The use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided.Clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension

Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension p. 63

Hiroyuki Oshika, Yukihide Koyama, Yutaka Usuda, Tomio Andoh

DOI:10.4103/sja.SJA_367_18  

We report a case of intravenous ephedrine administration that abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension and who was subsequently diagnosed postoperatively as having bronchial asthma. A 54-year-old man who had childhood asthma was scheduled for laparoscopic cholecystectomy at our institution. The preanesthetic interview suggested full resolution of his childhood asthma. His capnogram showed an airway obstructive pattern immediately after the initiation of mechanical ventilation. However, after administration of ephedrine due to low blood pressure during surgery, his obstructive capnogram reverted to normal. On postoperative day 3, he was diagnosed as having bronchial asthma. Furthermore, we found that small airway obstruction as indicated in his preoperative pulmonary function test (PFT) had been overlooked. Two important points arise from this case. First, the use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided. Second, clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.

Bedside ultrasonography for the confirmation of gastric tube placement in the neonate

Yunus Oktay Atalay, Ahmet Veysel Polat, Elif Ozyazici Ozkan, Leman Tomak, Canan Aygun, Joseph Drew Tobias

DOI:10.4103/sja.SJA_413_18  

Background: Naso/Orogastric tube (NOGT) misplacement can lead to significant complications. Therefore, the assessment of tube position is essential to ensure patient safety. Although radiography is considered the gold standard for determining NOGT location, new methods may be helpful in reducing repetitive radiation exposure, especially for neonates. In this study, we sought to investigate if bedside ultrasonography (BUSG) can be used to verify NOGT placement in neonatal intensive care patients. Materials and Methods: Infants requiring NOGT placement were enrolled. After insertion of the NOGT, the location was first identified using BUSG and then confirmed using abdominal radiography for comparison. Results: The study cohort included 51 infants with an average gestational age of 34 ± 4.9 weeks. BUSG determined the NOGT location correctly with a sensitivity of 92.2%. The location of the NOGT could not be determined by BUSG in four neonates (7.8%). In one infant, the NOGT was positioned in the esophagus, as determined both by BUSG and radiography. Conclusion: BUSG is a promising diagnostic tool for determining NOGT location in neonates, thereby eliminating the need for abdominal radiography.

Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of Postoperative acute kidney injury (AKI) : Hydroxyethyl starch (HES) solutions,Stroke volume variation-guided tetrastarch,Ringer's lactate

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate 

Asha Tyagi, Gaurav Verma, Ankit Luthra, Shubham Lahan, Shukla Das, Gargi Rai, Ashok Kumar Sethi

DOI:10.4103/sja.SJA_410_18  

Background: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. Materials and Methods: Adults scheduled for orthopedic surgery under general anesthesia with >200–300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. Results: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. 

Conclusion: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.

Mitral regurgitation (MR)

Segmentation of jet area to quantity the severity of mitral regurgitation by color Doppler echocardiography p. 134

N Chidambaram, GN Balaji, TS Subashini

DOI:10.4103/jncd.jncd_50_18  

Mitral regurgitation (MR) is a disorder of mitral valve and it is one of the most common causes of cardiovascular morbidity and mortality. Mitral valve allows blood to flow from left atrium, to the left ventricle and Mitral Valve regurgitation results in poor apposition of the valvular leaflets, so that the heart's mitral valve doesn't close tightly, allowing blood to flow backward into the left atrium. Transthoracic Echocardiography (TTE) with Doppler is the widely used non-invasive technology for the detection and evaluation of severity of valvular regurgitation. Proximal isovelocity surface area (PISA) method has been widely accepted by clinicians as a means for grading MR severity. In this paper an alternate method to PISA to automatically quantify mitral valve regurgitation severity is proposed. This work attempts to automatically segment the jet region in color Doppler images using K-Means clustering. Further to quantify mitral regurgitation, jet area parameters and shape features are extracted from the segmented jet region which are then modeled using classifiers such as Support Vector machine (SVM) and Back Propagation Neural Network (BPNN). Quantifying MR with PISA calls for considerable expertise as a number of components must be taken into account to fully assess the severity of mitral regurgitation, however the results of the proposed method indicate that it could be used as an alternate method to automatically assess the severity of mitral regurgitation.

Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures

Osteonecrosis and nonunion as complication of fracture neck femur p. 23

Rudra P. S. Thakur, Alok C Agrawal, Bikas K Sahoo, Vishal K Kujur

DOI:10.4103/jodp.JODP_14_18  

Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. Fixation failure and nonunion are the main modes of failure following fixation of displaced or undisplaced femoral neck fractures. The two problems are difficult to distinguish as most displaced fractures take a long time to heal after fixation, which increases the risk of fixation failure. Avascular necrosis of the femoral head occurs in 9%–18% of patients, between 2 and 8 years postfracture. Risk factors include the degree of fracture displacement, patient age, and delay in surgical treatment.

Vascularity of femoral head

and its assessment after femoral neck fractures p. 1

Harshal Sakale, Alok C Agrawal, Bikram Keshri Kar, Bikas Sahoo, Sandeep K Yadav

DOI:10.4103/jodp.JODP_5_18  

Femoral neck fracture has an annual incidence of 1 per 1000 population; in young patients, functional prognosis is not good due to risk of osteonecrosis. Femoral head vascularity is mostly contributed by retinacular vessels and lateral epiphyseal artery. The vascular impact is due to displacement, interrupting retinacular vessel, interrupting ligament teres vascularization, and increased intracapsular pressure, producing a tamponade effect leading to osteonecrosis. This study reviewed the different methods of assessment of femoral head vascularity after femoral neck fractures. There are many techniques for the assessment of residual femoral head vascularity after femoral neck fractures and for the assessment of post-traumatic osteonecrosis risk. Some invasive techniques are superselective angiography, intraosseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others are noninvasive scintigraphy and conventional or dynamic magnetic resonance imaging (MRI). The future seems to lie with dynamic MRI, which gives new classification of femoral neck fractures, based on a noninvasive assessment of femoral head vascularity.

Orthodontic Rehabilitation

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Complications of mini-implant anchorage A Sumathi Felicita International Journal of Orthodontic Rehabilitation 2018 9(4):133-133

Analysis of facial pattern among 12–16-year-old students in Lagos, Nigeria Olawande A Ajisafe, Babatunde O Ogunbanjo, Kikelomo O Adegbite, Afolabi Oyapero International Journal of Orthodontic Rehabilitation 2018 9(4):134-140 Background: Facial patterns or biotypes have been known to influence the treatment plan of orthodontic patients and analyze the facial patterns described by Ricketts. Determining the facial type is extremely important for orthodontic diagnosis and planning since the muscular and skeletal configuration of each facial type responds differently to the orthodontic treatment. Materials and Methods: A sample of 100 individuals was recruited by multistage sampling from three schools in Ikeja local government, Lagos State. Those aged between 12 and 16 years who met the inclusion criteria were enrolled in the study after obtaining informed consent and assent from the parents and participants. Lateral cephalometric radiographs were taken for all participants, and the final sample after analysis of the radiographs was 84. The error of the cephalometric method was assessed using the intraclass correlation coefficient. Facial axis angle (Ptm-Gn/Ba-N) was used to classify the facial pattern into brachyfacial (<87°), mesofacial (87°–93°), and dolichofacial (>93°) Results: Out of the 84 participants, 60 (71.4%) had mesofacial facial pattern which consisted of 27 (32.1%) males and 33 (39.3%) females. 10 (11.9%) had brachyfacial pattern out of which 9 (10.7%) were male and 1 (1.2%) was a female. This difference between the males and females in the brachyfacial pattern was statistically significant with a P value of 0.014 (P ≤ 0.05). 14 (16.67%) participants had dolichofacial pattern with 5 (6.0%) males and 9 (10.7%) females. Conclusion: The mesofacial pattern had the highest frequency among the facial pattern types studied in this Nigerian population and was found to be more predominant among females. The brachyfacial pattern was seen more frequently in males while the dolichofacial pattern was more prevalent among females. The facial pattern assessment should guide the orthodontist in the use of appropriate mechanics to achieve an overall balanced occlusion and facial profile following orthodontic treatment.

