Search results for: clinical pharmacology

Authors: Jeong-Moh John Yahng, Angelika Na

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Introduction: Increasing numbers of general surgical patients are being prescribed antiplatelet and anticoagulant medications (APAC) for various cardiovascular and cerebrovascular conditions. Surgical patients who are on APAC present a management challenge as bleeding risk needs to be balanced with thromboembolic risk. Although guidelines exist in regards to APAC management in elective surgery, there is a lack of guidelines in the emergency surgery setting. In this study we aim to characterise APAC usage in emergency general surgical patients admitted to a rural hospital. We also assess the impact of APAC usage on clinical management of these patients. Methods: Prospective study of emergency general surgical admissions at Northeast Health Wangaratta (Victoria) from 2 July to 25 Oct 2014. Questionnaire collected demographics data, admission diagnosis, APAC usage, anaesthesia techniques, operation types, transfusion requirement and morbidity / mortality data. Results: During the 4 month study, 118 patients were classified into two groups: non-APAC (n=96, 81%) and APAC (n=22, 19%). Patients in the APAC group were older compared to the non-APAC patients (mean age 72 vs 42 years old). Amongst patients younger than 60 years old, only 1% of them were on APAC. In contrast, 49% of patients older than 60 years old were on APAC (p<0.001). Patients who were admitted with a bleeding problem were more likely to be on APAC (p<0.05). 19% of emergency general surgery patients were on APAC. The majority (91%) of them were on antiplatelet medication, with two patients being on dual antiplatelet agents (aspirin + clopidogrel or ticagrelor). 15% of emergency general surgical patients requiring operations were on APAC. 11% of all laparotomies and 33% of gastroscopy for haematemesis/melaena patients were on APAC. Both of the patients operated for bleeding following surgery at another hospital were in the APAC group. In regards to impact on clinical management, 59% of APAC patients had their medications interrupted or ceased, on average by 3.5 days (range 1-13 days). 2 out of 75 operations were delayed due to APAC usage. There was no difference in the use of central venous or arterial line for increased monitoring (p=0.14) or in the use of warming blanket (Bair Hugger™) (p=0.94). Overall, transfusion rate was higher amongst APAC patients (14% vs 3%) (p 0.04). The recorded morbidity (n=2) and mortality (n=1) in this study were all in the APAC group. Discussion: Nineteen percent of emergency general surgical admissions and fifteen percent of operated patients were on APAC. The prevalence of APAC usage was higher in those aged sixty and above. General surgical patients who were admitted with a bleeding problem were more likely to be on APAC. Two patients who were operated for bleeding following surgery at another hospital were in the APAC group. Note that there was no patient in the non-APAC group who was admitted for post-operative bleeding. We observed two cases in which operation was delayed due to APAC usage. Transfusion, morbidity and mortality rate were higher in the APAC group. Conclusion: In this study, nineteen percent of emergency general surgical admissions were on APAC. The use of APAC is more prevalent in the older age group, particularly those aged sixty and above. Higher proportion of APAC compared to non-APAC patients were admitted and operated for bleeding problems. There is an urgent need for clinical guidelines regarding APAC management in emergency general surgical patients.

Keywords: antiplatelet, anticoagulants, emergency general surgery, rural general surgery, morbidity, mortality

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Authors: R. Periyasamy, Deepak Joshi, Sneh Anand

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Foot posture assessment is important to evaluate foot type, causing gait and postural defects in all age groups. Although different methods are used for classification of foot arch type in clinical/research examination, there is no clear approach for selecting the most appropriate measurement system. Therefore, the aim of this study was to develop a system for evaluation of foot type as clinical decision-making aids for diagnosis of flat and normal arch based on the Arch Index (AI) and foot pressure distribution parameter - Power Ratio (PR) data. The accuracy of the system was evaluated for 27 subjects with age ranging from 24 to 65 years. Foot area measurements (hind foot, mid foot, and forefoot) were acquired simultaneously from foot pressure intensity image using portable PedoPowerGraph system and analysis of the image in frequency domain to obtain foot pressure distribution parameter - PR data. From our results, we obtain 100% classification accuracy of normal and flat foot by using the linear discriminant analysis method. We observe there is no misclassification of foot types because of incorporating foot pressure distribution data instead of only arch index (AI). We found that the mid-foot pressure distribution ratio data and arch index (AI) value are well correlated to foot arch type based on visual analysis. Therefore, this paper suggests that the proposed system is accurate and easy to determine foot arch type from arch index (AI), as well as incorporating mid-foot pressure distribution ratio data instead of physical area of contact. Hence, such computational tool based system can help the clinicians for assessment of foot structure and cross-check their diagnosis of flat foot from mid-foot pressure distribution.

Keywords: arch index, computational tool, static foot pressure intensity image, foot pressure distribution, linear discriminant analysis

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Authors: Bency Ann Massinello, Nancy Day, Janet Fellini

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Background: The use of an appropriate mode of communication among the multidisciplinary care team members regarding coordination of care is an extremely complicated yet important patient safety initiative. Effective communication among the team members(nursing staff, medical staff, respiratory therapists, rehabilitation therapists, patient-family services team…) become essential to develop a culture of trust and collaboration to deliver the highest quality care to patients are their families. The inpatient post-acute pediatrics, where children and their caregivers come for continuity of care, is no exceptions to the increasing use of text messages as a means to communication among clinicians. One such platform is the Vocera Communications (Vocera Smart Mobile App called Vocera Edge) allows the teams to use the application and share sensitive patient information through an encrypted platform using IOS company provided shared and assigned mobile devices. Objective: This paper discusses the quality initiative of implementing the transition from Vocera Smartbage to Vocera Edge Mobile App, technology advantage, use case expansion, and lessons learned about a secure alternative modality that allows sending and receiving secure text messages in a pediatric post-acute setting using an IOS device. This implementation process included all direct care staff, ancillary teams, and administrative teams on the clinical units. Methods: Our institution launched this transition from voice prompted hands-free Vocera Smartbage to Vocera Edge mobile based app for secure care team texting using a big bang approach during the first PDSA cycle. The pre and post implementation data was gathered using a qualitative survey of about 500 multidisciplinary team members to determine the ease of use of the application and its efficiency in care coordination. The technology was further expanded in its use by implementing clinical alerts and alarms notification using middleware integration with patient monitoring (Masimo) and life safety (Nurse call) systems. Additional use of the smart mobile iPhone use include pushing out apps like Lexicomp and Up to Date to have it readily available for users for evident-based practice in medication and disease management. Results: Successful implementation of the communication system in a shared and assigned model with all of the multidisciplinary teams in our pediatric post-acute setting. In just a 3-monthperiod post implementation, we noticed a 14% increase from 7,993 messages in 6 days in December 2020 to 9,116messages in March 2021. This confirmed that all clinical and non-clinical teams were using this mode of communication for coordinating the care for their patients. System generated data analytics used in addition to the pre and post implementation staff survey for process evaluation. Conclusion: A secure texting option using a mobile device is a safe and efficient mode for care team communication and collaboration using technology in real time. This allows for the settings like post-acute pediatric care areas to be in line with the widespread use of mobile apps and technology in our mainstream healthcare.

