Anaesthesia

From the desk of the New President S Bala Bhaskar Indian Journal of Anaesthesia 2019 63(1):1-2

The President's inaugural address during ISACON 2018 on November 28, 2018 at Agra Kuchela V Babu Indian Journal of Anaesthesia 2019 63(1):3-5

Endothelial glycocalyx: Role in body fluid homeostasis and fluid management Pankaj Kundra, Shreya Goswami Indian Journal of Anaesthesia 2019 63(1):6-14 Endothelial glycocalyx layer (EGL) coating the luminal surface of vascular endothelium plays an essential role in maintaining the normal fluid homeostasis of the body. This highly fragile layer can be damaged by a number of pathophysiological conditions and interventions. Disease state management should be directed to maintain EGL integrity to improve patient's outcome. When intravenous (IV) fluids are used, appropriate type, rate and amount of fluid should be determined by the pathophysiology of the condition and measures to maintain the integrity of the EGL. This review depicts the structure and function of the EGL, its alteration in common pathological states and the rationale of IV fluid management to preserve EGL in such conditions.

Comparison between macintosh, miller and mccoy laryngoscope blade size 2 in paediatric patients – A randomised controlled trial Pratishtha Yadav, Sudeshna Bhar Kundu, Dhurjoti P Bhattacharjee Indian Journal of Anaesthesia 2019 63(1):15-20 Background and Aims: Paediatric airway needs special consideration as it is not a miniature replica of adult airway, rather it has different anatomy with different proportion and angulations. This study was conducted with the aim to find a laryngoscope blade that provides best laryngoscopic and intubation conditions in paediatric patients of age 2–6 years. Methods: This trial was conducted in a total of 75 children age 2–6 years, either gender, with American Society of Anesthesiologists grade I or II scheduled for elective surgery under general anaesthesia. They were randomly allocated to groups A, B and C to be intubated with Macintosh, Miller and McCoy blades, respectively. Intubation Difficulty Score (IDS) was considered as primary outcome, and Cormack–Lehane grade and Percentage of Glottic Opening (POGO) score were taken as secondary outcome. Data were compared by ANOVA or Kruskal-Wallis or chi square test using Statistica, SPSS and GraphPad Prism softwares. P < 0.05 was considered statistically significant. Results: IDS score was significantly lower (P = 0.002) in group B (0.6 ± 0.7) as compared to group A (1.4 ± 0.9) and group C (1.3 ± 1.1); majority of patients in group B (48%) had Cormack–Lehane grade Ι (P = 0.002) unlike group A (0%) and group C (20%) and POGO score (P < 0.001) was higher in group B (86 ± 23.4) when compared with groups A (68.2 ± 20.5) and C (59.8 ± 28.9). Haemodynamic changes and other intubation parameters were comparable among the groups. Conclusion: Miller blade may be considered superior to Macintosh and McCoy blades in terms of glottic visualisation and ease of intubation in paediatric patients.

Correlation of early ROTEM parameters with conventional coagulation tests in patients with chronic liver disease undergoing liver transplant A Hashir, Shweta A Singh, Gopi Krishnan, Rajkumar Subramanian, Subhash Gupta Indian Journal of Anaesthesia 2019 63(1):21-25 Background and Aims: Viscoelastic tests such as rotational thromboelastometry (ROTEM) provide a quick and holistic assessment of coagulation status to guide transfusion during liver transplant (LT). Conventional coagulation tests (CCTs) measure single parameters in isolation, and also the results are delayed hampering management of patients during surgery. We evaluated the correlation of early ROTEM-derived parameters with CCTs and also assessed the ability of ROTEM-derived parameters to predict thrombocytopaenia and hypofibrinogenaemia during LT in patients with end-stage liver disease (ESLD). Methods: This retrospective study was carried out in 100 patients with decompensated ESLD undergoing LT. Correlation between CCTs and ROTEM parameters was analyzed. Receiver operating characteristic curves with area under the curve were used to determine the cut-off values of A5 andA10 on EXTEM and FIBTEM. Results: The values of A5EXTEM and A10EXTEM highly correlated with fibrinogen levels and platelet count, whereas A5FIBTEM and A10FIBTEM correlated well with fibrinogen levels. A5EXTEM<21 mm and A10EXTEM<28 mm correlated with a platelet count <75,000 mm−3, whereas A5EXTEM<18 mm and A10EXTEM<25 mm correlated with a platelet count <50,000 mm−3. Fibrinogen levels <100 mg/dL better correlated with A5FIBTEM<5 mm, A10FIBTEM<6 mm, A5EXTEM<21 mm and A10EXTEM<30 mm. Conclusion: Early ROTEM parameters A5 and A10 of both EXTEM and FIBTEM had an excellent correlation with thrombocytopaenia and hypofibrinogenaemia and may potentially guide early transfusion of relevant blood products during LT.

Existing practice of perioperative management of colorectal surgeries in a regional cancer institute and compliance with ERAS guidelines Angshuman Rudra Pal, Suparna Mitra, Sobhan Aich, Jyotsna Goswami Indian Journal of Anaesthesia 2019 63(1):26-30 Background and Aims: Enhanced recovery after surgery (ERAS) protocol in colorectal surgery has been shown to result in reduced rates of postoperative complications and length of stay (LOS) in the hospital. Although there is clear guideline and evidences available, their implementation into daily clinical practice faces some difficulties. We aimed to audit the existing practice of perioperative care in colorectal surgeries and find out the adherence to ERAS protocol. Methods: We collected data from medical record of 215 patients undergoing colorectal surgery in a regional cancer institute of eastern India. The patient data were retrospectively collected, which included, demographic data, adherence to major components of ERAS pathway, postoperative complications, and length of hospital stay. Results: The median LOS after surgery was 9 days (interquartile range [IQR] 6-12.75). Approximately, 15% patients had postoperative complications. We found good adherence (more than 80%) to certain elements of ERAS such as preoperative counseling and nutritional assessments, selective bowel preparation, antibiotic and antithrombotic prophylaxis, etc. Conclusion: The audit revealed that compliance to individual ERAS elements were variable, which needed urgent modification for better adherence to ERAS guidelines.

Cancer relapse in surgical patients who received perioperative transfusion of blood and blood products: A case-control study R Subha, Kurian Cherian, Archana Nair, Rachel Cherian Koshy, Jagathnath Krishna Indian Journal of Anaesthesia 2019 63(1):31-35 Background and Aims: Immunomodulatory consequences of allogeneic blood transfusion may outweigh the advantages of improved oxygen delivery and tissue perfusion, especially in patients with cancer. In colorectal cancer, there is evidence of cancer relapse in patients who received transfusion. This retrospective analysis was undertaken to evaluate the relationship between perioperative blood transfusion and cancer recurrence in patients undergoing oncosurgery. Methods: In this case-control study, we retrospectively analysed the case sheets of 194 patients who had perioperative transfusion and underwent cancer surgery from March to December 2013(Study group, Cases). They were compared with controls matched for cancer site and TNM staging who did not receive perioperative transfusions (Control Group, Controls). We intended to find out if the Study group had any increased risk of cancer relapse compared with the controls. Records from the institute cancer registry were analysed in 2018 to give a follow-up period of 5 years. Continuous variables were analysed using Student's T test and Mann Whitney U test for normally distributed and skewed data respectively. For Categorical data Fisher's exact test and Chi square test were applied. The risk for recurrence was estimated using odds ratio. Results: The recurrence rate in cases and controls was 53.09% and 19.59% respectively and the odds ratio, 4.647 (CI: 2.954, 7.309). In Cases, significant relapse was noted for carcinomas of ovary, colorectal, bladder, larynx, head of pancreas and liver. Conclusion: In surgical oncology patients, ABT is associated with greater rate of recurrence.