Norms for anterior–posterior assessment of jaw relationship in Maharashtra population Niyati B Potode, Twinkle D Bajaj, Amol A Verulkar, Swapnil B Wankhade, Ratndeep A Lohakpure, Jimmy K Sangatani International Journal of Orthodontic Rehabilitation 2018 9(4):141-144 Background: Regularly used parameters for anteroposterior assessment of jaw relationships are ANB angle and Wits appraisal, and recently, beta angle, Yen angle, and W angle are introduced. ANB angle depends on the cranial landmarks and is affected by various factors and often can be misleading. The Wits appraisal does not depend on cranial landmarks, but still has the problem of correctly identifying the functional occlusal plane, which can sometimes be impossible. To overcome these problems, a new measurement, beta angle, was developed at Tufts University. The present study was carried out on Maharashtra population to derive norms of beta angle. Materials and Methods: For selection of sample, the lateral cephalograms were selected from the available patient's records, and the sample was divided into three groups based on the ANB angle, Wits appraisal, and profile. Conclusion: The norms of beta angle are between 28.5° and 36.5° in skeletal Class I pattern, <28.5° in skeletal Class II pattern, and >36.5° in skeletal Class III pattern.

Evaluation of the effect of moisture and saliva on the shear bond strength of brackets bonded with conventional bonding system and moisture insensitive primer: An in vitro study I Girish Kumar, A Bhagyalakshmi, BM Shivalinga, N Raghunath International Journal of Orthodontic Rehabilitation 2018 9(4):145-154 Introduction: Bonding of orthodontic attachments with acid etching is the most commonly used orthodontic procedure. However, there are certain limitations with acid etching procedure like/moisture contamination, etching time, the concentration of adhesive, etc., Moisture insensitive primers (MIPs) were introduced to overcome these limitations. Objectives: The aim of this study is to compare the shear bond strength of orthodontic brackets bonded with a MIP (Transbond MIP, 3M Unitek) against a conventional primer (Transbond XT, 3M Unitek) when contaminated with saliva – in vitro study. Methodology: Sixty maxillary premolars extracted for orthodontic purpose or due to periodontal involvement with sound buccal surfaces were collected, cleaned thoroughly, and stored in 0.1% (wt/vol) thymol at room temperature for 2 weeks. Following materials were used: Transbond XT Light cure adhesive (3M unitek), Transbond XT primer (3m unitek), Transbond MIP primer (3M unitek), and Metal brackets (3M unitek). A commercially available artificial saliva (AQWET, CIPLA) was used for contamination purpose. Ivoclarbluephase N LED light curing unit were used for curing purpose. Results: Mean bond strength was well above the clinically acceptable bond strength values indicating the use of these hydrophilic bonding materials in contaminated environments (8.5 Mpa for Transbond XT and 9.25 Mpa for Transbond MIP). On comparison of bond strengths of MIP and XT when contaminated with saliva, statistically significant values were obtained with contamination with saliva after primer application. There was a statistically significant increase in the bond strength after primer application (P = 0.233) and before and after primer application (P = 0.027*). Transbond MIP can be used to achieve adequate bond strength in saliva contaminated condition. Conclusion: Under dry condition, the shear bond strength of conventional primer (TRANSBOND XT) was significantly increased when compared to MIP. Under wet conditions MIP (TRANSBOND MIP) showed the highest shear bond strength and hence can be considered as a material of choice in wet conditions.

An overview of evidence-based dentistry and randomized controlled trials: Importance in the current orthodontic research Jasleen Kaur, Harpreet Kaur, Shikha Virdi International Journal of Orthodontic Rehabilitation 2018 9(4):155-158 Evidence-based dentistry (EBD) was developed to help dental care professionals in incorporating the current, valid, and bias-free research into their clinical practice. It is equally important to review and critically appraise the evidence before its adoption into clinical decision-making. In orthodontics, as there are emerging innumerable appliances, materials, and treatment approaches, there is an urgent need to conduct new trials to determine their effectiveness. Recently, randomized controlled trials (RCTs) are considered as the most powerful and strongest research design for the comparison of various treatment interventions. This article gives a brief overview about EBD and RCTs and their importance in the field of orthodontics.

Orthodontic consideration with patients with bleeding disorders Vaidehi N Arekar, Pushpak Ladhe, Apurva Nikte, Pawankumar Dnyandeo Tekale International Journal of Orthodontic Rehabilitation 2018 9(4):159-162 Orthodontist must be aware of the impact of bleeding disorders on the management of orthodontic treatment. Initial recognition of a bleeding disorder, which may indicate the presence of a systemic pathologic process, may occur in dental practice. Patients should be queried about any previous unusual bleeding episode after surgery or injury, spontaneous bleeding, and easy or frequent bruising. The purpose of this paper is to review bleeding disorders and their effects on the delivery of orthodontic treatment.

Nutrition and orthodontics Jeevan M Khatri, Vijaymala D Kolhe International Journal of Orthodontic Rehabilitation 2018 9(4):163-167 Orthodontic patients avoid many types of food, particularly fruits, raw vegetables, and other hard and tough foods, as they cannot chew these properly because of pressure sensitivity of the teeth in the initial 3–5 days period after routine. As a result, such individuals consume significantly less proteins and other key nutrients, fiber, calcium, nonhem iron, and some vitamins. This article presents an overview of the relationship between diet and orthodontic treatment. The nutritional guidelines to obtain good oral and general health in orthodontic patients are discussed.

Treatment of Class II division 1 malocclusion using forsus fatigue-resistant device S B V Ramana Reddy, Venkata Naga Sravanthi Jonnalagadda International Journal of Orthodontic Rehabilitation 2018 9(4):168-172 Functional orthopedic appliances are mostly used to treat Class II malocclusion originated from mandibular retrusion. Removable or fixed functional appliances are available to advance the mandible. Fixed appliances can be treated in tandem with multibarcket therapy, thus making it a single-phase treatment. The major disadvantage of fixed functional appliances is proclination of lower anterior teeth. To reduce this proclination, miniplates or miniimplants are being used; negative torque is added to the lower incisors. Despite these additions, the proclination could not be eliminated but minimized. This case report documents the successful treatment of skeletal Class II in late stages of puberty using forsus fatigue resistance appliance with soldered hooks placed distal to the lower canines.

Orthopaedic Diseases and Traumatology

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Vascularity of femoral head and its assessment after femoral neck fractures Harshal Sakale, Alok C Agrawal, Bikram Keshri Kar, Bikas Sahoo, Sandeep K Yadav Journal of Orthopaedic Diseases and Traumatology 2018 1(1):1-4 Femoral neck fracture has an annual incidence of 1 per 1000 population; in young patients, functional prognosis is not good due to risk of osteonecrosis. Femoral head vascularity is mostly contributed by retinacular vessels and lateral epiphyseal artery. The vascular impact is due to displacement, interrupting retinacular vessel, interrupting ligament teres vascularization, and increased intracapsular pressure, producing a tamponade effect leading to osteonecrosis. This study reviewed the different methods of assessment of femoral head vascularity after femoral neck fractures. There are many techniques for the assessment of residual femoral head vascularity after femoral neck fractures and for the assessment of post-traumatic osteonecrosis risk. Some invasive techniques are superselective angiography, intraosseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others are noninvasive scintigraphy and conventional or dynamic magnetic resonance imaging (MRI). The future seems to lie with dynamic MRI, which gives new classification of femoral neck fractures, based on a noninvasive assessment of femoral head vascularity.

Classification of fracture neck of femur Bikas Sahoo, Alok C Agrawal, Bikram K Kar, Harshal Sakale, Sandeep K Yadav, Sameer Mittal Journal of Orthopaedic Diseases and Traumatology 2018 1(1):5-7 There are numerous classification systems for fracture neck of femur in adults. A fracture classification is proposed either for taxonomical purpose, characterization, guiding intervention, or predicting outcomes of intervention. The classifications described in this chapter are needed to decide on choice of implant, stability, acceptability of reduction, vascularity and long term prognosis.

Early management of fracture neck of femur Abhishek Jain, Alok C Agrawal, Bikas K Sahoo, Sandeep K Yadav, Bikram Keshri Kar, Harshal S Sakale Journal of Orthopaedic Diseases and Traumatology 2018 1(1):8-10 Femoral neck fracture is considered a medical emergency as an early fixation helps in getting an accurate reduction, preservation of blood supply, removal of tamponade within the capsule, and early mobilization. This article deals with the science of early management of femoral neck fractures.

Pediatric fracture neck of femur Sandeep K Yadav, Alok C Agrawal, Bikram Keshri Kar, Harshal S Sakale, Bikas Sahoo, Rahul K Chandan Journal of Orthopaedic Diseases and Traumatology 2018 1(1):11-14 The incidence of hip fractures in children about 1% of total pediatric fractures. The most common cause is a high-energy trauma, such as motor vehicle accidents and falls from a height. In old cases, magnetic resonance imaging (MRI) may be needed to assess the vascularity of femoral head. Hip fractures can have deep impact on the development of hip. Vascularity of femoral head plays a vital role in the management of femoral neck fracture. The paper deals with the cited complications related to femoral neck fracture like avascular necrosis (AVN), nonunion, mal-union, and premature closure of the proximal femoral physis, leading to leg length discrepancy.