Keywords: nursing informatics, mobile secure texting, multidisciplinary communication, pediatrics post acute care

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Authors: Mohand Yaghi, O. Kehinde

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Background: For the diagnosis of prostate cancer Trans-rectal prostate biopsy (TRPB) is used commonly, the procedure is associated with infective complications. There is evidence that antibiotics (ABx) decrease infective events after TRPB, but different regimens are used. Aim: To systematically review different regimens of prophylactic oral antibiotics in TRPB. Design: Medline, Embase, Clinical trials site, and Cochrane library were searched, experts were consulted about relevant studies. Randomized clinical trials (RCT) conducted in the last twenty years, which investigated different oral antibiotic regimens in TRPB, and compared their efficacy to reduce infectious complications were analyzed. Measurements: Primary outcomes were bacteriuria, urinary tract infection (UTI), fever, bacteremia, sepsis. Secondary outcomes were hospitalization rate, and the prevalence of ABx-resistant bacteria. Results: Nine trials were eligible with 3012 patients. Antibiotics prevented bacteriuria (3.5% vs. 9.88%), UTI (4.46% vs. 9.75%), and hospitalization (0.21% vs. 2.13%) significantly in comparison with placebo or no treatment. No significant difference was found in all outcomes of the review between the single dose regimen and the 3 days. The single dose regimen was as effective as the multiple dose except in Bacteriuria (6.75% vs. 3.25%), and the prevalence of ABx-resistant bacteria (1.57% vs. 0.27%). Quinolones reduced only UTI significantly in comparison with other antibiotics. Lastly, Ciprofloxacin is the best Quinolone to prevent UTI, and hospitalization. Conclusion: it is essential to prescribe prophylactic Antibiotics in TRPB. No conclusive evidence could be claimed about the superiority of the multiple or the 3 days regimens to the single dose regimen. Unexpectedly, ABx-resistant bacteria was identified more often in the single dose cohorts.

Keywords: infection, prostate cancer, sepsis, TRPB

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Authors: Lívia Pinheiro Carvalho, Luciana Di Thommazo-Luporini, Rafael Luís Luporini, José Carlos Bonjorno Junior, Renata Pedrolongo Basso Vanelli, Manoel Carneiro de Oliveira Junior, Rodolfo de Paula Vieira, Renata Trimer, Renata G. Mendes, Mylène Aubertin-Leheudre, Audrey Borghi-Silva

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Rationale: Cardiorespiratory fitness (CRF) and functional capacity in young obese and normal-weight people are associated with metabolic and cardiovascular diseases and mortality. However, it remains unclear whether their metabolically healthy (MH) or at risk (AR) phenotype influences cardiorespiratory fitness in this vulnerable population such as obese adults but also in normal-weight people. HOMA insulin resistance index (HI) and leptin-adiponectin ratio (LA) are strong markers for characterizing those phenotypes that we hypothesized to be associated with physical fitness. We also hypothesized that an easy and feasible exercise test could identify a subpopulation at risk to develop metabolic and related disorders. Methods: Thirty-nine sedentary men and women (20-45y; 18.530 kg.m-2) underwent a clinical evaluation, including the six-minute step test (ST), a well-validated and reliable test for young people. Body composition assessment was done by a tetrapolar bioimpedance in a fasting state and in the folicular phase for women. A maximal cardiopulmonary exercise testing, as well as the ST, evaluated the oxygen uptake at the peak of the test (VO2peak) by an ergospirometer Oxycon Mobile. Lipids, glucose, insulin were analysed and the ELISA method quantified the serum leptin and adiponectin from blood samples. Volunteers were divided in two groups: AR or MH according to a HI cutoff of 1.95, which was previously determined in the literature. T-test for comparison between groups, Pearson´s test to correlate main variables and ROC analysis for discriminating AR from up-and-down cycles in ST (SC) were applied (p<0.05). Results: Higher LA, fat mass (FM) and lower HDL, SC, leg lean mass (LM) and VO2peak were found in AR than in MH. Significant correlations were found between VO2peak and SC (r= 0.80) as well as between LA and FM (r=0.87), VO2peak (r=-0.73), and SC (r=-0.65). Area under de curve showed moderate accuracy (0.75) of SC <173 to discriminate AR phenotype. Conclusion: Our study found that at risk obese and normal-weight subjects showed an unhealthy metabolism as well as a poor CRF and functional daily activity capacity. Additionally, a simple and less costly functional test associated with above-mentioned aspects is able to identify ‘at risk’ subjects for primary intervention with important clinical and health implications.

Keywords: aerobic capacity, exercise, fitness, metabolism, obesity, 6MST

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Authors: Salwa M. Almomen, Mona A. Almaghrabi, Saja M. Alhabardi, Adel A. Alrwisan

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Background: Hepatotoxicity is a major reason for medication withdrawal from the markets. Unfortunately, serious adverse hepatic effects can occur after marketing with limited indicators during clinical development. Therefore, finding possible predictors for hepatotoxicity might guide the monitoring program of various stakeholders. Methods: We examined the clinical review documents for drugs approved in the US from 2011 to 2016 to evaluate their hepatic safety profile. Predictors: we assessed whether these medications meet Hy’s Law with hepatotoxicity grade ≥ 3, labeled hepatic adverse effects at approval, or accelerated approval status. Outcome: post-marketing regulatory action related to hepatotoxicity, including product withdrawal or updates to warning, precaution, or adverse effects sections. Statistical analysis: drugs were included in the analysis from the time of approval until the end of 2019 or the first post-marketing regulatory action related to hepatotoxicity, whichever occurred first. The hazard ratio (HR) was estimated using Cox-regression analysis. Results: We included 192 medications in the study. We classified 48 drugs as having grade ≥ 3 hepatotoxicities, 43 had accelerated approval status, and 74 had labeled information about hepatotoxicity prior to marketing. The adjusted HRs for post-marketing regulatory action for products with grade ≥ 3 hepatotoxicity was 0.61 (95% confidence interval [CI], 0.17-2.23), 0.92 (95%CI, 0.29-2.93) for a drug approved via accelerated approval program, and was 0.91 (95%CI, 0.33-2.56) for drugs with labeled hepatotoxicity information at approval time. Conclusion: This study does not provide conclusive evidence on the association between post-marketing regulatory action and grade ≥ 3 hepatotoxicity, accelerated approval status, or availability of labeled information at approval due to sampling size and channeling bias.

Keywords: accelerated approvals, hepatic adverse effects, drug-induced liver injury, hepatotoxicity predictors, post-marketing withdrawal

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Authors: Somaye Ghafarpour, Kamran Yazdanbakhsh, Mohamad Reza Zarbakhsh, Simin Hosseinian, Samira Ghafarpour

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Unsatisfactory sleep quality is one of the most common complications of pregnancy, which can predispose mothers to postpartum depression, requiring implementing effective psychological interventions to prevent and modify behaviors accentuating sleep problems. This study was a randomized clinical controlled trial with a pre-test/post-test design aiming to investigate the effectiveness of sleep behavioral interventions during the third trimester of pregnancy on sleep quality and postpartum depression. A total of 50 pregnant mothers in the 26-30 weeks of pregnancy suffering from sleep problems (based on the score obtained from the Pittsburgh Sleep Questionnaire) were randomized into two groups (control and intervention, n= 25 per group). The data were collected using interviews, the Pittsburgh Sleep Quality Index (PSQI), and the Edinburgh Postnatal Depression Scale (EPDS) were used. The participants in the intervention group received eight 60-minute sessions of combinational training for behavioral therapy techniques. At the end of the intervention and four weeks after delivery, sleep quality and postpartum depression were evaluated. Considering that the Kolmogorov Smirnov test confirmed the normal distribution of the data, the independent t-test and analysis of covariance were used to analyze the data, showing that the behavioral interventions were effective on the overall sleep quality after delivery (p=0.001); however, no statistically significant effects were observed on postpartum depression, the sub-scales of sleep disorders, and daily functioning (p>0.05). Considering the potential effectiveness of behavioral interventions in improving sleep quality and alleviating insomnia symptoms, it is recommended to implement such measures as an effective intervention to prevent or treat these problems during prenatal and postnatal periods.