Comparison of weight-based and pinna size–based selection of ProSeal laryngeal mask airway in paediatric population – A prospective exploratory trial Ramya Ravi, VK Mohan, Ashok Shankar Badhe, Sandeep Kumar Mishra, Prasanna Udupi Bidkar Indian Journal of Anaesthesia 2019 63(1):36-41 Background and Aims: Weight-based selection of ProSeal laryngeal mask airway (PLMA) size may be unreliable in some situations. The aim of this study was to compare the ventilation parameters using PLMA during controlled ventilation between weight-based size selection and pinna size–based selection in children. Methods: A total of 204 patients were randomised to receive either pinna size–based (Group P) or weight-based (Group W) size selection of PLMA. We tested the hypothesis that pinna size–based selection of PLMA was better than weight-based selection of PLMA in paediatric patients during controlled ventilation under general anaesthesia in terms of oropharyngeal sealing pressure (the primary end-point) and Brimacombe score. Cuff pressure was maintained at 60 cm of H2O during the study. Secondary outcomes included the number of attempts for successful placement of PLMA, peak airway pressure, gastric tube placement, traumatic insertion, and complications were also compared. Parametric variables were analysed using unpaired t-test and categorical variables were analysed using Mann–Whitney and Chi-square test. Results: In all, 200 patients were analysed. The mean oropharyngeal sealing pressure in Group P was 25.4 ± 3.5 cmH2O and 24.9 ± 3.8 cmH2O in Group W, (P = 0.34). There was no significant difference between the two groups in any of the secondary outcomes. There were no traumatic insertion or complications reported in both the groups. Conclusion: Pinna-based size selection method can be used in PLMA placement in the paediatric population for positive pressure ventilation and it serves as an alternative method to weight-based selection.

Interest and experience of anaesthesiology residents in doing research during residency training Ha T T Truong, Jason J I Chan, Wan Ling Leong, Rehena Sultana, Darren L K Koh, Ban Leong Sng Indian Journal of Anaesthesia 2019 63(1):42-48 Background and Aims: The SingHealth Anaesthesiology Residency Program is a 5-year postgraduate training programme whose curriculum covers clinical and academic training, through research and educational activities. This study aimed to describe the needs of the residents in promoting research participation during residency. Methods: After obtaining ethics committee approval, we conducted an online anonymous survey among all residents in the Residency Program. The questionnaire comprised questions of demographic data, levels of research interest, areas of interest, the obstacles to research and the potential areas where help can be improved. SAS (version 9.4, 2017; SAS Institute Inc.) was used for descriptive analysis and logistic regression. Results: Sixty-seven of the 79 residents (84.8%) in the Program responded with 58 (73.4%) completing the survey. Fifty-six of the 62 (90%) expressed some level of interest in research. The top two areas of research interest were clinical research and medical education research. The top obstacles to research were lack of time (due to competing clinical time and work–life balance) and lack of mentorship. The top three areas of research support needed by residents were supervised research protected time, departmental research manpower support and mentorship with topic expertise. Senior Residents were more likely to have higher research interest, self-initiated research participation and consideration for research as part of career progression, compared with junior residents. Conclusion: Residents faced many obstacles in doing research during residency training. Our findings also highlighted some of the needs for research support reported by the residents during their specialty training.

