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Aims: This study aimed to examine the effect of high fat diet (HFD) to modulate brain dysfunction, and understand the linkages between obesity, metabolic disturbances and the brain oxidative stress (BOS) dysfunction and modulation with hydroxyl citric acid of G. Cambogia. Methods: Rats were divided into 3 groups; 1st control, maintained on standard normal rat chow diet, 2st HFD, maintained on high fat diet along 12 week and 3rd HFD+G, administered G. Cambogia for 4 weeks and each group include 8 rats. Blood, brain and abdominal fat were collected for biochemical measurements. Results: HFD group showed significant increase in energy intake, final BW and BW gain. Also significant increase in weight of abdominal fat in HFD group. HFD induce metabolic disturbance through increasing the lipid profile (LDL, TG, TC), γGT and α-amylase activity, uric acid level and hyperglycemia, while decreasing creatine kinase (CK) activity. These changes associated with lowering in brain nitric oxide (NO) level and rising in serum butyrylcholinesterase (BChE), brain catalase activity and MDA levels as oxidative stress markers. These alterations improved by G. Cambogia that decrease BOS and increased NO level. Conclusions: Rats fed HFD showed, metabolic disturbances produce hyperglycemia, hypertriglyceridemia, hypercholesterolemia and increased LDL associated with increased BOS. Involvement of BuChE, NO and oxidative stress associated with metabolic disturbances in the pathophysiological progression in brain, suggesting association between obesity, metabolic disorders and brain alteration while, using G. Cambogia, ameliorate the damaging effects of the HFD via lowering feed intake and BOS. [ABSTRACT FROM AUTHOR]

Background: Obesity became major health problem in the world, the objective of this work was to examine the effect of high sucrose and high fat diet to induce obesity on antioxidant defense system, biochemical changes in blood and tissue of control, non treated and treated groups by administration of Garcinia cambogia, and explore the mechanisms that link obesity with altered renal function Methods: Rats were fed a standard control diet for 12 week (wk) or a diet containing 65% high sucrose (HSD) or 35% fat (HFD) for 8 wk and then HFD group divided into two groups for the following 4 wks. One group was given Garcinia+HFD, the second only high fat, Also the HSD divided into two groups, 1st HSD+Garcinia and 2nd HSD. Blood and renal, mesenteric, Perirenal and epididymal adipose tissues were collected for biochemical assays. Results: HFD and HSD groups of rats showed a significant increase in feed intake, Body weight (BW) and body mass index (BMI). Also there were significant increases in weights of mesenteric, Perirenal and epididymal adipose tissues in HFD and HSD groups. HFD and HSD affect the kidney by increasing serum urea and creatinine levels and decreased level of nitric oxide (NO) and increased blood glucose, low density lipoproteins (LDL), triacylglycerol (TG), total cholesterol (TC) and malondialdehyde (MDA). Glucose 6-phosphate dehydrogenase (G6PD) activities were significantly decreased in HFD while there were significant increases in HSD and HSD+G groups p ≤ 0.05 compared with control. Moreover, renal catalase activities and MDA levels were significantly increased while NO level was lowered. These changes improved by Garcinia that decreased the oxidative stress biomarkers and increased NO level. There were significant positive correlations among BMI, kidney functions (Creatinine and urea), TG and Oxidative markers (renal MDA and catalase). Conclusions: Rats fed a diet with HFD or HSD showed, hypertriglyceridemia, increased LDL production, increased oxidative stress and renal alteration. Moreover, suggesting association between lipid peroxidation, obesity and nephropathy, while Garcinia ameliorated the damaging effects of the HFD or HSD and decreased feed intake, MDA level and decreased oxidative stress in renal tissues. [ABSTRACT FROM AUTHOR]

Background: This research explores the relationships between the educational environment, student engagement, and academic achievement in Health Professions Education (HPE) , specifically examining the mediating role of engagement., Methods: The study used cross-sectional design, and data were collected from 554 HPE students via self-report questionnaires. The Dundee Ready Education Environment Measure (DREEM) assessed the educational environment while the University Student Engagement Inventory measured learning engagement across the behavioral, emotional, and cognitive dimensions. Academic achievement was measured using cumulative GPA. Relationships between study variables were analyzed using path analysis., Results: Path analysis demonstrated that four educational environment subscales directly affected emotional engagement (48% variance explained). Students' perception of learning and academic self-perceptions influenced behavioral engagement (28% variance explained), while cognitive engagement was influenced by academic self-perceptions (39% variance explained). GPA was positively influenced by behavioral and cognitive engagement but negatively by emotional engagement. Cognitive and behavioral engagement mediated the relationship between students' academic self-perceptions and academic achievement., Conclusions: Students' perceptions of the educational environment significantly influenced emotional engagement, followed by cognitive and behavioral engagement. Cognitive and behavioral engagement directly affected academic achievement and mediated the relationship between the educational environment and academic achievement., (© 2024. The Author(s).)