Keywords: behavioral interventions, sleep quality, postpartum depression, pregnancy, delivery

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Authors: Sundaresan Soundararajan, Chor Ngee Tan

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Introduction: Pyogenic spondylitis, otherwise treated conservatively with long term antibiotics, would require surgical debridement and reconstruction in about 10% to 20% of cases. The classical approach adopted many surgeons have always been anterior approach in ensuring thorough and complete debridement. This, however, comes with high rates of morbidity due to the nature of its access. Direct lateral retroperitoneal approach, which has been growing in usage in degenerative lumbar diseases, has the potential in treating pyogenic spondylitis with its ease of approach and relatively low risk of complications. Aims/Objectives: The objective of this study was to evaluate the effectiveness and clinical outcome of using lateral approach surgery in the surgical management of pyogenic spondylitis of the lumbar spine. Methods: Retrospective chart analysis was done on all patients who presented with pyogenic spondylitis (lumbar discitis/vertebral osteomyelitis) and had undergone direct lateral retroperitoneal lumbar vertebral debridement and posterior instrumentation between 2014 and 2016. Data on blood loss, surgical operating time, surgical complications, clinical outcomes and fusion rates were recorded. Results: A total of 6 patients (3 male and 3 female) underwent this procedure at a single institution by a single surgeon during the defined period. One patient presented with infected implant (PLIF) and vertebral osteomyelitis while the other five presented with single level spondylodiscitis. All patients underwent lumbar debridement, iliac strut grafting and posterior instrumentation (revision of screws for infected PLIF case). The mean operating time was 308.3 mins for all 6 cases. Mean blood loss was reported at 341cc (range from 200cc to 600cc). Presenting symptom of back pain resolved in all 6 cases while 2 cases that presented with lower limb weakness had improvement of neurological deficits. One patient had dislodged strut graft while performing posterior instrumentation and needed graft revision intraoperatively. Infective markers normalized for all patients subsequently. All subjects also showed radiological evidence of fusion on 6 months follow up. Conclusions: Lateral approach in treating pyogenic spondylitis is a viable option as it allows debridement and reconstruction without the risk that comes with other anterior approaches. It allows efficient debridement, short surgical time, moderate blood loss and low risk of vascular injuries. Clinical outcomes and fusion rates by this approach also support its use as practical MIS option surgery for such infection cases.

Keywords: lateral approach, minimally invasive, pyogenic spondylitis, XLIF

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Authors: Fatemeh Rezaei, Mohammad H. Yarmohammadian, Masoud Ferdosi, Abbas Haghshnas

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Background: Failure Modes and Effect Analysis is now having known as the main methods of risk assessment and the accreditation requirements for many organizations. The Risk Priority Number (RPN) approach is generally preferred, especially for its easiness of use. Indeed it does not require statistical data, but it is based on subjective evaluations given by the experts about the Occurrence (O i), the Severity (Si) and the Detectability (D i) of each cause of failure. Methods: This study is a quantitative – qualitative research. In terms of qualitative dimension, method of focus groups with inductive approach is used. To evaluate the results of the qualitative study, quantitative assessment was conducted to calculate RPN score. Results; We have studied patient’s journey process in surgery ward and the most important phase of the process determined Transport of the patient from the holding area to the operating room. Failures of the phase with the highest priority determined by defining inclusion criteria included severity (clinical effect, claim consequence, waste of time and financial loss), occurrence (time- unit occurrence and degree of exposure to risk) and preventability (degree of preventability and defensive barriers) and quantifying risks priority criteria in the context of RPN index. Ability of improved RPN reassess by root cause (RCA) analysis showed some variations. Conclusions: Finally, It could be concluded that understandable criteria should have been developed according to personnel specialized language and communication field. Therefore, participation of both technical and clinical groups is necessary to modify and apply these models.

Keywords: failure mode, effects analysis, risk priority number(RPN), health system, risk assessment

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Authors: Pechpailin Kortnoi, Tanitnun Paprad

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Background: Myasthenia gravis (MG) is an autoimmune disorder characterized by impaired neuromuscular transmission due to antibodies against nicotinic receptors, leading to muscle weakness, ptosis, and respiratory issues. The incidence of MG has risen globally, emphasizing the need for effective diagnostics. Objective: This study evaluates the validity of a combined bedside test (the ice pack test and fatigability test) for diagnosing juvenile myasthenia gravis (JMG) in pediatric patients with ptosis. Methods: This cross-sectional study, conducted from January 2012 to May 2024 at King Chulalongkorn Memorial Hospital, Thailand, included pediatric patients (1 month to 18 years) with ptosis undergoing ice pack and fatigability tests. Data included demographics, clinical findings, and test results. Diagnostic efficacy was assessed using sensitivity, specificity, accuracy, PPV, NPV, Fagan Nomogram, Kappa Statistics, and McNemar’s Chi-Square. Results: Of 43 identified patients, 32 were included, with 47% male and a mean age of 7 years. The combined bedside test had high sensitivity (92.8%) and accuracy (87.5%) but moderate specificity (50%). It significantly outperformed the ice pack test (P = 0.0005), which showed low sensitivity (42.8%) and accuracy (43.8%). The fatigability test had 82% sensitivity and 92% PPV. Confirmatory tests (AChR-Ab, MuSK-Ab, neostigmine, repetitive nerve stimulation) supported most diagnoses. Conclusions: The combined bedside test, with high sensitivity (92.8%) and accuracy (87.5%), is an effective screening tool for juvenile myasthenia gravis, outperforming the ice pack test. Integrating it into clinical practice may improve diagnosis and enable timely treatment. The fatigability test (82% sensitivity) is also useful as an adjunct screening tool.

Keywords: myasthenia gravis, the fatigability test, the ice pack test, the combined bedside test

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Authors: Soumaya Mrabet, Imen Akkari, Amira Atig, Elhem Ben Jazia

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Introduction: Primary biliary cirrhosis (PBC) is a cholestatic cholangitis of unknown etiology. It is frequently associated with autoimmune diseases, which explains their systematic screening. The aim of our study was to determine the prevalence and the type of autoimmune disorders associated with PBC and to assess their impact on the prognosis of the disease. Material and methods: It is a retrospective study over a period of 16 years (2000-2015) including all patients followed for PBC. In all these patients we have systematically researched: dysthyroidism (thyroid balance, antithyroid autoantibodies), type 1 diabetes, dry syndrome (ophthalmologic examination, Schirmer test and lip biopsy in case of Presence of suggestive clinical signs), celiac disease(celiac disease serology and duodenal biopsies) and dermatological involvement (clinical examination). Results: Fifty-one patients (50 women and one men) followed for PBC were collected. The Mean age was 54 years (37-77 years). Among these patients, 30 patients(58.8%) had at least one autoimmune disease associated with PBC. The discovery of these autoimmune diseases preceded the diagnosis of PBC in 8 cases (26.6%) and was concomitant, through systematic screening, in the remaining cases. Autoimmune hepatitis was found in 12 patients (40%), defining thus an overlap syndrome. Other diseases were Hashimoto's thyroiditis (n = 10), dry syndrome (n = 7), Gougerot Sjogren syndrome (n=6), celiac disease (n = 3), insulin-dependent diabetes (n = 1), scleroderma (n = 1), rheumatoid arthritis (n = 1), Biermer Anemia (n=1) and Systemic erythematosus lupus (n=1). The two groups of patients with PBC with or without associated autoimmune disorders were comparable for bilirubin levels, Child-Pugh score, and response to treatment. Conclusion: In our series, the prevalence of autoimmune diseases in PBC was 58.8%. These diseases were dominated by autoimmune hepatitis and Hashimoto's thyroiditis. Even if their association does not seem to alter the prognosis, screening should be systematic in order to institute an early and adequate management.