Comparative evaluation of anaesthetic efficacy and haemodynamic effects of a combination of isobaric bupivacaine with buprenorphine vs. isobaric levobupivacaine with buprenorphine for spinal anaesthesia – A double blinded randomised clinical trial Pushpavathi Ture, Ashwini H Ramaswamy, Safiya I Shaikh, Jagadish B Alur, Ajay V Ture Indian Journal of Anaesthesia 2019 63(1):49-54 Background and Aims: Bupivacaine is the most frequently used local anaesthetic for spinal anaesthesia, however, use of levobupivacaine in clinical practice has advanced recently. This study aimed to compare the anaesthetic potency and haemodynamic effects of intrathecal bupivacaine with buprenorphine versus levobupivacaine with buprenorphine in infraumbilical surgeries. Methods: This prospective randomised double blind study was conducted in seventy patients aged 18&#8211;65 years, American Society of Anesthesiologists grade I-II, scheduled for lower abdominal and lower limb surgery under spinal anaesthesia. The patients either received 0.5&#37; isobaric racemic bupivacaine 3 ml with 2 &#956;g/kg of buprenorphine (Group B) or 0.5&#37; isobaric levobupivacaine 3 ml with 2 &#956;g/kg of buprenorphine (Group L). The time for onset of sensory block between the two groups was the priomary end-point. Other measurements included haemodynamic variables, sensory and motor blockade characteristics, postoperative analgesia, and complications in the first 24 h. Results: There was no significant difference in the onset of sensory block between the two groups. Sensory and motor blockade characteristics were similar between the two groups. However, there was significant fall in the heart rate at 5 min in Group B compared to Group L. There was statistically significant fall in systolic blood pressure in group B compared to Group L from 5 min up to 60 min and fall in diastolic blood pressure from 10 min to 45 min. Conclusion: Our study showed that onset of sensory block is similar between isobaric levobupivacaine with buprenorphine 37 38 and isobaric bupivacaine with buprenorphine.  PRESIDENT MESSAGE   From the desk of the New President p. 1 S Bala Bhaskar DOI:10.4103/ija.IJA_865_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta PAST PRESIDENT'S MESSAGE The President's inaugural address during ISACON 2018 on November 28, 2018 at Agra p. 3 Kuchela V Babu DOI:10.4103/ija.IJA_869_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta REVIEW ARTICLE Endothelial glycocalyx: Role in body fluid homeostasis and fluid management  p. 6 Pankaj Kundra, Shreya Goswami DOI:10.4103/ija.IJA_751_18   Endothelial glycocalyx layer (EGL) coating the luminal surface of vascular endothelium plays an essential role in maintaining the normal fluid homeostasis of the body. This highly fragile layer can be damaged by a number of pathophysiological conditions and interventions. Disease state management should be directed to maintain EGL integrity to improve patient's outcome. When intravenous (IV) fluids are used, appropriate type, rate and amount of fluid should be determined by the pathophysiology of the condition and measures to maintain the integrity of the EGL. This review depicts the structure and function of the EGL, its alteration in common pathological states and the rationale of IV fluid management to preserve EGL in such conditions. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta ORIGINAL ARTICLES Comparison between macintosh, miller and mccoy laryngoscope blade size 2 in paediatric patients – A randomised controlled trial p. 15 Pratishtha Yadav, Sudeshna Bhar Kundu, Dhurjoti P Bhattacharjee DOI:10.4103/ija.IJA_307_18   Background and Aims: Paediatric airway needs special consideration as it is not a miniature replica of adult airway, rather it has different anatomy with different proportion and angulations. This study was conducted with the aim to find a laryngoscope blade that provides best laryngoscopic and intubation conditions in paediatric patients of age 2–6 years. Methods: This trial was conducted in a total of 75 children age 2–6 years, either gender, with American Society of Anesthesiologists grade I or II scheduled for elective surgery under general anaesthesia. They were randomly allocated to groups A, B and C to be intubated with Macintosh, Miller and McCoy blades, respectively. Intubation Difficulty Score (IDS) was considered as primary outcome, and Cormack–Lehane grade and Percentage of Glottic Opening (POGO) score were taken as secondary outcome. Data were compared by ANOVA or Kruskal-Wallis or chi square test using Statistica, SPSS and GraphPad Prism softwares. P < 0.05 was considered statistically significant. Results: IDS score was significantly lower (P = 0.002) in group B (0.6 ± 0.7) as compared to group A (1.4 ± 0.9) and group C (1.3 ± 1.1); majority of patients in group B (48%) had Cormack–Lehane grade Ι (P = 0.002) unlike group A (0%) and group C (20%) and POGO score (P < 0.001) was higher in group B (86 ± 23.4) when compared with groups A (68.2 ± 20.5) and C (59.8 ± 28.9). Haemodynamic changes and other intubation parameters were comparable among the groups. Conclusion: Miller blade may be considered superior to Macintosh and McCoy blades in terms of glottic visualisation and ease of intubation in paediatric patients. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Correlation of early ROTEM parameters with conventional coagulation tests in patients with chronic liver disease undergoing liver transplant p. 21 A Hashir, Shweta A Singh, Gopi Krishnan, Rajkumar Subramanian, Subhash Gupta DOI:10.4103/ija.IJA_334_18   Background and Aims: Viscoelastic tests such as rotational thromboelastometry (ROTEM) provide a quick and holistic assessment of coagulation status to guide transfusion during liver transplant (LT). Conventional coagulation tests (CCTs) measure single parameters in isolation, and also the results are delayed hampering management of patients during surgery. We evaluated the correlation of early ROTEM-derived parameters with CCTs and also assessed the ability of ROTEM-derived parameters to predict thrombocytopaenia and hypofibrinogenaemia during LT in patients with end-stage liver disease (ESLD). Methods: This retrospective study was carried out in 100 patients with decompensated ESLD undergoing LT. Correlation between CCTs and ROTEM parameters was analyzed. Receiver operating characteristic curves with area under the curve were used to determine the cut-off values of A5 andA10 on EXTEM and FIBTEM. Results: The values of A5EXTEM and A10EXTEM highly correlated with fibrinogen levels and platelet count, whereas A5FIBTEMand A10FIBTEM correlated well with fibrinogen levels. A5EXTEM<21 mm and A10EXTEM<28 mm correlated with a platelet count <75,000 mm−3, whereas A5EXTEM<18 mm and A10EXTEM<25 mm correlated with a platelet count <50,000 mm−3. Fibrinogen levels <100 mg/dL better correlated with A5FIBTEM<5 mm, A10FIBTEM<6 mm, A5EXTEM<21 mm and A10EXTEM<30 mm. Conclusion:Early ROTEM parameters A5 and A10 of both EXTEM and FIBTEM had an excellent correlation with thrombocytopaenia and hypofibrinogenaemia and may potentially guide early transfusion of relevant blood products during LT. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Existing practice of perioperative management of colorectal surgeries in a regional cancer institute and compliance with ERAS guidelines  p. 26 Angshuman Rudra Pal, Suparna Mitra, Sobhan Aich, Jyotsna Goswami DOI:10.4103/ija.IJA_382_18   Background and Aims: Enhanced recovery after surgery (ERAS) protocol in colorectal surgery has been shown to result in reduced rates of postoperative complications and length of stay (LOS) in the hospital. Although there is clear guideline and evidences available, their implementation into daily clinical practice faces some difficulties. We aimed to audit the existing practice of perioperative care in colorectal surgeries and find out the adherence to ERAS protocol. Methods: We collected data from medical record of 215 patients undergoing colorectal surgery in a regional cancer institute of eastern India. The patient data were retrospectively collected, which included, demographic data, adherence to major components of ERAS pathway, postoperative complications, and length of hospital stay. Results: The median LOS after surgery was 9 days (interquartile range [IQR] 6-12.75). Approximately, 15% patients had postoperative complications. We found good adherence (more than 80%) to certain elements of ERAS such as preoperative counseling and nutritional assessments, selective bowel preparation, antibiotic and antithrombotic prophylaxis, etc. Conclusion: The audit revealed that compliance to individual ERAS elements were variable, which needed urgent modification for better adherence to ERAS guidelines. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Cancer relapse in surgical patients who received perioperative transfusion of blood and blood products: A case-control study p. 31 R Subha, Kurian Cherian, Archana Nair, Rachel Cherian Koshy, Jagathnath Krishna DOI:10.4103/ija.IJA_409_18   Background and Aims: Immunomodulatory consequences of allogeneic blood transfusion may outweigh the advantages of improved oxygen delivery and tissue perfusion, especially in patients with cancer. In colorectal cancer, there is evidence of cancer relapse in patients who received transfusion. This retrospective analysis was undertaken to evaluate the relationship between perioperative blood transfusion and cancer recurrence in patients undergoing oncosurgery. Methods: In this case-control study, we retrospectively analysed the case sheets of 194 patients who had perioperative transfusion and underwent cancer surgery from March to December 2013(Study group, Cases). They were compared with controls matched for cancer site and TNM staging who did not receive perioperative transfusions (Control Group, Controls). We intended to find out if the Study group had any increased risk of cancer relapse compared with the controls. Records from the institute cancer registry were analysed in 2018 to give a follow-up period of 5 years. Continuous variables were analysed using Student's T test and Mann Whitney U test for normally distributed and skewed data respectively. For Categorical data Fisher's exact test and Chi square test were applied. The risk for recurrence was estimated using odds ratio. Results: The recurrence rate in cases and controls was 53.09% and 19.59% respectively and the odds ratio, 4.647 (CI: 2.954, 7.309). In Cases, significant relapse was noted for carcinomas of ovary, colorectal, bladder, larynx, head of pancreas and liver. Conclusion: In surgical oncology patients, ABT is associated with greater rate of recurrence. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Comparison of weight-based and pinna size–based selection of ProSeal laryngeal mask airway in paediatric population – A prospective exploratory trial p. 36 Ramya Ravi, VK Mohan, Ashok Shankar Badhe, Sandeep Kumar Mishra, Prasanna Udupi Bidkar DOI:10.4103/ija.IJA_423_18   Background and Aims: Weight-based selection of ProSeal laryngeal mask airway (PLMA) size may be unreliable in some situations. The aim of this study was to compare the ventilation parameters using PLMA during controlled ventilation between weight-based size selection and pinna size–based selection in children. Methods: A total of 204 patients were randomised to receive either pinna size–based (Group P) or weight-based (Group W) size selection of PLMA. We tested the hypothesis that pinna size–based selection of PLMA was better than weight-based selection of PLMA in paediatric patients during controlled ventilation under general anaesthesia in terms of oropharyngeal sealing pressure (the primary end-point) and Brimacombe score. Cuff pressure was maintained at 60 cm of H2O during the study. Secondary outcomes included the number of attempts for successful placement of PLMA, peak airway pressure, gastric tube placement, traumatic insertion, and complications were also compared. Parametric variables were analysed using unpaired t-test and categorical variables were analysed using Mann–Whitney and Chi-square test. Results: In all, 200 patients were analysed. The mean oropharyngeal sealing pressure in Group P was 25.4 ± 3.5 cmH2O and 24.9 ± 3.8 cmH2O in Group W, (P = 0.34). There was no significant difference between the two groups in any of the secondary outcomes. There were no traumatic insertion or complications reported in both the groups. Conclusion: Pinna-based size selection method can be used in PLMA placement in the paediatric population for positive pressure ventilation and it serves as an alternative method to weight-based selection. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Interest and experience of anaesthesiology residents in doing research during residency training p. 42 Ha T T Truong, Jason J I Chan, Wan Ling Leong, Rehena Sultana, Darren L K Koh, Ban Leong Sng DOI:10.4103/ija.IJA_543_18   Background and Aims: The SingHealth Anaesthesiology Residency Program is a 5-year postgraduate training programme whose curriculum covers clinical and academic training, through research and educational activities. This study aimed to describe the needs of the residents in promoting research participation during residency. Methods: After obtaining ethics committee approval, we conducted an online anonymous survey among all residents in the Residency Program. The questionnaire comprised questions of demographic data, levels of research interest, areas of interest, the obstacles to research and the potential areas where help can be improved. SAS (version 9.4, 2017; SAS Institute Inc.) was used for descriptive analysis and logistic regression. Results: Sixty-seven of the 79 residents (84.8%) in the Program responded with 58 (73.4%) completing the survey. Fifty-six of the 62 (90%) expressed some level of interest in research. The top two areas of research interest were clinical research and medical education research. The top obstacles to research were lack of time (due to competing clinical time and work–life balance) and lack of mentorship. The top three areas of research support needed by residents were supervised research protected time, departmental research manpower support and mentorship with topic expertise. Senior Residents were more likely to have higher research interest, self-initiated research participation and consideration for research as part of career progression, compared with junior residents. Conclusion: Residents faced many obstacles in doing research during residency training. Our findings also highlighted some of the needs for research support reported by the residents during their specialty training. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Comparative evaluation of anaesthetic efficacy and haemodynamic effects of a combination of isobaric bupivacaine with buprenorphine vs. isobaric levobupivacaine with buprenorphine for spinal anaesthesia – A double blinded randomised clinical trial p. 49 Pushpavathi Ture, Ashwini H Ramaswamy, Safiya I Shaikh, Jagadish B Alur, Ajay V Ture DOI:10.4103/ija.IJA_667_17   Background and Aims: Bupivacaine is the most frequently used local anaesthetic for spinal anaesthesia, however, use of levobupivacaine in clinical practice has advanced recently. This study aimed to compare the anaesthetic potency and haemodynamic effects of intrathecal bupivacaine with buprenorphine versus levobupivacaine with buprenorphine in infraumbilical surgeries. Methods: This prospective randomised double blind study was conducted in seventy patients aged 18–65 years, American Society of Anesthesiologists grade I-II, scheduled for lower abdominal and lower limb surgery under spinal anaesthesia. The patients either received 0.5% isobaric racemic bupivacaine 3 ml with 2 μg/kg of buprenorphine (Group B) or 0.5% isobaric levobupivacaine 3 ml with 2 μg/kg of buprenorphine (Group L). The time for onset of sensory block between the two groups was the priomary end-point. Other measurements included haemodynamic variables, sensory and motor blockade characteristics, postoperative analgesia, and complications in the first 24 h. Results: There was no significant difference in the onset of sensory block between the two groups. Sensory and motor blockade characteristics were similar between the two groups. However, there was significant fall in the heart rate at 5 min in Group B compared to Group L. There was statistically significant fall in systolic blood pressure in group B compared to Group L from 5 min up to 60 min and fall in diastolic blood pressure from 10 min to 45 min. Conclusion: Our study showed that onset of sensory block is similar between isobaric levobupivacaine with buprenorphine 37 38 and isobaric bupivacaine with buprenorphine. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta CASE REPORT Weakness of contralateral upper limb after interscalene block – A case report p. 55 Ashok Jadon, Swapnil Nage, Chintala Pavana Swarupa, Mayur Motaka DOI:10.4103/ija.IJA_554_18   We have reported a case of right upper limb injury of shoulder and elbow who was managed with ultrasound-guided interscalene block during surgery and indwelling catheter for postoperative analgesia. He developed weakness in the contralateral upper limb in the postoperative period due to inadvertent spread of local anaesthetic in the cervical epidural space. No serious complication occurred due to timely intervention. The possible pathways of such unwanted epidural spread and methods to reduce such complications have been discussed. [ABSTRACT]  [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta BRIEF COMMUNICATIONS Comparison between the Quincke's 22-gauge spinal needle and the 22-gauge hypodermic BD needle for the administration of caudal blocks in paediatric regional anaesthesia – A prospective randomised study p. 58 Vrushali C Ponde, Vinit V Bedekar, Ankit P Desai, Rishiraj Borhazowal DOI:10.4103/ija.IJA_114_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Ultrasound-guided bilateral subcostal TAP block for epigastric hernia repair: A case series p. 60 Pradeep Bhatia, Pooja Bihani, Swati Chhabra, Vandana Sharma, Rishabh Jaju DOI:10.4103/ija.IJA_594_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta LETTERS TO EDITOR Anaesthetic management of tracheoesophageal fistula with accidental ingestion of button battery cell p. 64 Sushma D Ladi, Abhijit R Kokari, S Swami DOI:10.4103/ija.IJA_516_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Superficial cervical plexus block for urgent tracheostomy p. 65 Rachel C Koshy, Hally Thankamony DOI:10.4103/ija.IJA_559_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Perioperative management of patient with Conn's syndrome and severe hypokalaemia: How low is too low? p. 67 Bandi Joshiraj, Ankur Sharma, Rajeshwari Subramaniam, Varuna Vyas DOI:10.4103/ija.IJA_562_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Management of local anaesthetic systemic toxicity by timely lipid resuscitation in a paraturient - A case report p. 68 Swati Singh, Dusu Lalin, Vinod K Verma DOI:10.4103/ija.IJA_574_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Incidental finding of pulmonary lymphangitis carcinomatosa in a patient of chest trauma p. 70 Vanita Ahuja, Sofia Jaswal, Deepak Aggarwal, Harkirat Kaur DOI:10.4103/ija.IJA_581_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Unilateral giant Internal Jugular Vein impeding brachial plexus nerve block p. 72 Venkata Ganesh, B Naveen Naik, Kamal Kajal DOI:10.4103/ija.IJA_586_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Anaesthetic management of a rare case of paediatric epidermolysis bullosa p. 73 Shalendra Singh, Arijit Ray, Nipun Gupta, Navdeep Sethi DOI:10.4103/ija.IJA_595_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Transient isolated unilateral oculomotor nerve palsy following accidental dural puncture after bilateral total knee replacement p. 75 BG Arun, Chandrashekar Puttaswamygowda, Amardeep Kulkarni DOI:10.4103/ija.IJA_604_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta Are we misusing the ILMA tube? A cause of concern? p. 76 Anju Romina Bhalotra DOI:10.4103/ija.IJA_616_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta COMMENTS ON PUBLISHED ARTICLE A modified Bailey's manoeuvre for supraglottic airway continuum using LMA ProtectorTM p. 78 Massimiliano Sorbello, Gerardo Cortese, Cory Gaçonnet, Marcus Skinner DOI:10.4103/ija.IJA_502_18   [HTML Full text]  [PDF]  [Mobile Full text]  [EPub]  [Sword Plugin for Repository]Beta