Background: Taste buds' innervation is necessary to sustain their cell turnover, differentiated taste buds and nerve fibers in circumvallate papilla (CVP) disappear following glossopharyngeal nerve transection. Normally, taste buds recover to baseline number in about 70 days. Bone marrow stem cell (BM-MSC) derived exosomes or their combination with Zinc chloride are used to assess their potential to speed up the regeneration process of CVP following bilateral deafferentation., Methods: Twenty-eight male Sprague-Dawley rats were randomly divided into four groups; Group I: subjected to sham operation followed by IP injection of saline. The other experimental groups (II, III and IV) were subjected to surgical bilateral transection of glossopharyngeal nerve. Group II received single IP injection of saline. Group III received single IV injection of BM-MSC-derived exosomes (100 µg). Group IV received single IV injection of BM-MSC-derived exosomes and single IP injection of zinc chloride (5 mg/kg). After 28 days, CVP was dissected and prepared for histological and histomorphometric analysis, RT-PCR for cytokeratin 8 gene expression, ELISA to assess protein level of brain-derived neurotrophic factor, redox state analysis of malondialdehyde and glutathione content, followed by statistical analysis., Results: Histopathologically, group II exhibited great tissue damage with marked reduction in taste buds and signs of degeneration in the remaining ones. Group III was close to control group with marked improvement in taste buds' number and structure. Group IV showed inferior results when compared to group III, with many immature taste buds and signs of degeneration. Statistical results showed that groups I and III have significantly higher values than groups II and IV regarding taste buds' number, cytokeratin 8, and reduced glutathione. However, malondialdehyde demonstrated high significant values in group IV compared to groups I and III. Regarding brain-derived neurotrophic factor, group III had significantly higher values than group II., Conclusion: BM-MSC-derived exosomes have superior regenerative potentials in acceleration of CVP and nerve healing following bilateral transection of glossopharyngeal nerve in contrary to its combination with zinc chloride., (© 2024. The Author(s).)

Background: Sciatic nerve repair becomes a focus of research in neurological aspect to restore the normal physical ability of the animal to stand and walk. Tissue engineered nerve grafts (TENGs) provide a promising alternative therapy for regeneration of large gap defects. The present study investigates the regenerative capacity of PRP, ADSCs, and PRP mixed ADSCs on a long sciatic nerve defect (40-mm) bridged by a polyglycolic polypropylene (PGA-PRL) mesh which acts as a neural scaffold., Materials and Methods: The study was conducted on 12 adult male mongrel dogs that were randomly divided into 4 groups: Group I (scaffold group); where the sciatic defect was bridged by a (PGA-PRL) mesh only while the mesh was injected with ADSCs in Group II (ADSCs group), PRP in Group III (PRP group). Mixture of PRP and ADSCs was allocated in Group IV (PRP + ADSCs group). Monthly, all animals were monitored for improvement in their gait and a numerical lameness score was recorded for all groups. 6 months-post surgery, the structural and functional recovery of sciatic nerve was evaluated electrophysiologically, and on the level of gene expression, and both sciatic nerve and the gastrocnemius muscle were evaluated morphometrically, histopathologically., Results: Numerical lameness score showed improvement in the motor activities of both Group II and Group III followed by Group IV and the scaffold group showed mild improvement even after 6 months. Histopathologically, all treated groups showed axonal sprouting and numerous regenerated fascicles with obvious angiogenesis in proximal cut, and distal portion where Group IV exhibited a significant remyelination with the MCOOL technique. The regenerative ratio of gastrocnemius muscle was 23.81%, 56.68%, 52.06% and 40.69% for Group I, II, III and IV; respectively. The expression of NGF showed significant up regulation in the proximal portion for both Group III and Group IV (P ≤ 0.0001) while Group II showed no significant difference. PDGF-A, and VEGF expressions were up-regulated in Group II, III, and IV whereas Group I showed significant down-regulation for NGF, PDGF-A, and VEGF (P ≤ 0.0001)., Conclusion: ADSCs have a great role in restoring the damaged nerve fibers by secreting several types of growth factors like NGF that have a proliferative effect on Schwann cells and their migration. In addition, PRP therapy potentiates the effect of ADSCs by synthesis another growth factors such as PDGF-A, VEGF, NGF for better healing of large sciatic gap defects., (© 2024. The Author(s).)