Keywords: autoimmune diseases, autoimmune hepatitis, primary biliary cirrhosis, prognosis

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Authors: Jennifer M. Glennon, Hana D'Souza, Luke Mason, Annette Karmiloff-Smith, Michael S. C. Thomas

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Genetic syndrome groups that feature high rates of autism comorbidity, like Down syndrome (DS) and fragile X syndrome (FXS), have been presented as useful models for understanding risk and protective factors involved in the emergence of autistic traits. Yet despite reaching clinical thresholds, these ‘syndromic’ forms of autism appear to differ in important ways from the idiopathic or ‘non-syndromic’ autism phenotype. To uncover the true nature of these comorbidities, it is necessary to extend definitions of autism to include the cognitive characteristics of the disorder and to then apply this broadened conceptualisation to the study of syndromic autism profiles. The current study employs a variety of well-established eye-tracking paradigms to assess visual attentional performance in children with DS and FXS who reach thresholds for autism on the Social Communication Questionnaire. It investigates whether autism profiles in these children are accompanied by visual orienting difficulties (‘sticky attention’), decreased social attention, and enhanced visual search performance, all of which are characteristic of the idiopathic autism phenotype. Data is collected from children with DS and FXS aged between 6 and 10 years, in addition to two control groups matched on age and intellectual ability (i.e., children with idiopathic autism and neurotypical controls). Cross-sectional developmental trajectory analyses are conducted to enable visuo-attentional profile comparisons. Significant differences in the visuo-attentional processes underpinning autism presentations in children with FXS and DS are hypothesised, supporting notions of syndrome specificity. The study provides insight into the complex heterogeneity associated with syndromic autism presentations and autism per se, with clinical implications for the utility of autism intervention programmes in DS and FXS populations.

Keywords: autism, down syndrome, fragile X syndrome, eye tracking

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Authors: A. C. Facin, M. C. Maronezi , M. P. Menezes, G. L. Montanhim, L. Pavan, M. A. R. Feliciano, R. P. Nociti, R. A. R. Uscategui, P. C. Moraes

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The incidence of brachycephalic syndrome (BS) in the clinical routine of small animals has increased significantly giving the higher proportion of brachycephalic pets in the last years and has been considered as an animal welfare problem. The treatment of BS is surgical and the clinical signs related can be considerably attenuated. Nevertheless, the systemic effects of the BS are still poorly reported and little is known about these when the surgical correction is not performed early. Affected dogs are more likely to develop cardiopulmonary, gastrointestinal and sleep disorders in which the chronic hypoxemia plays a major role. This syndrome is compared with the obstructive sleep apnea (OSA) in humans, both considered as causes of systemic and metabolic dysfunction. Among the several consequences of the BS little is known if the syndrome also affects the hepatic tissue of brachycephalic patients. Elastography is a promising ultrasound technique that evaluates tissue elasticity and has been recently used with the purpose of diagnosis of liver fibrosis. In medicine, it is a growing concern regarding the hepatic injury of patients affected by OSA. This prospective study hypothesizes if there is any consequence of BS in the hepatic parenchyma of brachycephalic dogs that don’t receive any surgical treatment. This study was conducted following the approval of the Animal Ethics and Welfare Committee of the Faculdade de Ciências Agrárias e Veterinárias, UNESP, Campus Jaboticabal, Brazil (protocol no 17944/2017) and funded by Sao Paulo Research Foundation (FAPESP, process no 2017/24809-4). The methodology was based in ARFI elastography using the ACUSON S2000/SIEMENS device, with convex multifrequential transducer and specific software as well as clinical evaluation of the syndrome, in order to determine if they can be used as a prognostic non-invasive tool. On quantitative elastography, it was collected three measures of shear wave velocity (meters per second) and depth in centimeters in the left lateral, left medial, right lateral, right medial and caudate lobe of the liver. The brachycephalic patients, 16 pugs and 30 french bulldogs, were classified using a previously established 4-point functional grading system based on clinical evaluation before and after a 3-minute exercise tolerance test already established and validated. The control group was based on the same features collected in 22 beagles. The software R version 3.3.0 was used for the analysis and the significance level was set at 0.05. The data were analysed for normality of residuals and homogeneity of variances by Shapiro-Wilks test. Comparisons of parametric continuous variables between breeds were performed by using ANOVA with a post hoc test for pair wise comparison. The preliminary results show significant statistic differences between the brachycephalic groups and the control group in all lobes analysed (p ≤ 0,05), with higher values of shear wave velocities in the hepatic tissue of brachycephalic dogs. In this context, the results obtained in this study contributes to the understanding of BS as well as its consequences in our patients, reflecting in evidence that one more systemic consequence of the syndrome may occur in brachycephalic patients, which was not related in the veterinary literature yet.

Keywords: airway obstruction, brachycephalic airway obstructive syndrome, hepatic injury, obstructive sleep apnea

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Authors: Yasmeen Jamal Alabdallat, Almutazballlah Bassam Qablan, Hamza Al-Salhi, Salameh Alarood, Ibraheem Alkhawaldeh, Obada Abunar, Adam Abdallah

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Obstructive sleep apnea (OSA) is a disorder caused by the repeated collapse of the upper airway during sleep. It is the most common cause of sleep-related breathing disorder, as OSA can cause loud snoring, daytime fatigue, or more severe problems such as high blood pressure, cardiovascular disease, coronary artery disease, insulin-resistant diabetes, and depression. The hypoglossal nerve stimulator (HNS) is an implantable medical device that reduces the occurrence of obstructive sleep apnea by electrically stimulating the hypoglossal nerve in rhythm with the patient's breathing, causing the tongue to move. This stimulation helps keep the patient's airways clear while they sleep. This systematic review and meta-analysis aimed to assess the clinical outcome of hypoglossal nerve stimulation as a treatment of obstructive sleep apnea. A computer literature search of PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted from inception until August 2022. Studies assessing the following clinical outcomes (Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Oxygen Desaturation Indices (ODI), (Oxygen Saturation (SaO2)) were pooled in the meta-analysis using Review Manager Software. We assessed the quality of studies according to the Cochrane risk-of-bias tool for randomized trials (RoB2), Risk of Bias In Non-randomized Studies - of Interventions (ROBINS-I), and a modified version of NOS for the non-comparative cohort studies.13 Studies (Six Clinical Trials and Seven prospective cohort studies) with a total of 817 patients were included in the meta-analysis. The results of AHI were reported in 11 studies examining OSA 696 patients. We found that there was a significant improvement in the AHI after 12 months of HNS (MD = 18.2 with 95% CI, (16.7 to 19.7; I2 = 0%); P < 0.00001). Further, 12 studies reported the results of ESS after 12 months of intervention with a significant improvement in the range of sleepiness among the examined 757 OSA patients (MD = 5.3 with 95% CI, (4.75 to 5.86; I2 = 65%); P < 0.0001). Moreover, nine studies involving 699 participants reported the results of FOSQ after 12 months of HNS with a significant reported improvement (MD = -3.09 with 95% CI, (-3.41 to 2.77; I2 = 0%); P < 0.00001). In addition, ten studies reported the results of ODI with a significant improvement after 12 months of HNS among the 817 examined patients (MD = 14.8 with 95% CI, (13.25 to 16.32; I2 = 0%); P < 000001). The Hypoglossal Nerve Stimulation showed a significant positive impact on obstructive sleep apnea patients after 12 months of therapy in terms of apnea-hypopnea index, oxygen desaturation indices, manifestations of the behavioral morbidity associated with obstructive sleep apnea, and functional status resulting from sleepiness.