Delayed diagnosed femoral neck fractures Bikram K Kar, Alok C Agrawal, Sandeep K Yadav, Harshal Sakale, Bikas Sahoo Journal of Orthopaedic Diseases and Traumatology 2018 1(1):15-20 Treatment of displaced femoral neck fractures includes internal fixation with/without graft supplementation or internal fixation plus osteotomy or arthroplasty. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in patients with displaced femoral neck fractures who present delayed, treated either by internal fixation or arthroplasty. The purpose of our study was to summarize the management protocol of fracture of neck of femur when they present at different duration and at different stage.

Neglected fracture neck of femur: Our experience Alok C Agrawal Journal of Orthopaedic Diseases and Traumatology 2018 1(1):21-22 Fracture neck of femur continues to be neglected in rural India. Several salvage options tried in the past are now out of local interest in favor of some sort of arthroplasty. Although the long-term viability of this policy is not known, only the future will guide to a definite path.

Osteonecrosis and nonunion as complication of fracture neck femur Rudra P. S. Thakur, Alok C Agrawal, Bikas K Sahoo, Vishal K Kujur Journal of Orthopaedic Diseases and Traumatology 2018 1(1):23-28 Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. Fixation failure and nonunion are the main modes of failure following fixation of displaced or undisplaced femoral neck fractures. The two problems are difficult to distinguish as most displaced fractures take a long time to heal after fixation, which increases the risk of fixation failure. Avascular necrosis of the femoral head occurs in 9%–18% of patients, between 2 and 8 years postfracture. Risk factors include the degree of fracture displacement, patient age, and delay in surgical treatment.

Failure of fixation of fracture neck of femur and remedies for management Sameer Mittal, Alok C Agrawal, Bikram K Kar, Harshal Sakale, Bikas Sahoo, Sandeep K Yadav Journal of Orthopaedic Diseases and Traumatology 2018 1(1):29-32 Failure of fixation is common complication of fracture neck of femur, more common in displaced fractures than in undisplaced fractures. Early diagnosis and treatment of fixation failure is very important for good outcome. Physiological age of patient, status of the hip joint, viability of the femoral head, and presence of occult infection are the factors that should be considered before deciding the suitable salvage procedure. In patients younger than 50 years, preservation of the femoral head is preferred as salvage treatment. Hemiarthroplasty or total hip arthroplasty is the choice of salvage for femoral neck fracture nonunions in physiologically older patients.

Do we need internal fixation devices for giant cell tumors around knee joint? An outcome study Ritesh Runu, Vidya Sagar, Ashutosh Kumar, Arnab Sinha, Santosh Kumar Journal of Orthopaedic Diseases and Traumatology 2018 1(1):33-37 Introduction: Giant cell tumors around the knee joint are the most common aggressive benign tumors. Several limb sparing and limb ablation surgeries are practiced with varying level of success. Here we present an original outcome study conducted on 14 patients with giant cell tumor around the knee joint, treated with intralesional curettage, bone grafting and bone cementing with or without internal fixation. Material and Methods: This is a retrospective study carried out in an institutional set up. Fourteen patients were operated and Internal fixation was used in five cases. the patients were followed up for 2 years minimum. Results: Total fourteen patients were treated with giant cell tumors around knee joint. Phenol cauterization showed reduced recurrence compared to no phenol cauterization. Collapse was noted in cases done with curettage and only cementing or only bone grafting. plating group showed no collapse. No collapse was noted in cases with subchondral bone more than 5 mm. Conclusion: For giant cell tumor, campannaci grade III, internal fixation is suggested if subchondral bone is less than 5 mm and articular involvement is more than 50%.

Dome osteotomy in cubitus varus: Our results Ashutosh Kumar, Vidya Sagar, Pawan Kumar, Deepak Kumar, Ritesh Runu, Gaurav Khemka Journal of Orthopaedic Diseases and Traumatology 2018 1(1):38-42 Introduction: Cubitus varus (gunstock deformity) is the most common complication of supracondylar fracture of the humerus. Several osteotomies and various fixation techniques are described for its correction. The most commonly used is the lateral closing-wedge osteotomy, also known as French osteotomy with variable results. Persistent lateral condyle prominence leads to cosmetically unacceptable appearance and poor patient satisfaction. To avoid this problem, dome osteotomy is performed. We have evaluated results of dome osteotomy in our population. Material and Methods: This was a retrospective study carried out in our institute. Ten patients with cubitus varus treated by dome osteotomy were evaluated at 24 months. All patients were operated by triceps-splitting approach. Pre- and postoperative carrying angle of elbow, range of motion, and lateral condyle prominence index were compared according to Banerjee criteria. Results: Ten patients with average age of 9.1 years were followed up for 2 years. Mean gap between injury and surgery was 15 months. Postoperative improvement in carrying angle and lateral condylar prominence index was significant. One case developed ulnar neuropraxia, which recovered fully within 2 weeks. Pin tract infection was seen in three cases and skin infections in two cases. Conclusion: Dome osteotomy is a technically demanding surgery. The functional and cosmetic correction is better compared to that for French osteotomy.

Noncommunicable Diseases

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Noncommunicable diseases surveillance in India: Moving toward a more comprehensive approach Jai Prakash Narain, KR Thankappan International Journal of Noncommunicable Diseases 2018 3(4):111-114

Diabetic care delivery with package of essential noncommunicable diseases interventions protocol in rural Nepal: A district hospital-based study Pawan Agrawal, Priyanka Gupta, Bikash Gauchan, Biplav Shrestha International Journal of Noncommunicable Diseases 2018 3(4):115-119 Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization's Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow-up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty-six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow-up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions.

Health professionals' perspectives on factors needed to implement nutrition strategy: A questionnaire validation study Reem Saleh Al Gurg, Mohammed Alameddine, Amar Hassan Khamis International Journal of Noncommunicable Diseases 2018 3(4):120-125 Background: Noncommunicable diseases (NCDs) increasingly recognized as a serious, worldwide public health concern. According to the WHO, NCDs are currently responsible for two-thirds of global deaths annually. Nutritional food and unhealthy diet are contributing to an immense portion of NCDs. Exploring the role of nutrition in healthcare delivery with a particular focus on the United Arab Emirates (UAE) context is also aligned with the UAE Government's Vision 2021. Aim: To develop a reliable and valid questionnaire that helps to assess the agreement about factors needed to implement a nutrition strategy in the UAE. Materials and Methods: One hundred and sixty-one health professionals were invited to respond to a questionnaire assessing agreement with factors needed to implement a nutrition strategy. The questionnaire consisted of 11 factors, each containing four items that made a total of 44 items assessed on a 7-point Likert scale (1 strongly disagree to 7 strongly agree). The questionnaire was evaluated using factor analysis, and Cronbach's alpha was used to test the internal consistency of the responses of participants. Ethical approval was given by the Chair of Humanities and Health Sciences Research Ethics Panel (UAE). Results: The questionnaire was validated by an expert panel. A factor analysis was carried out through responses of the health professional and revealed that the 11 factors are included in the questionnaire; only one item from the factor of resources and enablement was excluded: the exclusion of the item “hospital uses the lifespan approach in nutrition interventions” due to singularity and insufficient load of the variance extracted. Conclusion: The study concluded that the questionnaire was valid and reliable on its form of 43 items divided into 11 factors to assess the agreement toward factors needed to implement a nutrition strategy in the UAE.

Effectiveness of "percutaneous coronary intervention care program" on selected variables among patients undergoing percutaneous coronary intervention Poonam Sharma, Sandhya Ghai, Manoj Kumar Rohit, Monika Dutta International Journal of Noncommunicable Diseases 2018 3(4):126-133 Objective: The study was conducted to assess the effectiveness of “percutaneous coronary intervention (PCI) care program” among patients undergoing PCI. Subjects and Methods: A quasi-experimental design was adopted, and purposive sampling technique was used to enroll the patients in the experimental and control groups. Different tools were used to collect the data, which include numerical pain and comfort rating scale, Barthel Index for activities of daily living, assessment for the presence of vascular complications, modified CADEQ-SV questionnaire, State-Trait Anxiety Inventory scale, self-structured satisfaction scale, and PCI manual. Results: There was a significant decrease observed in state anxiety (P < 0.001), pain level at 12 h (P = 0.03), discomfort within 12 h (P < 0.001) and 24 h (P = 0.002), improving knowledge regarding coronary artery disease (CAD) (P < 0.001), and activities of daily living as well as significant increase in satisfaction level (P < 0.001) among patients undergoing PCI in the experimental group than the control group. Conclusion: The study concluded that this program was effective in reducing anxiety, pain, and discomfort and increased satisfaction level, knowledge regarding CAD, and independence in self-care activities for PCI patients.