Medical Gas Research (Med Gas Res) 2018 | October-December | Volume 8 | Issue 4

RESEARCH ARTICLES
	A survey of anaphylaxis etiology and treatment	p. 129
	Hamid Ahanchian, Fatemeh Behmanesh, Farahzad Jabbari Azad, Elham Ansari, Maryam Khoshkhui, Reza Farid, Yalda Hassanpur, Samaneh Kouzegaran DOI:10.4103/2045-9912.248262   Identifying the causes of anaphylaxis which is an acute, potentially fatal systemic reaction is very important in every community. Treatment strategies and pitfalls should also be determined. We sought to determine the most common triggers of anaphylaxis, clinical manifestations and treatment strategies in Mashhad, northeast of Iran. An observational cross-sectional study was conducted to evaluate all patients with a history of anaphylactic reaction who were referred to University Allergy Clinics between 2006 and 2016 in Mashhad Iran. We used a combination of patient's clinical history and allergy diagnostic testing including radioallergosorbant test and skin prick test in order to determine the etiology of anaphylaxis. We identified 172 anaphylactic reactions in 70 patients. Median age was 15 years with a range from 6 months to 48 years. The triggers included: foods, 61.4%; drugs, 15.7%; hymenoptera venom, 8.6%; idiopathic, 5.7%; immunotherapy, 4.3% and other etiologies: 5.7%. Nuts and seeds were the most important triggers of food induced anaphylaxis, especially in school children, adolescents and young adults, followed by fruits. However, Cow's milk and hen's egg were the main triggers of anaphylaxis in children aged under 2 years. The most common symptoms were cutaneous and cardiovascular. Corticosteroids (94.3%) and/or antihistamines (85.7%) were used most frequently for treatment followed by intravenous fluids (54.3%), whereas epinephrine was only used in 17.1% of the cases. Food related anaphylaxis and other typical triggers of anaphylaxis are age dependent and the risks and triggers change with age. Epinephrine injection should be increased by improving the awareness of physician and medical teams. The study was approved by the Ethics Committee of the Faculty of Medicine of Mashhad University of Medical Sciences (approved number: IR.MUMS.REC.1393.960).
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	Effects of the long-term consumption of hydrogen-rich water on the antioxidant activity and the gut flora in female juvenile soccer players from Suzhou, China	p. 135
	Ji-Bin Sha, Shuang-Shuang Zhang, Yi-Ming Lu, Wen-Jing Gong, Xiao-Ping Jiang, Jian-Jun Wang, Tong-Ling Qiao, Hong-Hong Zhang, Min-Qian Zhao, Da-Peng Wang, Hua Xia, Zhong-Wei Li, Jian-Liang Chen, Lin Zhang, Cheng-Gang Zhang DOI:10.4103/2045-9912.248263   Expending a considerable amount of physical energy inevitably leads to fatigue during both training and competition in football. An increasing number of experimental findings have confirmed the relationship between the generation and clearance of free radicals, fatigue, and exercise injury. Recently, hydrogen was identified as a new selective antioxidant with potential beneficial applications in sports. The present study evaluated the effect of 2-month consumption of hydrogen-rich water on the gut flora in juvenile female soccer players from Suzhou. As demonstrated by enzyme linked immunosorbent assay and 16S rDNA sequence analysis of stool samples, the consumption of hydrogen-rich water for two months significantly reduced serum malondialdehyde, interleukin-1, interleukin-6, tumour necrosis factor-α levels; then significantly increased serum superoxide dismutase, total antioxidant capacity levels and haemoglobin levels of whole blood. Furthermore, the consumption of hydrogen-rich water improved the diversity and abundance of the gut flora in athletes. All examined indices, including the shannon, sobs, ace, and chao indices, were higher in the control group than those proposed to result from hydrogen-rich water consumption prior to the trial, but these indices were all reversed and were higher than those in the controls after the 2-month intervention. Nevertheless, there were some differences in the gut flora components of these two groups before the trial, whereas there were no significant changes in the gut flora composition during the trial period. Thus, the consumption of hydrogen-rich water for two months might play a role modulating in the gut flora of athletes based on its selective antioxidant and anti-inflammatory activities. The study protocol was approved by the ethics committee of the Suzhou Sports School (approved number: SSS-EC150903).
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	Inhalation of hydrogen gas elevates urinary 8-hydroxy-2′-deoxyguanine in Parkinson's disease	p. 144
	Masaaki Hirayama, Mikako Ito, Tomomi Minato, Asako Yoritaka, Tyler W LeBaron, Kinji Ohno DOI:10.4103/2045-9912.248264   Hyposmia is one of the earliest and the most common symptoms in Parkinson's disease (PD). The benefits of hydrogen water on motor deficits have been reported in animal PD models and PD patients, but the effects of hydrogen gas on PD patients have not been studied. We evaluated the effect of inhalation of hydrogen gas on olfactory function, non-motor symptoms, activities of daily living, and urinary 8-hydroxy-2′-deoxyguanine (8-OHdG) levels by a randomized, double-blinded, placebo-controlled, crossover trial with an 8-week washout period in 20 patients with PD. Patients inhaled either ~1.2–1.4% hydrogen-air mixture or placebo for 10 minutes twice a day for 4 weeks. Inhalation of low dose hydrogen did not significantly influence the PD clinical parameters, but it did increase urinary 8-OHdG levels by 16%. This increase in 8-OHdG is markedly less than the over 300% increase in diabetes, and is more comparable to the increase after a bout of strenuous exercise. Although increased reactive oxygen species is often associated with toxicity and disease, they also play essential roles in mediating cytoprotective cellular adaptations in a process known as hormesis. Increases of oxidative stress by hydrogen have been previously reported, along with its ability to activate the Nrf2, NF-κB pathways, and heat shock responses. Although we did not observe any beneficial effect of hydrogen in our short trial, we propose that the increased 8-OHdG and other reported stress responses from hydrogen may indicate that its beneficial effects are partly or largely mediated by hormetic mechanisms. The study was approved by the ethics review committee of Nagoya University Graduate School of Medicine (approval number 2015-0295). The clinical trial was registered at the University Hospital Medical Information Network (identifier UMIN000019082).
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	Frequency of anesthetic overdose with mean alveolar concentration-guided anesthesia at high altitude	p. 150
	Juan C Giraldo, Claudia Acosta, Manuel Giraldo-Grueso DOI:10.4103/2045-9912.248265   This study reported the frequency of anesthetic overdose measured with the bispectral index in a high altitude city (Bogotá-Colombia, 2600 meters above sea level). We assembled a prospective cohort of patients. Preoperative variables were described, and 10 minutes after the surgical incision, bispectral index, mean alveolar concentration, mean arterial pressure, and oxygen saturation were recorded. Bispectral index was classified as superficial (60), adequate (40–60), and deep (> 40). Mean alveolar concentration was classified as low (< 0.8), normal (0.8–1.2), and high (> 1.2). We included 50 patients. The mean age of the patients was 36.3 ± 13.5 years; 48% were male and 78% were categorized as ASA I. Mean values of mean alveolar concentration and bispectral index were 1.14 ± 0.18 and 38.66 ± 6.9, respectively. Frequency of anesthetic overdose measured with bispectral index was 54% and only 20% with mean alveolar concentration. In total, 78% of patients received normal mean alveolar concentration values, and among these patients, 49% had deep bispectral index levels and 51% were adequate. There was no correlation between mean alveolar concentration and bispectral index (Pearson r = 0.161, P = 0.246) or between bispectral index and mean arterial pressure (Pearson r = 0.367, P = 0.08). All patients older than 60 years exhibited deep bispectral index levels, and although we did not identify a correlation between age and bispectral index, a tendency was observed (Pearson r = –0.087, P = 0.538). Safe and effective anesthesia overdose could be a common phenomenon. Bispectral index-guided anesthesia could be a helpful and reliable tool in the assessment and prevention of anesthesia overdose at high altitude. The study was approved by the ethics committee of the Fundación Cardioinfantil-Instituto de cardiología, Bogota, Colombia (approved number: 312017).
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	Effects of hydrogen on polarization of macrophages and microglia in a stroke model	p. 154
	Ke Ning, Wen-Wu Liu, Jun-Long Huang, Hong-Tao Lu, Xue-Jun Sun DOI:10.4103/2045-9912.248266   It has been confirmed that inflammation plays an important role in the pathogenesis of ischemic stroke. The polarization of microglia as an important participant in the inflammation following stroke is also found to be involved in stroke. This study aimed to investigate the effects of hydrogen gas on the polarization of macrophages/microglia in vitro. Raw264.7 cells were treated with lipopolysaccharides and then exposed to hydrogen. The microglia were treated with the supernatant from oxygen and glucose deprivation-treated neurons and then exposed to hydrogen. The phenotypes of Raw 264.7 cells and microglia were determined by flow cytometry, and cell morphology was observed. Results showed lipopolysaccharides significantly increased the M1 macrophages, and the supernatant from oxygen and glucose deprivation-treated neurons dramatically elevated the proportion of M1 microglia, but both treatments had little influence on the M2 cells. In addition, hydrogen treatment significantly inhibited the increase in M1 cells, but had no influence on M2 ones. Our findings suggest that the neuroprotection of hydrogen may be related to its regulation of microglia in the nervous system after stroke.
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	Daily ingestion of alkaline electrolyzed water containing hydrogen influences human health, including gastrointestinal symptoms	p. 160
	Yoshinori Tanaka, Yasuhiro Saihara, Kyoko Izumotani, Hajime Nakamura DOI:10.4103/2045-9912.248267   In Japan, alkaline electrolyzed water (AEW) apparatus have been approved as a medical device. And for the patients with gastrointestinal symptoms, drinking AEW has been found to be effective in relieving gastrointestinal symptoms. But some users of AEW apparatus do not have abdominal indefinite complaint. Little attention has been given to the benefit for the users which have no abdominal indefinite complaint. The object of this study is to evaluate the effect on health, including gastrointestinal symptoms, when a person without abdominal indefinite complaint, etc., drinks AEW on a daily basis. A double-blind, randomized controlled trial has been designed. Four-week period of everyday water drinking, PW drinking group: drink purified tap water as a placebo, AEW drinking group: drink alkaline electrolyzed water which made by electrolysis of purified tap water. Before the experiment and after the 4-week period of water drinking, Blood tests, physical fitness evaluations, and questionnaire evaluations is conducted. In this study, we did not specifically select patients with gastrointestinal symptoms. Sufficiently clear effect could not be confirmed. But the stools were more normal, and, as shown in the previous report, that drinking AEW is considered to contribute to intestinal normalization. In addition, when drinking AEW, a high proportion of the respondents said that they felt they were able to sleep soundly, and the proportion of subjects who answered that they felt good when awakening increased. The effect of reducing oxidative stress, thus allowing for improved sleep, was exhibited by drinking AEW containing hydrogen, which is considered to be an antioxidant substance. This research were approved by the Ethics Committee of the Osaka City University Graduate School of Medicine (No. 837) and were registered in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN ID: UMIN000031800) on March 22, 2018.
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REVIEWS
	Further application of hyperbaric oxygen in prostate cancer	p. 167
	Qi-Zhong Lu, Xiang Li, Jun Ouyang, Jin-Quan Li, Gang Chen DOI:10.4103/2045-9912.248268   Hyperbaric oxygen therapy (HBOT) has been used as an adjuvant treatment for multiple pathological states, which involves hypoxic conditions. Over the past 50 years, HBOT has been recommended and used in a wide variety of medical conditions, clinically in the treatment of ischemic or nonhealing wounds and radiation-injured tissue, and in the treatment of malignancy. The mechanism of this treatment is providing oxygen under pressure which is higher than the atmosphere thus increasing tissue oxygen concentration. When cells get enough oxygen in the microenvironment, they become active and replicate effectively. Prostate cancer is the second most common cancer and the fifth leading cause of cancer death among male around the world. It is estimated that more than 29,000 men died from metastatic prostate cancer in 2014. With the development of the prostate-specific antigen-based screening technology, prostate cancer incidence has increased markedly over time. According to the survey, the morbidity and mortality of prostate cancer have surpassed bladder cancer and renal carcinoma, becoming the most common cancer in urology in Chinese adults. Nowadays, the main solution to deal with prostate cancer is still the surgical ways, including laparoscopic radical prostatectomy and robot-assisted radical prostatectomy. Nevertheless, the complications of the surgical treatment have not been completely avoided. HBOT has gained great clinical recognition over the decade. It has been demonstrated that HBOT has considerable effects on carcinoma, especially on decreasing complications and improving mortality. So, it is important to combine the HBOT with patients who suffer from prostate cancer. This review illuminates the effect and underlying mechanism of the HBOT in prostate cancer for further clinical application.
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	Combined application of hypothermia and medical gases in cerebrovascular diseases	p. 172
	Hao Li, Xin Tan, Qun Xue, Jue-Hua Zhu, Gang Chen DOI:10.4103/2045-9912.248269   Cerebrovascular diseases have a heavy burden on society and the family. At present, in the treatment of cerebrovascular diseases, the recognized effective treatment method is a thrombolytic therapy after cerebral infarction, but limited to the time window problem, many patients cannot benefit. Other treatments for cerebrovascular disease are still in the exploration stage. The study found that medical gas and hypothermia have brain protection effects. Further research found that when the two are used in combination, the therapeutic effect has a superimposed effect. This article reviews the current research progress of hypothermia therapy combined with medical gas therapy for cerebrovascular disease.
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	The role of hydrogen in Alzheimer's disease	p. 176
	Xin Tan, Fang Shen, Wan-Li Dong, Yi Yang, Gang Chen DOI:10.4103/2045-9912.248270   Alzheimer's disease is one of the most common neurodegenerative diseases in the elderly. It is often manifested as learning and memory impairment, cognitive function decline, normal social and emotional disorders. However, for this high-risk common disease, there is currently no effective treatment, which has plagued many clinicians. As a new type of medical therapeutic gas, hydrogen has attracted much attention recently. As a recognized reducing gas, hydrogen has shown great anti-oxidative stress and anti-inflammatory effect in many cerebral disease models. It can ameliorate neuronal damage, maintain the number of neurons, prolong the lifespan of neurons, and ultimately inhibit disease progression. Therefore, the role and mechanism of hydrogen in the pathological process of Alzheimer's disease will be discussed in this paper.
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CASE REPORT
	Hyperbaric oxygen therapy for Alzheimer's dementia with positron emission tomography imaging: A case report	p. 181
	Paul G Harch, Edward F Fogarty DOI:10.4103/2045-9912.248271   A 58-year-old female was diagnosed with Alzheimer's dementia (AD) which was rapidly progressive in the 8 months prior to initiation of hyperbaric oxygen therapy (HBOT). 18Fluorodeoxyglucose (18FDG) positron emission tomography (PET) brain imaging demonstrated global and typical metabolic deficits in AD (posterior temporal-parietal watershed and cingulate areas). An 8-week course of HBOT reversed the patient's symptomatic decline. Repeat PET imaging demonstrated a corresponding 6.5–38% regional and global increase in brain metabolism, including increased metabolism in the typical AD diagnostic areas of the brain. Continued HBOT in conjunction with standard pharmacotherapy maintained the patient's symptomatic level of function over an ensuing 22 months. This is the first reported case of simultaneous HBOT-induced symptomatic and 18FDG PET documented improvement of brain metabolism in AD and suggests an effect on global pathology in AD.
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LETTER TO EDITOR
	The role of hydrogen sulfide in dentistry	p. 185
	Thorakkal Shamim DOI:10.4103/2045-9912.248272
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Endodontics