Keywords: apnea, meta-analysis, hypoglossal, stimulation

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Authors: Aisha Arshad, Samina Naz Mukry, Tahir Shamsi

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Background: Immune thrombocytopenia (ITP) is an autoimmune disorder. Besides platelets counts, immature platelets fraction (IPF) can be used as tool to predict megakaryocytic activity in ITP patients. The clinical biomarkers like Neutrophils to lymphocytes ratio (NLR) and platelet to lymphocytes ratio(PLR) predicts inflammation and can be used as prognostic markers.The present study was planned to assess the ratios in ITP and their utility in predicting prognosis after treatment. Methods: A total of 111 patients of ITP with same number of healthy individuals were included in this case control study during the period of January 2015 to December 2017.All the ITP patients were grouped according to guidelines of International working group of ITP. A 3cc blood was collected in EDTA tube and blood parameters were evaluated using Sysmex 1000 analyzer.The ratios were calculated by using absolute counts of Neutrophils,Lymphocytes and platelets.The significant (p=<0.05) difference between ITP patients and healthy control groups was determined by Kruskal wallis test, Dunn’s test and spearman’s correlation test was done using SPSS version 23. Results: The significantly raised total leucocytes counts (TLC) and IPF along with low platelets counts were observed in ITP patients as compared to healthy controls.In ITP groups,very low platelet count with median and IQR of 2(3.8)3x109/l with highest mean and IQR IPF 25.4(19.8)% was observed in newly diagnosed ITP group. The NLR was high with prognosis of disease as higher levels were observed in P-ITP. The PLR was significantly low in ND-ITP ,P-ITP, C-ITP, R-ITP and compared to controls with p=<0.001 as platelet were less in number in all ITP patients. Conclusion: The IPF can be used in evaluation of bone marrow response in ITP. The simple, reliable and calculated NLR and PLR ratios can be used in predicting prognosis and response to treatment in ITP and to some extend the severity of disease.

Keywords: neutrophils, platelets, lymphocytes, infection

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Authors: Riyas Peringattuthodiyil, Mark Taylor, Ian Wallace, Ailish Nugent, Mike Mitchell, Judith Thompson, Allison McKee, Philip C. Johnston

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Aim of Study: The purpose of the study was to screen for diabetes through HbA1c in patients with chronic pancreatitis (CP) within the Belfast Trust. Background: Patients with chronic pancreatitis are at risk of developing diabetes, earlier diagnosis with subsequent multi-disciplinary input has the potential to improve clinical outcomes. Methods: Clinical and laboratory data of patients with chronic pancreatitis were obtained through the Northern Ireland Electronic Healthcare Record (NIECR), specialist hepatobiliary, and gastrointestinal clinics. Patients were invited to have a blood test for HbA1c. Newly diagnosed patients with diabetes were then invited to attend a dedicated Belfast City Hospital (BCH) specialist chronic pancreatitis and diabetes clinic for follow up. Results: A total of 89 chronic pancreatitis patients were identified; Male54; Female:35, mean age 52 years, range 12-90 years. Aetiology of CP included alcohol 52/89 (58%), gallstones 18/89 (20%), idiopathic 10/89 11%, 2 were genetic, 1: post ECRP, 1: IgG autoimmune, 1: medication induced, 1: lipoprotein lipase deficiency 1: mumps, 1: IVDU and 1: pancreatic divisum. No patients had pancreatic carcinoma. Mean duration of CP was nine years, range 3-30 years. 15/89 (16%) of patients underwent previous pancreatic surgery/resections. Recent mean BMI was 25.1 range 14-40 kg/m². 62/89 (70%) patients had HbA1c performed. Mean HbA1c was 42 mmol/mol, range 27-97mmol/mol, 42/62 (68%) had normal HbA1c (< 42 mmol/mol) 13/62 (21%) had pre-diabetes (42-47mmol/mol) and 7/62 (11%) had diabetes (≥ 48 mmol/mol). Conclusions: Of those that participated in the screening program around one-third of patients with CP had glycaemic control in the pre and diabetic range. Potential opportunities for improving screening rates for diabetes in this cohort could include regular yearly testing at gastrointestinal and hepatobiliary clinics.

Keywords: pancreatogenic diabetes, screening, chronic pancreatitis, trust experience

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Authors: Maria L. G. Lourenco, Viviane Y. Hibaru, Keylla H. N. P. Pereira, Fabiana F. Souza, Joao C. P. Ferreira, Simone B. Chiacchio, Luiz H. A. Machado

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Neonatal conjunctivitis, or ophthalmia, is an infection of the conjunctiva or cornea before opening the eyelids. It is believed that immunodeficiency contributes to the development of the condition. This study aims at reporting a case of ophthalmia neonatorum in a dog, in addition to its diagnosis and treatment. A litter of five pug neonates was admitted to the Sao Paulo State University (UNESP) Veterinary Hospital, Botucatu, Sao Paulo, Brazil, with complaints of ocular secretion. The neonates were five days old. The clinical examination revealed that three newborns presented swelling in the ocular region and a purulent secretion in the medial corner of the eye that was exerting pressure on the ocular globes, which are compatible with the description of this disease. The diagnosis was made based on the clinical signs and bacterial culture of the secretion, which revealed the presence of bacteria belonging to the genus Staphylococcus sp. The laboratory assays did not reveal any alterations. The treatment was instituted gently, opening the eyelids early and cleaning the purulent ocular secretion with saline solution. An ophthalmic ointment with retinol, amino acids, methionine, and chloramphenicol (Epitezan®) was prescribed four times a day for seven days. Blood plasma (2 mL/100 g) was administered subcutaneously because bacterial infections in neonates may represent a failure in the transference of passive immunity. A more thorough cleaning of the environment was also recommended. Neonatal conjunctivitis has a simple diagnosis and treatment. If not treated early, it can evolve to adherence of the eyelids to the cornea, ulceration, and perforation of the cornea. Therefore, the prognosis is favorable as long as the condition is diagnosed early, and the treatment is instituted quickly.

Keywords: ophthalmia neonatorum, neonatal infection, puppy, newborn

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Authors: Fadwa Chtioui

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Vital Pulp Therapy (VPT) is nowadays challenging the deep-rooted dogma of root canal treatment, being the only therapeutic option for permanent teeth diagnosed with irreversible pulpitis or carious pulp exposure. Histologic and clinical research has shown that compromised dental pulp can be treated without the full removal or excavation of all healthy pulp, and the outcome of the partial or full pulpotomy followed by a Tricalcium-Silicate-based dressing seems to show promising results in maintaining pulp vitality and preserving affected teeth in the long term. By reviewing recent advances in the techniques of VPT and their clinical effectiveness and safety in permanent teeth with irreversible Pulpitis, this work provides a new understanding of pulp pathophysiology and defense mechanisms and will reform dental practitioners' decision-making in treating irreversible pulpits from root canal therapy to vital pulp therapy by taking advantage of the biological effects of Tricalcium Silicate materials. Biography of presenting author: Fadwa Chitoui graduated from the school of Dental Medicine of Monastir, Tunisia, in 2015. After getting her DDS degree with honors, she earned her Postgraduate master's Degree in Endodontics and Restorative Dentistry from her Faculty. Since 2021, she has Started her own private and specialized practice based in the capital Tunis. She enjoys the sphere of associative life, worked with national and international associations, and got engaged in scientific dental research, whereby she tailored her passion for her field of specialty towards broadening her knowledge and ambitions, holding conferences and workshops nationally and internationally and publishing scientific articles in several journals.