Segmentation of jet area to quantity the severity of mitral regurgitation by color Doppler echocardiography N Chidambaram, GN Balaji, TS Subashini International Journal of Noncommunicable Diseases 2018 3(4):134-138 Mitral regurgitation (MR) is a disorder of mitral valve and it is one of the most common causes of cardiovascular morbidity and mortality. Mitral valve allows blood to flow from left atrium, to the left ventricle and Mitral Valve regurgitation results in poor apposition of the valvular leaflets, so that the heart's mitral valve doesn't close tightly, allowing blood to flow backward into the left atrium. Transthoracic Echocardiography (TTE) with Doppler is the widely used non-invasive technology for the detection and evaluation of severity of valvular regurgitation. Proximal isovelocity surface area (PISA) method has been widely accepted by clinicians as a means for grading MR severity. In this paper an alternate method to PISA to automatically quantify mitral valve regurgitation severity is proposed. This work attempts to automatically segment the jet region in color Doppler images using K-Means clustering. Further to quantify mitral regurgitation, jet area parameters and shape features are extracted from the segmented jet region which are then modeled using classifiers such as Support Vector machine (SVM) and Back Propagation Neural Network (BPNN). Quantifying MR with PISA calls for considerable expertise as a number of components must be taken into account to fully assess the severity of mitral regurgitation, however the results of the proposed method indicate that it could be used as an alternate method to automatically assess the severity of mitral regurgitation.

Decoding increasing prevalence of noncommunicable diseases Alok K S Thakur International Journal of Noncommunicable Diseases 2018 3(4):139-144 Background: In recent times, noncommunicable diseases (NCDs) have attained epidemic status in India and several other countries. Globally, each year, NCDs cause premature deaths of nearly 40 million people younger than 60 years accounting for 70% of all deaths; 80% of these premature deaths are reportedly in the low- and middle-income countries. Many studies have reported increasing prevalence of NCDs such as type 2 diabetes, coronary and pulmonary diseases, and cancer. Incidentally, all these studies besides discussing environmental pollution have grossly ignored dietary profiling of affected populace despite the fact that several studies have established a direct correlation between food quality and good health. Objective: Besides pollutants, an attempt is made to analyze mathematically effects of dietary changes over the last four decades on constantly increasing prevalence of NCDs at cellular level. A relationship seems to exist between increasing prevalence of NCD and large-scale consumption of synthetic salt. Conclusions: Elimination of essential trace elements and micro- and macro-minerals in regular diet through synthetic salt fortified with iodine alone appears to cause more harm than benefits associated with iodization of salt than pollutants. Regular intake of essential trace elements is necessary for normal functioning of many fundamental functions of the body such as Na-K pump, electron–proton transport, biochemistry, and thermodynamics. An attempt has been made to study effects of salt constituents used in food at the most fundamental cellular level by means of disturbances in body electrolyte through heat and ion transport mechanism that is fundamental to various underlying processes in human body. Interestingly, almost all the families who switched over to unprocessed rock salt from synthetic iodized salt reported improvement in general health and reported reduction in medical visits.

Anaesthesia

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Erector spinae plane block: New block with great expectations Can Aksu, Yavuz Gürkan Saudi Journal of Anaesthesia 2019 13(1):1-2

Physiological and operative severity score for the enumeration of mortality and morbidity, frailty, and perioperative quality of life in the elderly Maria João M. Lima, Daniela F M Cristelo, Joana B Mourão Saudi Journal of Anaesthesia 2019 13(1):3-8 Background: Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a validated instrument used to predict morbidity. The aim of our study was to evaluate the performance of the POSSUM score system on predicting perioperative frailty and quality of life (QOL) in elderly surgical patients. Patients and Methods: An observational prospective study was conducted during 3 months. POSSUM was used to determine operative morbidity risk. Patients with a POSSUM score ≥26 were considered as having a high POSSUM (PHP). WHODAS 2.0, EuroQOL-5 dimensions (EQ-5D), Charlson score, and the Clinical Frailty Scale were used to assess the QOL and frailty. Chi-square, Fisher's exact, or Mann–Whitney tests were used for comparisons. Results: Two hundred and thirty-five patients were included. Median age was 69 years; 58% were ASA I/II and 42% ASA III/IV. Frailty was present in 53 patients (23%). Median POSSUM score was 26. Patients PHP were older (median age 71 vs. 68, P = 0.008), more frequently ASA III/IV (P = 0.001), had higher median Charlson scores (7 vs. 5, P = 0.006) and were more frail (49% vs. 26%, P < 0.001). PHP presented more problems in EQ-5D dimensions preoperatively (mobility: 59% vs 41%, P = 0.008; care: 41% vs. 25%, P = 0.013; activity: 52% vs. 32%, P = 0.002; pain: 59% vs. 45%, P = 0.041) but not anxiety (P = 0.137). Three months after surgery, PHP patients presented more problems in mobility: 63% vs. 38%, P < 0.001; care: 48% vs. 31%, P = 0.009; activity: 58% vs. 44%, P = 0.036; pain 59% vs. 37%, P = 0.001 and anxiety: 54% vs. 50%, P = 0.025. Conclusions: Patients PHP were frailer and had worse perioperative QOL.

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate Asha Tyagi, Gaurav Verma, Ankit Luthra, Shubham Lahan, Shukla Das, Gargi Rai, Ashok Kumar Sethi Saudi Journal of Anaesthesia 2019 13(1):9-15 Background: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. Materials and Methods: Adults scheduled for orthopedic surgery under general anesthesia with >200–300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. Results: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. Conclusion: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.

The quality of life and satisfaction rate of patients with upper limb hyperhidrosis before and after bilateral endoscopic thoracic sympathectomy Waseem M Hajjar, Sami A Al-Nassar, Heba M Al-Sharif, Dana M Al-Olayet, Wejdan S Al-Otiebi, Alanoud A Al-Huqayl, Adnan W Hajjar Saudi Journal of Anaesthesia 2019 13(1):16-22 Background: Hyperhidrosis is a functional disorder identified by excessive sweating. Its incidence is approximately 1% in any population. Bilateral endoscopic thoracic sympathectomy (BETS) intervention is the definitive treatment of choice for palmar and axillary hyperhidrosis. Aims and Objectives: The purpose of this study is to evaluate and compare the quality of life (QOL) and satisfaction rate of patients with upper limb hyperhidrosis before and after BETS surgery and the influence of compensatory hyperhidrosis (CH) on patients' QOL after surgery. Settings and Design: This study is a cross-sectional study designed to generate longitudinal data. Subjects and Methods: This study is a cross-sectional study designed to generate longitudinal data pre- and postbilateral BETS prospectively. This study was conducted in the surgery department of University Hospital in Riyadh, Saudi Arabia. Hundred patients with upper limb hyperhidrosis who underwent BETS from 2014 to 2017 were included. A modified and validated QOL questionnaire for hyperhidrosis was completed by the patients themselves in order to compare the QOL for patients both before and after BETS. Patients' satisfaction and the occurrence of CH were obtained postoperatively. Statistical Analysis Used: Data were analyzed using the SPSS® statistical package for social studies, version 22.0 (SPSS 22; IBM Corp., New York, NY, USA) for Windows®. Results: A total of 100 patients completed the questionnaire; 94% of patients had a positive QOL outcome after the surgery. The mean decrease in QOL scores was −42.0 points toward better QOL. The site of sweating had a significant effect on the patients' QOL before and after the surgery (P value < 0.001). Moreover, 76% of patients reported a high satisfaction rate. Conclusion: Primary hyperhidrosis can negatively impair patients' QOL in different domains. BETS showed to be an effective option for improving the QOL of patients and it provided both short- and long-term effectiveness in treating upper limb hyperhidrosis. CH did not interfere with the rate of patient satisfaction or their QOL postoperatively.