What opinions do Saudi endodontic residents hold about regenerative endodontics? Saeed S Al Qahtani, Salman Aziz, Hmoud Al Garni, Mohammed Sulmain Alaenazi Saudi Endodontic Journal 2019 9(1):1-7 Aim: The aim of this study is to investigate the opinions, current knowledge, and expectations of Saudi endodontic residents regarding the use of regenerative endodontics as part of future dental treatment and establishing a baseline for further research and development. Materials and Methods: Saudi endodontic residents all over Kingdom of Saudi Arabia (KSA) were contacted, for participation. A survey form consisting of 28 questions was personally distributed to all endodontic residents who were actively enrolled in a residency training program either Saudi board program or Master Degree and provided informed consent for inclusion into the study. Data were collected and statistical analysis was carried out using SPSS version 22. Results: Out of one hundred and fifteen endodontic residents 97 participated in this questionnaire-based survey. Two forms were excluded due to incomplete and unclear information. Out of the remaining 95 majority of the residents were male (67.4%) and belonged to Saudi board program. The greater part of residents agreed for the inclusion of regenerative endodontics in the dental curricula. Most of the candidates wanted to improve their skills in regenerative endodontics by participating in continuing dental education programs. The most popular belief (n = 81) was that regenerative therapy to save teeth is better than implants. Use of regenerative procedures in clinics was carried out by only 44 participants. Conclusion: The emerging importance of regenerative endodontics in KSA is evident through this study. This study highlights many core issues which need attention and forms a baseline for further research in regenerative endodontics.