Keywords: irreversible pulpitis, permanenet teeth, vital pulp therapy, pulpotomy

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Authors: Emad Kouhestani

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Background: Despite the enormous success of anterior cruciate ligament (ACL) reconstruction, acute neuropathic pain can develop postoperatively and is both distressing and difficult to treat once established. Pregabalin, as an anticonvulsant agent that selectively affects the nociceptive process, has been used as a pain relief agent. The purpose of this systematic review of randomized controlled trials (RCTs) was to evaluate the pain control effect of pregabalin versus placebo after ACL reconstruction. Method: A search of the literature was performed from inception to June 2022, using PubMed, Scopus, Google Scholar, Web of Science, Cochrane, and EBSCO. Studies considered for inclusion were RCTs that reported relevant outcomes (postoperative pain scores, or cumulative opioid consumption, adverse events) following the administration of pregabalin in patients undergoing ACL reconstruction. Result: Five placebo-controlled RCTs involving 272 participants met the inclusion criteria. 75 mg and 150 mg of oral pregabalin were used in included trials. Two studies used a single dose of pregabalin one hour before anesthesia induction. Two studies used pregabalin 1 hour before anesthesia induction and 12 hours after. One study used daily pregabalin 7 days before and 7 days after surgery. Out of five papers, three papers found significantly lower pain intensity and cumulative opioid consumption in the pregabalin group compared with the placebo group. However, a decrease in pain scores was found in all trials. Pregabalin administration was associated with dizziness and nausea. Conclusion: The use of pregabalin may be a valuable asset in pain management after ACL reconstruction. However, future studies with larger sample sizes and longer follow-up periods are required.

Keywords: pregabalin, anterior cruciate ligament, postoperative pain, clinical trial

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Authors: Murray David Schane

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Though years of clinical encounters with patients with autism spectrum disorders and those with a schizoid personality the many defining diagnostic features shared between these conditions have been explored and current neurobiological differences have been reviewed; and, critical and different treatment strategies for each have been devised. The paper compares and contrasts the apparent similarities between autism spectrum disorders and the schizoid personality are found in these DSM descriptive categories: restricted range of social-emotional reciprocity; poor non-verbal communicative behavior in social interactions; difficulty developing and maintaining relationships; detachment from social relationships; lack of the desire for or enjoyment of close relationships; and preference for solitary activities. In this paper autism, fundamentally a communicative disorder, is revealed to present clinically as a pervasive aversive response to efforts to engage with or be engaged by others. Autists with the Asperger presentation typically have language but have difficulty understanding humor, irony, sarcasm, metaphoric speech, and even narratives about social relationships. They also tend to seek sameness, possibly to avoid problems of social interpretation. Repetitive behaviors engage many autists as a screen against ambient noise, social activity, and challenging interactions. Also in this paper, the schizoid personality is revealed as a pattern of social avoidance, self-sufficiency and apparent indifference to others as a complex psychological defense against a deep, long-abiding fear of appropriation and perverse manipulation. Neither genetic nor MRI studies have yet located the explanatory data that identifies the cause or the neurobiology of autism. Similarly, studies of the schizoid have yet to group that condition with those found in schizophrenia. Through presentations of clinical examples, the treatment of autists of the Asperger type is revealed to address the autist’s extreme social aversion which also precludes the experience of empathy. Autists will be revealed as forming social attachments but without the capacity to interact with mutual concern. Empathy will be shown be teachable and, as social avoidance relents, understanding of the meaning and signs of empathic needs that autists can recognize and acknowledge. Treatment of schizoids will be shown to revolve around joining empathically with the schizoid’s apprehensions about interpersonal, interactive proximity. Models of both autism and schizoid personality traits have yet to be replicated in animals, thereby eliminating the role of translational research in providing the kind of clues to behavioral patterns that can be related to genetic, epigenetic and neurobiological measures. But as these clinical examples will attest, treatment strategies have significant impact.

Keywords: autism spectrum, schizoid personality traits, neurobiological implications, critical diagnostic distinctions

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Authors: Joao Paulo Matheus, Renan Fangel

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Rheumatoid arthritis is a chronic, inflammatory, systemic and progressive disease that affects the synovial joints bilaterally, causing definitive orthopedic damage. It has a higher prevalence in postmenopausal female patients. It is a disabling disease that causes joint deformities that may compromise the functionality of the affected segment. The aim of this study was to evaluate the influence of low-intensity therapeutic laser on the perception of pain and quality of life in patients with rheumatoid arthritis. This is a randomized clinical study involving 6 women with a mean age of 56.8+6.3 years. Exclusion criteria: patients with acute pain, chronic infectious disease, underlying acute or chronic underlying disease. An AsGaAl laser with 808nm wavelength, 100mW power, beam output area of 0.028cm2, power density of 3.57W/cm2 was used. The laser was applied at pre-defined points in the interphalangeal and metacarpophalangeal joints, totaling 24 points, 2 times a week, for 4 weeks, totaling 8 sessions. The Pain Inventory (IBD) and Visual Analogue Scale (VAS) were used for the analysis of pain and for the WHOQOL-bref quality of life assessment. There was no statistical difference between the onset (5.67±2.66) and the final (4.67±3.78) of treatments (p=0.70). There was also no statistical difference between the beginning (5.67±2.66) and the final (4.67±3.78) of the treatments in the VAS analysis (p=0.68). The overall mean quality of life obtained by the questionnaire at the start of treatment was 42.3±7.6, while at the end of treatment it was 58.5±7.6 (p=0.01) and the domains of the questionnaire with significant differences were: psychological domain 42.9±6.8 and 66.7±12.9 (p=0.004), social domain 39.9±5.7 and 68.1±6.3 (p=0,0005) and environmental domain 36.3±7.3 and 56.3±12.5 (p=0.003). It can be concluded that the low-intensity therapeutic laser did not produce significant changes in the painful period of rheumatoid arthritis patients. However, there was an improvement in patients' quality of life in the psychological, social and environmental aspects.

Keywords: laser therapy, pain, quality of life, rheumatoid arthritis

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Authors: Khader A. Almhdawi, Saddam F. Kanaan

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Background: Allied health (AH) students, including rehabilitation sciences students, are subjected to significant levels of physical and mental stressors, which could affect their education. This study aimed to study physical and mental of Health-related Quality of Life (HR-QoL) levels along with their predictors among students of nine AH majors. Methods: Students filled validated anonymous surveys covering demographics and life style, Nordic Musculoskeletal Questionnaire, 12-item Short-Form Health Survey (SF-12), and Depression Anxiety Stress Scale (DASS- 42). SF-12 Mental (MCS) and Physical (PCS) summary scores were compared between academic majors and gender. Multiple linear regression models were conducted to examine potential predictors of PCS and MCS scores. Results: 838 students (77.4% females) participated in this study. Participants’ PCS mean score was 45.64±7.93 and found statistically different between the nine academic majors (P < 0.001). Additionally, participants’’ MCS mean score was 39.45±10.86 and significantly greater in males (P < 0.001). Significant PCS scores predictors included hip and upper back musculoskeletal pain, anxiety score, diet self-evaluation, and GPA. Finally, MCS scores were statistically associated with neck musculoskeletal pain, stress score, depression score, number of weekly clinical training hours, gender, university year, GPA, sleep quality self-evaluation, and diet self-evaluation. Conclusion: Clinical educators of AH need to account for students’ low levels of HR-QoL and their academic-related, health-related, and lifestyle-related associated factors. More studies are recommended to investigate the progression of HR-QoL throughout university years and to create effective interventions to improve HR-QoL among healthcare students.