Bedside ultrasonography for the confirmation of gastric tube placement in the neonate Yunus Oktay Atalay, Ahmet Veysel Polat, Elif Ozyazici Ozkan, Leman Tomak, Canan Aygun, Joseph Drew Tobias Saudi Journal of Anaesthesia 2019 13(1):23-27 Background: Naso/Orogastric tube (NOGT) misplacement can lead to significant complications. Therefore, the assessment of tube position is essential to ensure patient safety. Although radiography is considered the gold standard for determining NOGT location, new methods may be helpful in reducing repetitive radiation exposure, especially for neonates. In this study, we sought to investigate if bedside ultrasonography (BUSG) can be used to verify NOGT placement in neonatal intensive care patients. Materials and Methods: Infants requiring NOGT placement were enrolled. After insertion of the NOGT, the location was first identified using BUSG and then confirmed using abdominal radiography for comparison. Results: The study cohort included 51 infants with an average gestational age of 34 ± 4.9 weeks. BUSG determined the NOGT location correctly with a sensitivity of 92.2%. The location of the NOGT could not be determined by BUSG in four neonates (7.8%). In one infant, the NOGT was positioned in the esophagus, as determined both by BUSG and radiography. Conclusion: BUSG is a promising diagnostic tool for determining NOGT location in neonates, thereby eliminating the need for abdominal radiography.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study Eman Ramadan Salama, Doaa El Amrousy Saudi Journal of Anaesthesia 2019 13(1):28-34 Background and Objective: Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia. Materials and Methods: Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded. Results: TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5–28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8–32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45–100 and median = 82.4, range 10–100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt. Conclusion: In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

Comparative evaluation of two approaches of infraclavicular brachial plexus block for upper-limb surgeries Chandni Sinha, Neeraj Kumar, Amarjeet Kumar, Ajeet Kumar, Anup Kumar Saudi Journal of Anaesthesia 2019 13(1):35-39 Background: Infraclavicular approach is a common technique of brachial plexus block. The main difficulty of ultrasound guided technique is in needle visualization due to deep location of the cords. Hebbard et al described a retroclavicular approach wherein the needle was inserted posteriorly to the clavicle. Materials and Methods: In this prospective randomized controlled study, we have compared the classical technique with the retroclavicular approach in terms of needle visibility, block success rate, number of needle passes, block performance time, procedure-related pain, complications, patient and operator comfort and satisfaction. Results: The rate of block success was similar in both the groups. The needle tip and shaft visibility was more in the retroclavicular group (P < 0.05). The number of needle passes was also less in the retroclavicular group. Time for the block procedure was less in retroclavicular group when compared to the classical coracoid group. The patients reported less pain in retroclavicular group (P < 0.05). Discussion: Retroclavicular approach is a feasible option of infraclavicular brachial plexus block in Indian Subpopulation in terms of needle visibility and block success rate.

Respiratory mechanics with volume-controlled auto-flow ventilation mode in cardiac surgery* Murat Arslan, Elvan Öçmen, Seden Duru, Belkis Şaşmaz, Şule Özbılgın, Hasan Hepağuşlar Saudi Journal of Anaesthesia 2019 13(1):40-45 Aim: We aimed to investigate the changes in respiratory mechanics in adult patients undergoing open heart surgery (OHS) while using volume-controlled auto-flow (VCAF) ventilation mode. Materials and Methods: After obtaining ethics committee's approval and informed consent, 30 patients (17 males and 13 females; mean age: 57.3 ± 17.0 years; mean weight; 74.9 ± 13.6 kg) scheduled for OHS were enrolled. Mechanical ventilation was carried out using VCAF mode (VT: 5–8 mL/kg, I/E: 1/2, 10 ± 2 fr/min). Values of dynamic compliance (Cdyn) and resistance (R) were obtained at six time points (TPs). Normally distributed variables were analyzed with repeated measure of analysis of variance and Bonferroni tests. For abnormally distributed variables, Friedman variance analysis and Wilcoxon signed-rank tests were used. Values were expressed as mean ± standard deviation. P value <0.05 was considered significant. Results: Cdyn (mL/mbar) and R (mbar/L/s) values were as follows – (1) before sternotomy (S): 49.9 ± 17.1 and 7.8 ± 3.6; (2) after S: 56.7 ± 18.3 and 7.1 ± 3.7; (3) after S and after sternal retractor placement: 48.7 ± 16.1 and 8.3 ± 4.4; (4) after weaning from cardiopulmonary bypass and following decannulation while retractor was in place: 49.6 ± 16.5 and 8.1 ± 4.0; (5) after retractor removal: 56.5 ± 19.6 and 7.4 ± 3.7; and (6) after sternal closure: 43.1 ± 14.2 and 9.6 ± 9.1, respectively. Significant differences were observed in Cdynand R between; first and second TPs, second and third TPs, fourth and fifth TPs, and fifth and sixth TPs. Also, significant difference in Cdynwas found between first and sixth TPs, but it was not found in R. Conclusion: Cdyndecreases, but R remains the same in cardiac surgical patients when mechanical ventilation is performed with VCAF ventilation mode. Additionally, Cdynis negatively affected by the presence of sternal retractor and the sternal closure in OHS.

Outcome prediction with physiological and operative severity score for the enumeration of mortality and morbidity score system in elderly patients submitted to elective surgery Diana F Torres Lima, Daniela Cristelo, Pedro Reis, Fernando Abelha, Joana Mourão Saudi Journal of Anaesthesia 2019 13(1):46-51 Context: Elderly patients have a higher risk of complications and 30-day mortality than younger patients. Population is aging and this is an emergent preoccupation. Aims: The aim of this study was to evaluate the performance of Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) system on 30-day mortality in elderly patients submitted to elective surgery. Additionally, the correlation of WHODAS 2.0 and Clinical Frailty Score (CFS) with mortality was evaluated. Settings and Design: An observational prospective study was conducted between May and July 2017. Methods and Material: Patients submitted to elective orthopedic, gynecologic, urologic, vascular, plastic, and general surgery were included. Exclusion criteria were as follows: age <60 years old; inability to give informed consent; emergency/urgency surgery, inability to understand Portuguese; patients admitted in the ICU after surgery. POSSUM was used to estimate postoperative mortality risk. WHODAS 2.0 and CFS were used to assess quality of life and health status. Mortality was evaluated during hospital stay and 30 days after surgery. area under the receiver operating characteristic (AUROC) was analyzed to test the discrimination of P-POSSUM, WHODAS 2.0 and CFS scale. Statistical Analysis Used: Statistical analysis was done using the SPSS Software (version 24.0). Results: POSSUM-predicted mortality was 3.0% with a standardized mortality ratio = 0.87; 95% CI 0.62–0.93; and a good calibration (H–L: P = 0.646); however, the AUROC was poor (0.563). We identified an association between mortality and a higher CFS grade (P = 0.000 and AUROC = 0.859) and a higher WHODAS 2.0 score (P = 0.000 and AUROC = 0.808). Conclusions: WHODAS and CFS appear to be a better assessment tolls for predicting postoperative mortality with a good discrimination comparing with P-POSSUM system.

Comparative study of mid-thoracic spinal versus epidural anesthesia for open nephrectomy in patients with obstructive/restrictive lung disease: A randomized controlled study Nazmy Edward Seif, Ahmed Mohamed ELbadawy Saudi Journal of Anaesthesia 2019 13(1):52-59 Background: The aim of this randomized controlled study is to compare the safety and efficacy of thoracic spinal versus thoracic epidural anesthesia for open nephrectomy in patients with obstructive/restrictive lung disease. Methods: Sixty patients with mild to moderate chronic obstructive/restrictive lung disease undergoing open nephrectomy were randomized into two groups, 30 patients each. The thoracic spinal group (TSA) group received ultrasound guided mid-thoracic spinal anesthesia, and the thoracic epidural group (TEA) group received thoracic epidural anesthesia. All blocks were performed at the T7-T8. Hemodynamics, visual analogue scale score, sensory and motor block profile as well as any adverse events, and patient satisfaction were all reported. Results: Both blocks were successfully performed and were effective for surgery in all patients, with the exception of only one patient in TSA group who needed to receive general anesthesia even after IV midazolam because of extreme anxiety and was excluded from the study analysis. The sensory block ranges were quiet close, with T2-T5 for the TSA group and T3-T6 for the TEA group as the upper level and L3-L5 as the same lower level. The values for the onset time and the duration of sensory and motor blocks were lower in TSA group. There were no statistically significant differences existed in intraoperative VAS, and hemodynamics between the two groups. Postoperative adverse effects were negligible and insignificant, with no case reporting any neurological sequel. Conclusion: Ultrasound guided thoracic spinal anesthesia can be performed safely and effectively for open nephrectomy in patients with obstructive/restrictive lung disease with the potential for an early ambulation and great patient satisfaction.