Removal ability of MTA-, bioceramic-, and resin-based sealers from obturated root canals, following XP-endo® Finisher R file: An ex vivo study Taxiarchis G Kontogiannis, Nikolaos P Kerezoudis, Konstantinos Kozyrakis, Elefterios Terry. R. Farmakis Saudi Endodontic Journal 2019 9(1):8-13 Aim: Removability assessment of mineral trioxide aggregate (MTA)-, bioceramic-, and epoxy resin-based sealers, with or without XP-endo® Finisher R file, was achieved. Materials and Methods: One hundred and twenty extracted single-rooted premolars were randomly organized into three equal groups, instrumented up to #40.04 and obturated with single-cone technique by gutta-percha and one of the following sealers: MTA Fillapex, TotalFill BC Sealer, or AH Plus. Following setting of the sealer, D-RaCe instruments were used in retreating all specimens. In half of the specimens, XP-endo® Finisher R file was additionally applied following D-RaCe, as a final step in retreatment. Working length (WL) following the procedure and patency were recorded. All specimens were split and observed for residuals under optical microscopy. Images were acquired, placed adjacent to each other forming continuous strips, and focus stacked with Helicon Focus software. A blinded observer evaluated all photographs. Analysis included Chi-square tests and one-way ANOVA. Results: WL was fully regained in all cases. Patency regaining (in terms of canal cleanness) was easier in AH Plus groups. Residuals were significantly more in TotalFill groups (P < 0.0001). XP-endo® Finisher R file improved removal only in the AH Plus subgroup. Conclusions: TotalFill residuals were harder to remove than those from MTA Fillapex or AH Plus groups. Patency is also harder to regain. XP-endo® Finisher R file had a positive removal influence only in the AH Plus subgroup.

Restorative methods to rehabilitate endodontically treated posterior teeth by students and new graduates of King Saud University: A survey study Sahar A AlZain Saudi Endodontic Journal 2019 9(1):14-20 Aim: The aim of the study was to evaluate the efficiency of dental students and new graduates of College of Dentistry, King Saud University, in Riyadh, Saudi Arabia, to select the appropriate methods of restoring endodontically treated posterior teeth (ETPT) at different conditions of remaining sound tooth structure. Materials and Methods: A questionnaire was distributed among the 4th- and 5th-year dental students and new graduates. Respondents were requested to indicate their gender and level of education and to select the preferred restoration of ETPT at different conditions. Results were analyzed using one-way frequency and two-way cross-tabulations. Results: At >50% tooth remaining (condition A), 39.9% of the respondents preferred to use an amalgam restoration, while 30.9% preferred to use a restoration followed by a crown at 50% of remaining tooth (condition B). At <50% tooth remaining (condition C), 74.6% preferred to use a cast post-and-core and a crown. Respondents changed their choices of restoration to more advanced ones when teeth served as abutments for fixed or removable prostheses. Chi-square analysis demonstrated a statistically significant relationship between the selected restorative method at condition A and both gender (P = 0.045) and level of education (P = 0.001), between the method of restoration at condition B and both the gender (P = 0.000) and the level of education (P = 0.003), and between the selected restorative method at condition C and the level of education (P = 0.000). Conclusions: Respondents demonstrated a high knowledge when selecting the appropriate method of restoring ETPT at different clinical conditions.

Comparative evaluation of shaping ability of rotary and reciprocating nickel-titanium single file instruments on simulated root canals Arvind Kumar, A Sheerin Sarthaj Saudi Endodontic Journal 2019 9(1):21-26 Introduction: Effective cleaning of the root canal system is the primary objective of rotary instrumentation. For three-dimensional obturation of the root canal system, ideal preparation should have a continuously tapering funnel shape from the orifice to the apex. The study aimed to evaluate the shaping ability of two rotary and two reciprocating nickel-titanium (NiTi) single-file instruments on simulated root canals using image analysis software. Materials and Methods: Forty resin blocks with simulated canals of 30° curvature were divided into four experimental groups containing ten samples in each group. The canals were prepared using Reciproc (VDW, Munich, Germany), WaveOne (Dentsply, Maillefer, Ballaigues, Switzerland), OneShape (Micro-Mega, Besancon, France), and F360 (Komet, Brasseler, Lemgo, Germany) size 25 NiTi systems using X Smart Plus (Dentsply). Pre- and post-preparation canals were photographed in a standardized manner and were superimposed. The inner and outer walls of canal curvature were evaluated to determine the most significant change using the image analysis software. Results: The amount of resin removed from the inner walls was less with rotary single-file NiTi systems when compared with reciprocating. Preparation time was less with rotary instruments. No instrument separation was noted. All instrument systems maintained the original canal curvature. Conclusion: Rotary single-file systems maintained the canal curvature better than reciprocating single-file systems.

Sodium hypochlorite use, storage, and delivery methods: A Survey Sumaya O Basudan Saudi Endodontic Journal 2019 9(1):27-33 Aim: The aim of this study is to investigate sodium hypochlorite (NaOCl) delivery and storage methods by general dental practitioners (GDPs) and specialists. Materials and Methods: A self-reporting questionnaire was distributed to academic, governmental, and private dental centers in Riyadh, Saudi Arabia. The survey consisted of questions related to the concentration, duration, volume, delivery methods of NaOCl irrigation, storage materials, and conditions. Results: Of the 261 dentists that responded, 63.2% were GDPs, 21.8% were endodontists, and 14.9% were advanced restorative specialists. A NaOCl concentration of 2.5%–5% was the most commonly selected (52.7%), 37.2% used 5–10 ml for irrigation of each canal and 44.8% performed irrigation for <1 min. Dentists who used higher concentrations reported longer irrigation durations. Irrigant delivery by needles and a syringe was reported by 83.9% of respondents, but only 5.7% applied irrigation activation methods. Regarding storage conditions, 40% used clear containers, and 75.5% stored it at room temperature. Endodontists used significantly higher concentrations, longer durations, and activated the irrigant more than GDPs. Conclusion: The most commonly used NaOCl concentration is 2.5%–5%. The storage conditions of NaOCl and use of activation methods need to be improved. In addition, practices of specialists differed from those of GDPs with regard to concentrations, duration of irrigation, storage of NaOCl, and use of irrigation adjuncts.

