at the same time for needle trajectory guidance. After imaging, the OCT probe was removed, and 5 mL of normal saline was injected via the needle to confirm correct fascia plane identification. RESULTS: In and ex vivo studies showed clear visual distinction of muscle, fascia, and interfascial layer with OCT, with limitations. Independent validation of OCT criteria for the muscle/fascia differentiation by 20 OCT readers for the in vivo data demonstrated the sensitivity = 0.91, specificity = 0.90, and accuracy = 0.89. Although the angle of needle entry affected the depth of OCT penetration in the muscle, the attenuation coefficient values of the fascia and muscle tissue were statistically different (P < .001) and with high area under the receiver operating characteristics (ROC) curve (AUC) (AUC = 0.93 in 0°–30° and AUC = 1 in 30°–60°) for fascia identification. CONCLUSIONS: This study introduced a novel needle imaging probe method to identify the transversus abdominis fascia plane in real-time. Quantitative calculation of the attenuation coefficients can further aid objective identification by providing direct confirmation of the tip position, increasing the first-pass success rate, and decreasing the need for needle repositioning. Combining OCT and ultrasound may improve the accuracy of anesthetics placement.

Incidence, Mortality, and Characteristics of 18 Pediatric Perioperative Cardiac Arrests: An Observational Trial From 22,650 Pediatric Anesthesias in a German Tertiary Care Hospital BACKGROUND: Recently, a very low incidence of 3 per 10,000 and a mortality of 30% were reported for pediatric perioperative cardiac arrest (POCA). However, high-risk patients, namely children already anesthetized on the intensive care unit (ICU), were excluded. This study investigates the incidence and mortality of POCA in children in whom anesthesia was induced in the ICU or in the operating room using real-world data. In addition, different classifications of POCA were compared with respect to outcome relevance. METHODS: This is a retrospective observational study conducted at a German level 1 perinatal center and tertiary care hospital between 2008 and 2018. Children ≤15 years who underwent an anesthetic procedure and suffered from POCA (defined as any condition requiring chest compressions and/or defibrillation) from the beginning of care provided by an anesthesiologist to 60 minutes after anesthesia or sedation were included. Primary end points were incidence and mortality of POCA in children with anesthesia induced in the ICU versus in the operating room. Secondary end points included incidences and outcomes with respect to the pathophysiological cause (respiratory versus circulatory associated). RESULTS: There were 18 POCA during 22,650 anesthetic procedures (incidence 7.9 per 10,000; 95% confidence interval [CI], 4.7-12.5). Thirty-day mortality was 3.5 per 10,000 (95% CI, 1.5-6.9). Incidence and mortality were higher in children in whom anesthesia was induced in the ICU versus in the operating room (incidence: 131.6; 95% CI, 57 to 257.6 versus 4.5; 95% CI, 2.2-8.3; P < .001; and mortality: 82.2; 95% CI, 26.7-190.8 versus 1.4; 95% CI, 0.3-3.9; P < .001). Mortality in circulatory-induced POCA (n = 8; 44%) was 100%, in respiratory-induced POCA (n = 9; 50%) 0% (P < .001). CONCLUSIONS: Children with anesthesia induction in the ICU represent a high-risk population for POCA and POCA-associated mortality. POCA classification should be based on the individual cause (respiratory versus circulatory) rather than on the perioperative phase or the responsible specialty.

A Bayesian Comparison of Frailty Instruments in Noncardiac Surgery: A Cohort Study BACKGROUND: Frailty—a multidimensional syndrome related to age- and disease-related deficits—is a key risk factor for older surgical patients. However, it is unknown which frailty instrument most accurately predicts postoperative outcomes. Our objectives were to quantify the probability of association and relative predictive performance of 2 frailty instruments (ie, the risk analysis index-administrative [RAI-A] and 5-item modified frailty index [mFI-5]) with postoperative outcomes in National Surgical Quality Improvement Program (NSQIP) data. METHODS: Retrospective cohort study using Bayesian analysis of NSQIP hospitals. Adults having inpatient small or large bowel surgery 2010–2015 (derivation cohort) or intermediate to high risk mixed noncardiac surgery in 2016 (validation cohort) had preoperative frailty assigned using 2 unique approaches (RAI-A and mFI-5). Probabilities of association were calculated based on posterior distributions and relative predictive performance using posterior predictive distributions and Bayes factors for 30-day mortality (primary outcome) and serious complications (secondary outcome). RESULTS: Of 50,630 participants, 7630 (14.0%) died and 19,545 (38.6%) had a serious complication. Without adjustment, the RAI-A and mFI-5 had >99% probability being associated with mortality with a ≥2.0 odds ratio (ie, large effect size). After adjustment for NSQIP risk calculator variables, only the RAI-A had ≥95% probability of a nonzero association with mortality. Similar results arose when predicting postoperative complications. The RAI-A provided better predictive accuracy for mortality than the mFI-5 (minimum Bayes factor 3.25 × 1014), and only the RAI-A improved predictive accuracy beyond that of the NSQIP risk calculator (minimum Bayes factor = 4.27 × 1013). Results were consistent in leave-one-out cross-validation. CONCLUSIONS: Translation of frailty-related findings from research and quality improvement studies to clinical care and surgical planning will be aided by a consistent approach to measuring frailty with a multidimensional instrument like RAI-A, which appears to be superior to the mFI-5 when predicting outcomes for inpatient noncardiac surgery.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

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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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