Treatment of Keloid Scars with Botulinum Toxin A Versus Triamcinolone in an Athymic Nude Mice Animal Model

Background: Keloid scarring is a serious condition that mostly affects patients of African or Asian descent. Often disfiguring, this condition can have devastating psychosocial consequences. To date, no treatment modality has been proven ideal. Our objectives were 1. To determine the efficacy of botulin toxin A injection for the treatment of keloid scars compared to steroid injection and to control saline injection. This was achieved through a basic science animal model using athymic nude mice and implanted human keloid tissue. 2. To analyze the histopathological changes that occur in an organized keloid scar following botulinum toxin A injection as compared to steroid and saline injections. Methods: Keloid scars from four patients were excised and implanted subcutaneously into 28 mice. Three small keloid tissue samples were implanted in each of the 28 mice. One week after implantation, each implant received one of three injections: botulinum toxin A (treatment drug), saline (control) or steroid injection (first line gold standard). The keloid tissue was extracted three weeks post implantation. Weight analysis, immunohistochemistry, and standard hematoxylin and eosin (H&E) pathology were performed on each extracted tissue sample. Results: Pre-post tissue weights paired t-test analysis revealed a statistically significant difference between the treatment and control groups (p

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Nonsyndromic unilateral coronal synostosis: A comparison of fronto-orbital advancement and endoscopic suturectomy

Background: Comparative effectiveness research is needed to optimize treatment of unilateral coronal synostosis (UCS). This study compares perioperative morbidity, ophthalmic, and aesthetic outcomes of patients with nonsyndromic UCS treated by endoscopic suturectomy (ES) or front-orbital advancement (FOA). Methods: From 2004-2015, patients with UCS were reviewed and data recorded for: operative details, re-operations, aesthetic result using Whitaker classification, severity of strabismus and need for surgical correction. Categorical data were analyzed by Fisher exact test and continuous data analyzed by Wilcoxon rank-sum test. Results: Ninety-four patients were treated with ES (n= 60) or FOA (n=34). Median age of follow-up was 3.5yrs (1-9) for ES and 5.0yrs (2-11) for FOA (p=0.06). The ES group had a lower operative time (42 vs. 216 mins), length of stay (1 vs. 4 days), blood loss (25 vs. 260cc), and transfusion rate (0% vs. 88%). Two patients treated with FOA required secondary intervention for intracranial pressure. Thirty-one percent (16/52) of the ES group and 65% (19/29) of the FOA group developed clinically significant strabismus requiring surgical repair (p=0.002). In the ES group, 88% (50/57) were Whitaker class I and 5% class II. In the FOA group, 41% (14/34) were class I and 44% class II. Need for bony revision (2/57 vs. 3/34) and secondary cranial procedure (2/57 vs. 2/34) was similar following ES and FOA. Conclusion: For treatment of UCS, ES is associated with lower morbidity and comparable aesthetics. Patients treated with ES are half as likely to require strabismus surgery compared to those treated with FOA. * Joint senior authorship Presented at: International Society of Craniofacial Surgery meeting, Cancun, Mexico, 2017. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Corresponding Author: Kathryn V. Isaac, MD, 300 Longwood Avenue, Boston, Massachusetts, USA. kisaac@hsph.harvard.edu ©2018American Society of Plastic Surgeons

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“Quality of Randomized Controlled Trials for Surgical Treatment of Carpal Tunnel Syndrome: A Systematic Review”

BACKGROUND: Randomized controlled trials (RCTs) are considered the gold standard in evidence-based medicine. We conducted a systematic review to evaluate the quantity, quality, and trends of RCTs that assess surgical treatment of carpal tunnel syndrome (CTS). METHODS: We identified RCTs comparing two or more surgical interventions for CTS in PubMed, Cochrane, Scopus, Google Scholar, and Clinicaltrials.gov. Two independent reviewers evaluated manuscripts for inclusion, extracted data, and assessed RCT quality using the Jadad score. RESULTS: Of 2,253 identified studies, 58 met full inclusion criteria. They were published between 1985–2015, with a significant increase over time (p=0.003). They were most frequently published in Journal of Hand Surgery (European Volume) (n=15, 25.9%). Most RCTs were single-center studies (n=54, 93.1%) conducted in the UK (n=13, 22.4%) or the US (n=10, 17.2%), with a mean study size of 80.1±55.5 patients. Funding source was unknown in 62.1% (n=36). Three-quarters (n=44, 75.9%) of RCTs did not define primary outcome measure(s).

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“Round versus anatomical implants in primary cosmetic breast augmentation: a meta-analysis and systematic review”

Background: Choosing implant shape (round or anatomical) is one of the most essential yet controversial decisions in cosmetic breast augmentation. Many surgeons choose implant shape based on personal experience or expert opinion. This is the first systematic review and meta-analysis comparing the aesthetic effect between anatomical and round implants in primary cosmetic breast augmentation. Methods: The authors searched the PubMed, MEDLINE, Embase, ScienceDirect, Web of Knowledge, Scopus, and Cochrane Central Register of Controlled Trials for studies that compared anatomical and round implants in primary cosmetic breast augmentation. Primary outcomes were postoperative aesthetic effect and correct identification rate of implant shape. Random effects models were used to obtain pooled standardized mean difference (SMD) and 95% confidence intervals (CIs). This systematic review has been registered with the international prospective register of systematic reviews (PROSPERO): CRD 42017079948. Results: One randomized comparative and four observational comparative studies met the inclusion criteria. No aesthetic superiority was found in the anatomical implant group with regard to overall look (SMD 0.06, 95% CI -0.40 to 0.53), naturalness (SMD -0.18, 95% CI -1.51 to 1.15), projection, upper pole contour, and lower pole contour. Pooled correct identification rate of implant shape by plastic surgeons was 52% (95% CI 0.46 to 0.58). Conclusion: Generally, anatomical implants do not seem to have an aesthetic superiority than round implants. Plastic surgeons seemed to be unable to accurately differentiate the two implant shapes in vivo. Further studies should focus on identifying the specific indications for the use of anatomical implants. Financial Disclosure Statement: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Acknowledgement: We thank Mr. Yinmeng Zhang in Schooli of International Studies, Communication school of China for English language assistance. Corresponding author: Ying Cen, MD, PhD., Department of Plastic& Burn Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China. cen_ying@126.com ©2018American Society of Plastic Surgeons

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Survival after digit replantation and revascularization is not affected by the use of interpositional grafts during arterial repair

Introduction: Interpositional grafts (IG) can be used to reconstruct the digital artery during revascularization and replantation when primary repair is not possible. The purpose of this study is to determine the effect of using interpositional graft on rates of digit survival. Methods: A retrospective review of all patients from 2007 to 2016 that required revascularization and/or replantation of one or more digits was performed. Results: 127 patients were identified with 171 affected digits (118 digital revascularizations, 53 digital replantation). A graft was used to repair the digital artery in 50% (59 of 118) of revascularizations and in 49% (26 of 53) of replantations. There was no difference in digit survival with use of an IG for arterial repair vs. primary repair in revascularization (91.5% in both groups) or replantation (48.1% vs. 46.2%, p = 0.88). Regression analysis demonstrated no association between use of IG and digit survival. The source of IG did not have any effect on digit survival (p=0.97). IG was more likely to be used in crush (62.5%) and avulsion injuries (72.2%) compared to sharp laceration injuries (11.1 %) with RR = 5.6 (p=0.01) and RR = 6.5 (p=0.006) respectively. Conclusion: There was no difference in the survival rate of amputated digits that required IG for arterial repair. The need for an IG in a large zone of injury should not be considered a contraindication to performing revascularization or replantation. Furthermore, hand surgeons should have a low threshold for using IG especially in crush or avulsion injuries. * The first two authors contributed equally to this manuscript. Disclosure: The authors have no financial interest to declare in relation to the content of this work. Meeting at which paper was presented: American Society for Surgery of Hand, 72nd Annual Meeting of the ASSH, September 7-9, 2017, San Francisco, CA Corresponding author: Jacques H. Hacquebord, MD, 530 First Avenue, Suite 8U, New York, NY 10016, Phone #: 646-501-2180Fax #: 646-754-9939, Jacques.Hacquebord@nyumc.org ©2018American Society of Plastic Surgeons

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Component Restoration in the Unilateral Intermediate Cleft Tip Rhinoplasty: Technique and Long-Term Outcomes