Keywords: medical education, quality of life, stress, anxiety, depression

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Authors: Angelis P. Barlampas

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Theoretical background Disorders of fixation and rotation of the large intestine, result in the existence of its parts in ectopic anatomical positions. In case of symptomatology, the clinical picture is complicated by the possible symptomatology of the neighboring anatomical structures and a differential diagnostic problem arises. Target The purpose of this work is to demonstrate the difficulty of revealing the real cause of abdominal pain, in cases of anatomical variants and the decisive contribution of imaging and especially that of computed tomography. Methods A patient came to the emergency room, because of acute pain in the right hypochondrium. Clinical examination revealed tenderness in the gallbladder area and a positive Murphy's sign. An ultrasound exam depicted a normal gallbladder and the patient was referred for a CT scan. Results Flexible, unfixed ascending colon and cecum, located in the anatomical region of the right mesentery. Opacities of the surrounding peritoneal fat and a small linear concentration of fluid can be seen. There was an appendix of normal anteroposterior diameter with the presence of air in its lumen and without clear signs of inflammation. There was an impression of possible inflammatory swelling at the base of the appendix, (DD phenomenon of partial volume; e.t.c.). Linear opacities of the peritoneal fat in the region of the second loop of the duodenum. Multiple diverticula throughout the colon. Differential Diagnosis The differential diagnosis includes the following: Inflammation of the base of the appendix, diverticulitis of the cecum-ascending colon, a rare case of second duodenal loop ulcer, tuberculosis, terminal ileitis, pancreatitis, torsion of unfixed cecum-ascending colon, embolism or thrombosis of a vascular intestinal branch. Final Diagnosis There is an unfixed cecum-ascending colon, which is exhibiting diverticulitis.

Keywords: unfixed cecum-ascending colon, abdominal pain, malrotation, abdominal CT, congenital anomalies

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Authors: Xiao-Yin Liu, Liang-Xue Zhou

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Traumatic brain injury (TBI), as a kind of nerve trauma caused by an external force, affects people all over the world and is a global public health problem. Although there are various clinical treatments for brain injury, including surgery, drug therapy, and rehabilitation therapy, the therapeutic effect is very limited. To improve the therapeutic effect of TBI, scaffolds combined with exosomes are a promising but challenging method for TBI repair. In this study, we examined whether a novel 3D-printed collagen/chitosan scaffold/exosomes derived from neural stem cells (NSCs) pretreated with insulin growth factor-1 (IGF-I) scaffolds (3D-CC-INExos) could be used to improve TBI repair and functional recovery after TBI. Our results showed that composite scaffolds of collagen-, chitosan- and exosomes derived from NSCs pretreated with IGF-I (INExos) could continuously release the exosomes for two weeks. In the rat TBI model, 3D-CC-INExos scaffold transplantation significantly improved motor and cognitive function after TBI, as assessed by the Morris water maze test and modified neurological severity scores. In addition, immunofluorescence staining and transmission electron microscopy showed that the recovery of damaged nerve tissue in the injured area was significantly improved by 3D-CC-INExos implantation. In conclusion, our data suggest that 3D-CC-INExos might provide a potential strategy for the treatment of TBI and lay a solid foundation for clinical translation.

Keywords: traumatic brain injury, exosomes, insulin growth factor-1, neural stem cells, collagen, chitosan, 3D printing, neural regeneration, angiogenesis, functional recovery

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Authors: Sundaresan Soundararajan, George Ezekiel Silvananthan, Chor Ngee Tan

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Introduction: Transforaminal Interbody Fusion (TLIF) has been adopted for many decades now, however, XLIF, still in relative infancy, has grown to be accepted as a new Minimally Invasive Surgery (MIS) option. There is a paucity of reports directly comparing lateral approach surgery to other MIS options such as TLIF in the treatment of lumbar degenerative disc diseases. Aims/Objectives: The objective of this study was to compare the efficacy and clinical outcomes between Minimally Invasive Transforaminal Interbody Fusion (TLIF) and Minimally Invasive Lateral Interbody Fusion (XLIF) in the treatment of patients with degenerative disc disease of the lumbar spine. Methods: A single center, retrospective cohort study involving a total of 38 patients undergoing surgical intervention between 2010 and 2013 for degenerative disc disease of lumbar spine at single L4/L5 level. 18 patients were treated with MIS TLIF, and 20 patients were treated with XLIF. Results: The XLIF group showed shorter duration of surgery compared to the TLIF group (176 mins vs. 208.3 mins, P = 0.03). Length of hospital stay was also significantly shorter in XLIF group (5.9 days vs. 9 days, p = 0.03). Intraoperative blood loss was favouring XLIF as 85% patients had blood loss less than 100cc compared to 58% in the TLIF group (P = 0.03). Radiologically, disc height was significantly improved post operatively in the XLIF group compared to the TLIF group (0.56mm vs. 0.39mm, P = 0.01). Foraminal height increment was also higher in the XLIF group (0.58mm vs. 0.45mm , P = 0.06). Clinically, back pain and leg pain improved in 85% of patients in the XLIF group and 78% in the TLIF group. Post op hip flexion weakness was more common in the XLIF group (40%) than in the TLIF group (0%). However, this weakness resolved within 6 months post operatively. There was one case of dural tear and surgical site infection in the TLIF group respectively and none in the XLIF group. Visual Analog Scale (VAS) score 6 months post operatively showed comparable reduction in both groups. TLIF group had Owsterty Disability Index (ODI) improvement on 67% while XLIF group showed improvement of 70% of its patients. Conclusions: Lateral approach surgery shows comparable clinical outcomes in resolution of back pain and radiculopathy to conventional MIS techniques such as TLIF. With significantly shorter duration of surgical time, minimal blood loss and shorter hospital stay, XLIF seems to be a reasonable MIS option compared to other MIS techniques in treating degenerative lumbar disc diseases.

Keywords: extreme lateral interbody fusion, lateral approach, minimally invasive, XLIF

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Authors: Dharshika Rajalingam, Jeffery W. Peng

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Acinetobacter baumannii is a challenging threat to global health, recognized as a multidrug-resistant pathogen. -lactamase is one of the principal resistant mechanisms developed by A. baumannii to survive against -lactam antibiotics. OXA24/40 is one of the types of -lactamases, a well-documented carbapenem hydrolyzing class D -lactamases (CHDL). It was revealed that OXA24/40 showed resistivity against doripenem, one of the carbapenems, by two different mechanisms as hydrolysis and -lactonization. Furthermore, it undergoes genetic mutations to broaden the -lactamase activity to survive against antibiotic environments. One of the crucial characterizations of prokaryotes to develop adaptation is post-translational modification (PTM), mainly phosphorylation. However, the PTM of OXA24/40 is an unknown feature, and the impact of PTM on antibiotic resistivity is yet to be explored. We approached these hypotheses using NMR and MS techniques and found that the OXA24/40 could be phosphorylated in vitro. The Ser81 at the active STFK motif of OXA24/40 of catalytic pocket was identified as the site of phosphorylation using 1D 31P NMR experiment, whereas S81 is required to form an acyl-enzyme complex between enzyme and -lactam antibiotics. The activity of completely phosphorylated OXA24/40 wild type against doripenem revealed that the phosphorylation of active Ser inactivates the -lactamases activity of OXA24/40. The 1D 1H CPMG NMR-based activity assay of phosphorylated OXA24/40 against doripenem confirmed that both deactivating mechanisms are inhibited by phosphorylation. Carbamylated Lysine at the active STFK motif is one of the critical features of CHDL required for the acylation and deacylation reactions of the enzyme. The 1D 13C NMR experiment confirmed that the K84 of phosphorylated OXA24/40 is de-carbamylated. Phosphorylation of OXA24/40 affects both active S81 and carbamylated K84 of OXA24 that are required for the resistivity of -lactamase. So, phosphorylation could be one of the reasons for the genetic mutation of OXA24/40 for the development of antibiotic resistivity. Further research can lead to an understanding of the effect of phosphorylation on the clinical mutants of the OXA24-like -lactamase family on the broadening of -lactamase activity.