Triple antibiotic paste versus propolis: A clinical quest for the reliable treatment of periapical lesions in primary molars DV Divya, Madu Ghanashyam Prasad, Ambati Naga Radhakrishna, Rayala Venkata Sandeep, Suravarapu Pavani Reddy, K V. K. Santosh Kumar Saudi Endodontic Journal 2019 9(1):34-39 Background: Teeth with infected root canals, particularly those in which the infection has reached the periradicular tissues, require effective treatment interventions to save the tooth. Lesion sterilization concept (lesion sterilization and tissue repair [LSTR]) was successful in treating periapical polymicrobial infection, but this poses a risk of development of antimicrobial resistance. Aim: The present study evaluated and compared both clinically and radiographically the healing abilities of Propolis liquid (natural therapeutic agent)-mixed Endoflas powder with LSTR (allopathic combination) for the management of periapical lesions in primary molars. Materials and Methods: A total of 30 selected primary molars were randomly divided into two groups of 15 each: Group 1 – Propolis liquid-mixed Endoflas powder and Group 2 – LSTR (3Mix). Follow-up after 3, 6, and 12 months was done to evaluate progress in clinical and radiographic parameters. The obtained data were subjected to statistical analysis. McNemar's test was applied between the time points in each group. Comparison of Group 1 with Group 2 was done using Chi-square test. Results: At the end of 12th-month follow-up, the overall clinical and radiographic success rate for Group 1 was 100%, whereas for Group 2, it was 93% and 60%, respectively. The difference in the radiographic success rate between the two groups was statistically significant (P < 0.05). Conclusion: In the present study, Propolis liquid-mixed Endoflas powder combination has shown better results than LSTR. This novel combination of Propolis liquid-mixed Endoflas powder can, therefore, be considered as the material of choice for pulpectomy in deciduous molars with extensive involvement of pulp and periradicular tissues.

The knowledge and attitude of general dental practitioners toward the proper standards of care while managing endodontic patients in Saudi Arabia Dania F Bogari, Nouran A Alzebiani, Rowaina M Mansouri, Faris G Aljiaid, Mohunned A Alghamdi, Majed Almalki, Khalid Merdad, Turki Y Alhazzazi Saudi Endodontic Journal 2019 9(1):40-50 Aim: The aim of this study was to assess the knowledge and attitude of general dental practitioners (GDPs) toward performing the proper standards of care while managing patients undergoing endodontic treatment in Saudi Arabia. Materials and Methods: An e-questionnaire was distributed among GDPs in Saudi Arabia (n = 650). The e-questionnaire questions covered the assessment of knowledge, attitude, and performance of GDPs toward practicing the proper standards of endodontic treatment in their clinic. Data were analyzed using SPSS version 22, and the relationships between categorical variables were established using Chi-square test. Results: Most of the participants reported obtaining full medical history before root canal treatment (RCT, 82.3%; P < 0.05). However, only 12.2% of the participants regularly measure the blood pressure for their patients before starting RCT. Only 56.3% of the participated dentists are applying rubber dam isolation during RCT, while 24.2% believe that partial isolation is sufficient for such a procedure (P < 0.05). Furthermore, 42.8% of the surveyed GDPs use cold test to confirm the endodontic diagnosis, while 55.5% think that percussion is a reliable method for diagnosis (P < 0.05). Surprisingly, 37.3% of the dentists still prefer leaving the tooth open for pain relief and drainage in abscess cases. Finally, only 28.7% of the participants mentioned performing regular follow-up after RCT. Conclusions: Our data show a clear deficiency in the standards of care provided by GDPs when performing RCT in Saudi Arabia. We hope that this publication will help highlight key areas where lack of knowledge and poor attitude exist while performing RCT by the GDPs in Saudi, thereby helping to raise treatment standards and improve treatment outcomes.

Effect of applying metal artifact reduction algorithm in cone beam computed tomography in detection of vertical root fractures of teeth with metallic post versus digital intraoral radiography Islam Shawky Shaker, Nashwa Salah Mohamed, Ahmed Mohamed Abdelsamad Saudi Endodontic Journal 2019 9(1):51-55 Background: Conventional radiographs are not an efficient diagnostic imaging modality to detect vertical root fracture. Cone-beam computed tomography (CBCT) is a three-dimensional imaging modality that overcomes the limitations of conventional radiography in the detection of vertical root fractures (VRFS), although metallic structures produce artifacts in the produced images and since most of the teeth with VRF are endodontically treated and have metallic posts in root canal so fracture detection may be difficult. Aim: This study aimed to determine the diagnostic accuracy of CBCT using metal artifact reduction algorithm in detection of VRF of teeth with metallic posts compared to digital intraoral radiography. Materials and Methods: One hundred and twenty single-rooted extracted human teeth were endodontically treated then placed in an acrylic block and metallic posts were inserted. The teeth roots were divided into two groups; one with induced VRF and the other having intact roots. Then, each tooth was coded and imaged three times using CBCT with and without metal artifact reduction algorithm and digital periapical radiography. Data were collected and statistically analyzed. Results: Digital periapical radiography showed statistically significantly lower diagnostic accuracy than CBCT modalities (P ≤ 0.05). The use of metal artifact reduction algorithm improved the diagnostic accuracy from CBCT1 to CBCT2 but with no statistically significant difference (P ≥ 0.05). Conclusion: From the study, we can conclude that in case of presence of metallic posts, CBCT with metal artifact reduction algorithm can improve detection of VRF.

Multidisciplinary approach to the treatment of a complicated crown-root fracture Badi B Alotaibi Saudi Endodontic Journal 2019 9(1):56-60 Complicated crown-root fractures are uncommon type of dental trauma but usually result in significant esthetic and functional problems to those affected. This case report demonstrates sequential endodontic, restorative, orthodontic, periodontal, and prosthodontic modalities for the conservative management of a complicated crown-root fracture of the maxillary left central incisor in a young patient. After root canal treatment and core buildup, the tooth was extruded using forced orthodontic eruption for 8 weeks and retention for 7 weeks. Zinc phosphate cement acrylic crown was used to preserve esthetics and function during the forced eruption and retention period.

A combined management of a rare case of a maxillary lateral incisor with accessory root and deep mesio-radicular groove Safura Anita Baharin, Masfueh Razali Saudi Endodontic Journal 2019 9(1):61-65 This case report describes the combined nonsurgical endodontic retreatment and surgical intervention of a failed root canal treatment associated with a maxillary lateral incisor with an accessory root and deep mesio-radicular groove. A 42-year-old female Malay patient presented with persistent infection associated with deep mesial pocket from her maxillary left lateral incisor (#22). The medical history was noncontributory and the tooth was previously root treated. Following comprehensive clinical and radiographic examination, a combined nonsurgical endodontic retreatment and surgical management of tooth #22 were carried out. The inability to debride the periodontal defect necessitates the amputation of the accessory root, and surgical debridement of the deep radicular groove was carried out. The clinical and radiographic examination 1 year after completion of treatment revealed evidence of healing. The early recognition of root and canal variation, correct diagnosis, and appropriate management of tooth with accessory root and deep radicular groove is essential to ensure favorable treatment outcome.