Background: The intermediate cleft tip rhinoplasty (ICTR) is performed in childhood to address residual tip asymmetries during the most critical period of psychosocial development. We describe and evaluate long-term outcomes of an ICTR approach for the unilateral cleft lip and palate (UCLCP) patient based on the concept of individual restoration of each abnormal anatomical component. Methods: Photomorphometric analyses of UCLCP patients (n=50) who underwent ICTR using the component restoration technique were evaluated preoperatively (t0) and postoperatively at 3 years (t3) and compared to age-matched UCLCP control patients. Nasal relationships (alar symmetry, nasal tip protrusion to alar base width ratio, and height to width dimensions for the cleft and non-cleft nostril) were compared over time using a linear mixed-effect model. Results: At t0, both groups demonstrated similar nasal relationships with the exception of a wider cleft-side nostril in relationship to height in the ICTR group. The component restoration ICTR technique improved all four nasal relationships at all postoperative timepoints compared to t0 in a statistically significant manner, whereas control UCLCP patients did not demonstrate significant changes at the corresponding ages. Long-term differences at t3 revealed a trend towards improved alar symmetry, cleft-side and non-cleft-side nostril dimensions and a significant improvement in the nasal tip protrusion to alar base width ratio in ICTR-treated versus control patients (p=0.002). Conclusions: The component restoration technique for the unilateral ICTR improves nasal relationships towards normal immediately and in a sustained manner for at least three years. Presented at the 96thAnnual Meeting of the American Association of Plastic Surgeons, March 25-28, 2017, Austin, Texas Disclosures: All authors have no financial interests including products, devices, or drugs associated with this manuscript. There are no commercial associations that might pose or create a conflict of interest with information presented in this submitted manuscript such as consultancies, stock ownership, or patent licensing arrangements. All sources of funds supporting the completion of this manuscript are under the auspices of the University of California Los Angeles. Acknowledgments: We wish to acknowledge Dr. Johnny Lin, PhD from the UCLA Institute for Digital Research and Education for his expert assistance with the statistical analyses. This work was supported by the Bernard G. Sarnat Endowment for Craniofacial Biology (JCL). JCL is additionally supported by the Jean Perkins Foundation and the US Department of Veterans Affairs under award number IK2 BX002442-01A2. Corresponding Author: Justine C. Lee, MD, PhD, FACS, University of California Los Angeles, Division of Plastic and Reconstructive Surgery, 200 Medical Plaza, Suite 465, Los Angeles, CA 90095-6960, Phone (310) 794-7616, Fax (310) 206-6833, justine@ucla.edu ©2018American Society of Plastic Surgeons

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A Rapid Protocol for Intraoperative Assessment of Peripheral Nerve Myelinated Axon Count and its Application to Cross-Facial Nerve Grafting

Background: Donor nerve myelinated axon counts correlate with functional outcomes in reanimation procedures, however there exists no reliable means for their intraoperative quantification. Herein, we report a novel protocol for rapid quantification of myelinated axons from frozen sections, and demonstrate its applicability to surgical practice. Methods: The impact of various fixation and FluoroMyelin Red™ staining strategies on resolved myelin sheath morphology from cryosections of rat and rabbit femoral and sciatic nerves was assessed. A protocol comprising fresh cryosection and rapid staining was developed, and histomorphometric results compared against conventional osmium post-fixed, resin-embedded, toluidine blue-stained sections of rat sciatic nerve. The rapid protocol was applied for intraoperative quantification of donor nerve myelinated axon count in a cross-facial nerve grafting procedure. Results: Resolution of myelinated axon morphology suitable for counting was realized within ten minutes of tissue harvest. Though mean myelinated axon diameter appeared larger using the rapid fresh-frozen as compared to conventional nerve processing techniques (mean ± standard deviation; rapid, 9.25 ± 0.62; conventional, 6.05 ± 0.71; p

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Small numbers of CD4+ T cells can induce development of lymphedema

Background: CD4+ T cells have been implicated in the pathology of lymphedema. Interestingly, however, there have been case reports of lymphedema development in patients with low levels of CD4+ T cells due to immunosuppression. In this study, we sought to delineate the effect of relative CD4+ T cell deficiency on the development of lymphedema in a mouse model. Methods: A mouse model of relative CD4+ T cell deficiency was created through lethal total body irradiation of wild-type (WT) mice that then underwent bone marrow transplantation with progenitors harvested from CD4 knockout (CD4KO) mice (WT/CD4KO). Irradiated CD4KO mice reconstituted with WT mouse-derived progenitors (CD4KO/WT), as well as unirradiated CD4KO and WT mice were used as controls. All mice underwent tail skin and lymphatic excision to induce lymphedema and analysis was performed six weeks later. Results: WT/CD4KO chimeras were not protected from developing lymphedema. Despite a global deficit in CD4+ T cells, these mice had swelling, fibrosis, inflammation, and impaired lymphatic transport function indistinguishable from that in WT and CD4KO/WT mice. In contrast, unirradiated CD4KO mice had no features of lymphedema after lymphatic injury. Conclusions: Relatively few numbers of bone marrow and peripheral CD4+ T cells are sufficient to induce the development of lymphedema. These findings suggest that lymphatic injury results in expansion of CD4+ T cell populations in lymphedematous tissues. Financial Disclosure Statement: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. This work was supported by the National Institutes of Health (NIH) R01 HL111130-01 and R21 CA194882 grants awarded to B.J.M., the NIH T32 CA9501-29 grant to C.L.L., the NIH T32 CA009685-21A1 grant to D.A.C., and the NIH/NCI P30 CA008748 (Cancer Center Support Grant) to Memorial Sloan Kettering Cancer Center. Presented at: Plastic Surgery Research Council 60th Annual Meeting; Seattle, Washington; May 15, 2015 Acknowledgements: The authors thank the Molecular Cytology and Flow Cytometry Cores at Memorial Sloan Kettering Cancer Center for their assistance (Core Grant P30 CA008748). Author contributions: D.A.C. and B.J.M. conceived of the concept and designed the experiments. C.L.L., D.A.C., R.P.K., and B.J.M. performed the experiments and/or analyzed the data. C.L.L. and B.J.M. prepared and edited the manuscript. Corresponding author: Babak J. Mehrara, MD, Member, Memorial Hospital, Professor of Plastic Surgery, Weill Cornell University Medical Center, 1275 York Avenue, Suite MRI 1006, New York, New York, USA 10065, mehrarab@mskcc.org ©2018American Society of Plastic Surgeons

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THE TIMING OF ALLOPLASTIC CRANIOPLASTY IN THE SETTING OF PREVIOUS OSTEOMYELITIS

BACKGROUND: Management of cranial osteomyelitis is challenging and often includes debridement of infected bone and delayed alloplastic cranioplasty. However, the optimal interval between the removal of infected bone and definitive reconstruction remains controversial. We investigated the optimal time for definitive reconstruction and factors influencing cranioplasty reinfection. METHODS: A retrospective review of 111 alloplastic cranioplasties for osteomyelitis between 2002 and 2015 was performed. Patients were divided into four subgroups based on timing of reconstruction: 1) (12 months). Multivariate logistic regression was used to calculate probability of cranioplasty reinfection based on risk factors. Median follow-up was 45.9 months (range 12.4–136.9). RESULTS: The combined reinfection rate was 23.4%. The reinfection rate in Group 1 was 39.6%, Group 2 12.5%, Group 3 8.0%, and Group 4 0.0% (p

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Forensic Science and Medicine

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Deaths due to electrocution: An evaluation of death scene investigations and autopsy findings Brittani K Massey, Mohammed A Sait, William L. A. Johnson, Mary Ripple, David R Fowler, Ling Li Journal of Forensic Science and Medicine 2018 4(4):179-183 The purpose of the study was to delineate the epidemiological characteristics of electrocution deaths in Maryland, identify any potential risks, and address preventive measures. A retrospective review of all the deaths due to electrocution was conducted at the Office of the Chief Medical Examiner in the State of Maryland from 2005 to 2015. During the 11-year period, a total of 55 electrocution deaths were identified from the autopsy cases at the statewide medical examiner system. More males died of electrocution than females with its ratio of (M: F) = 9:1. Of the 55 cases, 67.3% were White, 18.2% were African-American, 12.7% were Hispanic, and 1.8% were other races. The age of the victims ranged from 4 to 83 years with mean age of 40 years. >96% deaths due to accidents and 3.4% were suicide. The majority of deaths (70.9%) were caused by high-voltage circuits. Approximately 64% of fatalities were work-related accidents. The study indicated that electrocution deaths frequently affected young male workers who were in contact with a high-voltage currents while on the job. The detailed death scene investigation and autopsy findings are presented. The potential hazards of electricity must continue to be addressed in public safety campaigns to prevent such deaths. Strategies should ensure safe work environments for any contact with electric currents.