Keywords: OXA24/40, phosphorylation, clinical mutants, resistivity

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Authors: Yasuyuki Takahashi, Hayato Ishimura, Masao Miyagawa, Teruhito Mochizuki

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Quantitative measurement of myocardium perfusion is possible with single photon emission computed tomography (SPECT) using a semiconductor detector. However, accumulation of ^99mTc-tetrofosmin in the liver may make it difficult to assess that accurately in the inferior myocardium. Our idea is to reduce the high accumulation in the liver by using dynamic SPECT imaging and a technique called time subtraction. We evaluated the performance of a new SPECT system with a cadmium-zinc-telluride solid-state semi- conductor detector (Discovery NM 530c; GE Healthcare). Our system acquired list-mode raw data over 10 minutes for a typical patient. From the data, ten SPECT images were reconstructed, one for every minute of acquired data. Reconstruction with the semiconductor detector was based on an implementation of a 3-D iterative Bayesian reconstruction algorithm. We studied 20 patients with coronary artery disease (mean age 75.4 ± 12.1 years; range 42-86; 16 males and 4 females). In each subject, 259 MBq of ^99mTc-tetrofosmin was injected intravenously. We performed both a phantom and a clinical study using dynamic SPECT. An approximation to a liver-only image is obtained by reconstructing an image from the early projections during which time the liver accumulation dominates (0.5~2.5 minutes SPECT image-5~10 minutes SPECT image). The extracted liver-only image is then subtracted from a later SPECT image that shows both the liver and the myocardial uptake (5~10 minutes SPECT image-liver-only image). The time subtraction of liver was possible in both a phantom and the clinical study. The visualization of the inferior myocardium was improved. In past reports, higher accumulation in the myocardium due to the overlap of the liver is un-diagnosable. Using our time subtraction method, the image quality of the ^99mTc-tetorofosmin myocardial SPECT image is considerably improved.

Keywords: 99mTc-tetrofosmin, dynamic SPECT, time subtraction, semiconductor detector

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Authors: V. N. Chebotkevich, E. E. Schetinkina, V. V. Burylev, E. I. Kaytandzhan, N. P. Stizhak

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Objective: Blood stream infections (BSI) are severe, life-threatening illness for immuno compromised patients with hematological malignancies. We report the trend in blood-stream infections in this group of patients in the period 1991-2013. Methods: A total of 4742 blood samples investigated. All blood cultures were incubated in a continuous monitoring system for 7 days before discarding negative. On signaled positive, organism was identified by conventional methods. The Real-time polymerase chain reaction (PCR) was used for the indication of human herpes virus 6 (HHV-6), Cytomegalovirus (CMV) and Epstein-Barr virus (EBV). Results: Between 1991 and 2001 the incidence of Gram-positive bacteria (Staphylococcus epidermidis, Staphylococcus aureus) being the most common germs isolated (70,9%) were as Gram-negative rods (Escherichia coli, Klebsiella spp., Pseudomonas spp.) – 29,1%. In next decade 2002-2012 the number of Gram-negative bacteria was increased up to 40.2%. It is shown that the incidence of bacteremia was significantly more frequent at the background of detectable Cytomegalovirus and Epstein-Barr virus-specific DNA in blood. Over recent years, an increased frequency of micro mycetes was registered in blood of the patients with hematological malignancies (Candida spp. was predominant). Conclusion: Accurate and timely detection of BSI is important in determining appropriate treatment of infectious complications in patients with hematological malignancies. The isolation of Staphylococcus epidermidis from blood cultures remains a clinical dilemma for physicians and microbiologists. But in many cases this agent is of the clinical significance in immunocompromised patients with hematological malignancies. The role of CMV and EBV in development of bacteremia was demonstrated.

Keywords: infectious complications, blood stream infections, bacteremia, hemoblastosis

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Authors: Ashit Syngle, Inderjit Verma, Pawan Krishan

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Therapeutic approaches used previously relied on disease-modifying antirheumatic drugs (DMARDs) that had only partial clinical benefit and were associated with significant toxicity. Spironolactone, an oral aldosterone antagonist, suppresses inflammatory mediators. Clinical efficacy of spironolactone compared with placebo in patients with active psoriatic arthritis despite treatment with prior traditional DMARDs. In the 24-week, placebo-controlled study patients (n=31) were randomized to placebo and spironolactone (2 m/kg/day). Patients on background concurrent DMARDs continued stable doses (methotrexate, leflunomide, and/or sulfasalazine). Primary outcome measures were the assessment of disease activity measures i.e. 28-joint disease activity score (DAS28) and diseases activity in psoriatic arthritis (DAPSA) at week 24. The key secondary endpoint was change from baseline in Health Assessment Questionnaire–Disability Index (HAQ-DI) at week 24. Additional efficacy outcome measures at week 24 included improvements in the markers of inflammation (ESR and CRP) and pro-inflammatory cytokines TNF-α, IL-6 and IL-1. At week 24, spironolactone significantly reduced disease activity measure DAS-28 (p<0.001) and DAPSA (p=0.001) compared with placebo. Significant improvements in key secondary measures HAQ-DI (disability index) were evident with spironolactone (p=0.02) versus placebo. After week 24, there was significant reduction in pro-inflammatory cytokines level TNF-α, IL-6 (p<0.01) as compared with placebo group. However, there was no significant improvement in IL-1 in both treatment and placebo groups. There were minor side effects which did not mandate stopping of spironolactone. No change in any biochemical profile was noted after spironolactone treatment. Spironolactone was effective in the treatment of PsA, improving disease activity, physical function and suppressing the level of pro-inflammatory cytokines. Spironolactone demonstrated an acceptable safety profile and was well tolerated.

Keywords: spironolactone, inflammation, inflammatory cytokine, psoriatic arthritis

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Authors: Sarinra Thongmee, Adithep Mingsuan, Chanyapak Polkhet, Supattra Wongsuk, Krittaphon Prakobsaeng

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The purposes of this research and development was to develop and evaluation of clinical nursing practice guideline (CNPG) for the prevention of infection during intubation in patient withsuspected or confirmedCOVID-19 patient. This study was developed by using the evidence based practice model of Soukup (2000) as a conceptual framework. The study consisted of 4 steps: 1) situational analysis of intubation service in patients with confirmed COVID-19, 2) development the CNPG, 3) apply the NPG to trial, and 4) evaluation of the NPG. Thesample consisted of 52 nurse anesthetists and 25 infected or suspected COVID-19 patients. The research instrument consisted of 1) CNPG, 2) the nurses anesthetist opinion questionnaire to the guideline, 3) the evaluation practice form, and 4) the nurse anesthetist knowledge test on nursing care of patients infected with COVID-19. Data were analyzed by using descriptive statistics, and Wilcoxon matched-pairs signed rank test. The results found that this developed NPG consists of 4 sections: 1) NPG for Preventing Airborne Infection Prevention2) preparation of anesthetic and intubation equipments 3) roles and duties of the intubation team 4) guidelines for intubation in suspected or confirmed COVID-19patients. The result found that 1) provider: using NPG in providers revealed that nurse anesthetist had higher mean of knowledge scores than before using NPG statistically significant at the 0.05 level (p<0.01) and able to follow the NPG 100% in all activities. The anesthetic team was not infected with COVID-19from intubation outside operating room.2) Client: the patient was safe, no complications from intubation. Summary CNPG to prevent infection in intubation of suspected or confirmedCOVID-19 patient was appropriate and applicable to practice.

Keywords: nursing practice guideline, prevention of infection, endotracheal intubation, COVID-19

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