Determination of methadone and eight new psychoactive substances in hair samples by gas chromatography/mass spectrometry Luca Anzillotti, Luca Calò, Marianna Giacalone, Antonio Banchini, Rossana Cecchi Journal of Forensic Science and Medicine 2018 4(4):184-191 Many new psychoactive substances (NPSs) with different chemical structures have emerged in the illicit drug market in the last decade. The present work was aimed at the development of a simple method in gas chromatography/mass spectrometry (MS) for the determination of NPS of different classes, the use of cannabinoids, and, at the same time, the evaluation of methadone therapy in hair matrix, within our routine analysis control for methadone treatment or from autopsy cases. The determination of synthetic cannabinoids and methadone therapy used an extraction method based on incubation in concentrated sodium hydroxide (NaOH) solution, providing a dissolution of the keratin matrix. The described method was applied on 15 authentic specimens from our cases: five showed the presence of methadone and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP). The described method can be useful not only in the forensic investigation of NPS-related addiction histories but also in epidemiological and retrospective studies on the spread of NPS among specific safety-sensitive social workers. The GC instrument was an Agilent 7820A (Agilent Technologies, Santa Clara, CA, USA), and the detection system was an Agilent 5977B single quadrupole MS operating in selective ion monitoring mode. Validation parameters such as limit of detections (LODs), limit of quantifications (LOQs), repeatability, accuracy, and linearity were satisfactory for its application on real specimens. LODs, LOQs, R%CV, standard deviation, and the mean concentration for the analyzed compounds are reported in Table 1b. Accuracy and repeatability were acceptable for all the analytes at their respective LOQs. Recovery experiments varied from 58.3% to 103.0%, thus allowing the application on authentic specimens. The described method can be useful not only in the forensic investigation of NPS-related addiction histories but also in epidemiological and retrospective studies on the spread of NPS among specific safety-sensitive social workers, such as drivers.

Fast fourier transform: A Niche, but critical strategy in optimizing impression evidence Brian Dalrymple Journal of Forensic Science and Medicine 2018 4(4):192-196 The evolution from film to digital as the recording medium for forensic imaging has extended the reach of forensic photographers, both in original capture and postphotography processing. Images of fingermarks and footwear impressions are routinely obstructed by substrates displaying intrusive color and pattern. Such backgrounds are frequently sufficiently intrusive as to prevent the analysis and comparison of the images to known exemplars. Digital techniques such as Fast Fourier Transform (FFT) in postphotography processing can optimize the signal-to-noise ratio to a greater degree than was ever possible when film was the recording standard. Occasionally, unwanted backgrounds can be removed or diminished in Photoshop with techniques such as background subtraction and channel blending. These strategies, however, are dependent on either physical removal of the evidence impression to obtain a second image of the obstructive pattern or on differences in color between the impression and the offending substrate. FFT is unique in its ability to optimize the image signal to noise ratio by suppressing the obstructive background, in that it is not reliant on color, and is not applied in the spatial domain.

Is magnetic flux a valuable tool for the analysis of electrophotographic-printed documents? Williams David Mazzella, Bing Li Journal of Forensic Science and Medicine 2018 4(4):197-202 The goal of this preliminary study was to evaluate the potential application of magnetic flux for document screening. In this investigation, we examined the homogeneity of magnetic flux over the entire page of sample documents and provided recommendations on the measurements procedure.

Research on subjective bias cognition effect in handwriting identification Bing Li, Tiantian Ma Journal of Forensic Science and Medicine 2018 4(4):203-212 This article starts from the point of view that handwriting examination is dependent on empiricism and by analyzing the core steps of handwriting identification explains that it might be influenced by subjective bias. In practice, examiners cannot avoid biases in decision-making; instead, we must accept the existence of subjective bias in handwriting identification and then discuss its impact; for instance, feature selection in the process of comprehensive evaluation, which involves a comparison of the number and quality of similarities and differences between a questioned sample and the references. While we conclude that comprehensive evaluation is the most important step in the identification process, industries in China do not stipulate explicit and transparent criteria for it, making it hard to numerically quantify the characteristics of handwriting identification. In this article, forensic examiners' opinions on handwriting identification were obtained through a survey. One finding was that most handwriting examiners believe that handwriting identification is subject to subjective bias. In addition, they believe that the subjective cognition of handwriting identification can somehow help actively produce the correct opinion; before the examination, most handwriting examiners think that they should understand the context and so on. Finally, through the questionnaire, which contained variations such as the same case with different background information, different cases with the same background information, and the same case with or without context, it was concluded that handwriting identification does have certain subjectivity. However, which kind of factors influence this subjectivity is not presently clear. Furthermore, it is difficult to control uncertainties when forming an opinion on identification. An alternative way is to perform scrutiny after the formulation of handwriting opinions; for example, internal and external reviews such as appearing in court.

Modernization of medicine in the ottoman empire and its effects on forensic sciences Ferat Buran, Erdem Özkara Journal of Forensic Science and Medicine 2018 4(4):213-220 Modernization in medicine began in the Ottoman Empire in the 19th century. Until that time, medical education had been provided through the traditional master–apprentice practices and its methods had relied on custom or religion. The most important of these reforms was in 1827, when the first medical schools in surgical and clinical branches were opened in İstanbul. The lack of contemporary understanding in medical education until that time had caused an underdevelopment in forensic sciences as it had in various other fields. Following the reform movements, the contents of the forensic medicine curriculum, mainly influenced by the French medical schooling, touched upon all areas of forensic sciences such as pathology, toxicology, organic chemistry, neuropsychiatry, gynecology, handwriting analysis and criminalistics. It was noteworthy to see such rapid development in scientific modernization considering the fact that, before the reform movements, the religion had a repressive effect and it was forbidden to even perform laboratory tests or examinations on corpses. In the modern Turkish Republic, founded in 1923 after World War I, scientific reforms gained momentum and began competing with the modern world. Such that, after a letter sent to the Turkish Government by Albert Einstein in 1933, the contemporary Turkish universities embraced the scientists who escaped from the Nazi regime.

On trends of the role transition from expert assistant to expert witness Baosheng Zhang, Shuai Dong, Ping Yang Journal of Forensic Science and Medicine 2018 4(4):221-228 In the context of Chinese evidence law, the role of the expert assistant is to “offer opinion on the forensic expertise or specialized issues.” This role is multiple-facet, somewhat similar to a lawyer's role, and to some extent similar to that of a forensic expert or a witness. For this simple reason, the views on the legal status of opinions of the expert assistant also vary from “cross-examination method,” “forensic expertise” to “witness testimony.” This confusion regarding the role of the expert assistant often results in difficulties in deciding whether to admit the expert assistant opinion as evidence at trial. The regulation that the expert assistant opinion “can be taken as evidence for determining facts of a case after cross-examination” stipulated in Paragraph 2 of Article 15 of the Supreme People's Court Interpretation of the Law in the Conduct of Environmental Civil Public Interest Litigations promulgated in 2015 could be seen as trends of a transition in the role of the expert assistant towards that of the expert witness. This article attempts to analyze reasons, significance, and prospects of such a transition, and give suggestions to improve the application of examination rules for the expert witness and admissibility rules for scientific evidence.

Septicemic melioidosis: A forensic autopsy case report Atif Shamsudin, Heo Chong Chin, Ahmad Hafizam Hasmi, Hapizah Mohd Nawawi Journal of Forensic Science and Medicine 2018 4(4):229-232 We report a 27-year-old male from Kuwait who died due to melioidosis, and the diagnosis was achieved after the deceased underwent postmortem examination at the Forensic Department, Kuala Lumpur Hospital. While the disease is endemic in Southeast Asia and Northern Australia, human melioidosis infection has yet been reported in Kuwait. He was initially diagnosed as acute gastroenteritis at a private clinic before being found dead at a hotel in Kuala Lumpur. The autopsy revealed positive findings of Burkholderia pseudomallei in the deceased's brain, lung, liver, and spleen as well as in the blood and cerebrospinal fluid culture. The deceased's death highlights the importance of early accurate diagnosis, the common manifestations, and the need of effective antibiotic treatment of septicemic melioidosis in high prevalent areas.

Forensic investigation of atypical asphysia Zhe Cao, Zhiyuan An, Xiaoning Hou, Dong Zhao Journal of Forensic Science and Medicine 2018 4(4):233-237 Smothering, choking, confined spaces, traumatic asphyxia, positional asphyxia, and other kinds of atypical mechanical asphyxia are not rare in forensic practice. However, these are not commonly well demonstrated in forensic monographs worldwide. The authors researched related works and literatures and summarized these with a view to contribute to the existing teaching resources and provide help to forensic practitioners who are involved in scene investigation and identification of such deaths.