Background: Sociocultural engagement of students refers to broadening viewpoints and providing awareness of, and respect for, diverse backgrounds and perspectives. However, there are no existing validated instruments in the literature for measuring sociocultural engagement of health professions education (HPE) students. Therefore, the aim of this study is to develop and validate a questionnaire designed to assess sociocultural engagement among HPE students., Methods: The study included undergraduate HPE students (n = 683) at Gulf Medical University. The initial version of the sociocultural engagement of students' questionnaire (SESQ) was developed after extensive literature review and guided by the Global Learning Qualifications Framework. We then tested the content validity of the questionnaire by using focus group discussion with subject experts (n = 16) and pilot testing with students (n = 20). We distributed the content-validated version of the SESQ (16 items) to undergraduate students in six HPE colleges. To examine the construct validity and construct reliability of the questionnaire, we conducted exploratory factor analysis, followed by confirmatory factor analysis., Results: Confirmatory factor analysis supported the two-factor structure which consists of 13 items with good fitness indices (χ 2  = 214.35, df = 61, χ 2 /df = 3.51, CFI = 0.98, RMSEA = 0.06, SRMR = 0.025, and AIC = 208.00). The two factors were sociocultural interactions (8 items) and sociocultural adaptation (5 items). The construct reliability of the total questionnaire is 0.97 and the two factors were 0.93 and 0.92 for sociocultural interactions and sociocultural adaptation, respectively. In addition, there were significant weak correlations between both factors of sociocultural engagement scores and student satisfaction with the university experience (r = .19 for each, P = .01)., Conclusions: The sociocultural engagement of students' questionnaire exhibits good evidence of construct validity and reliability. Further studies will be required to test the validity of this questionnaire in other contexts., (© 2024. The Author(s).)

Background: Student engagement is student investment of time and energy in academic and non-academic experiences that include learning, teaching, research, governance, and community activities. Although previous studies provided some evidence of measuring student engagement in PBL tutorials, there are no existing quantitative studies in which cognitive, behavioral, and emotional engagement of students in PBL tutorials is measured. Therefore, this study aims to develop and examine the construct validity of a questionnaire for measuring cognitive, behavioral, and emotional engagement of students in PBL tutorials., Methods: A 15-item questionnaire was developed guided by a previously published conceptual framework of student engagement. Focus group discussion (n = 12) with medical education experts was then conducted and the questionnaire was piloted with medical students. The questionnaire was then distributed to year 2 and 3 medical students (n = 176) in problem-based tutorial groups at the end of an integrated course, where PBL is the main strategy of learning. The validity of the internal structure of the questionnaire was tested by confirmatory factor analysis using structural equation modeling assuming five different models. Predictive validity evidence of the questionnaire was studied by examining the correlations between students' engagement and academic achievement., Results: Confirmatory factor analysis indicates a good fit between the measurement and structural model of an 11-item questionnaire composed of a three-factor structure: behavioral engagement (3 items), emotional engagement (4 items), and cognitive engagement (4 items). Models in which the three latent factors were considered semi-independent provided the best fit. The construct reliabilities of behavioral, cognitive, and emotional factors were 0.82, 0.82, and 0.76, respectively. We failed however to find significant relationships between academic achievement and engagement., Conclusions: We found a strong evidence to support the construct validity of a three-factor structure of student engagement in PBL tutorial questionnaire. Further studies are required to test the validity of this instrument in other educational settings. The predictive validity is another area needing further scrutiny., (© 2023. The Author(s).)

Background: The effect of bariatric surgery on impaired semen parameters, hormonal profile and sexual function remains controversial to some extent., The Context and Purpose of the Study: To look at the long-term effects of sleeve gastrectomy on hormonal profiles, sperm parameters, and sexual function in infertile men with severe obesity. This prospective study included fifty-four obese patients with primary or secondary infertility who were scheduled for sleeve gastrectomy between February 2018 and March 2021. All participants were given a sperm analysis and a serum hormone profile before, 12, and 18 months after surgery. We used the International Index of Erectile Function questionnaire to assess sexual function., Results: There was a significant correlation between weight loss after sleeve gastrectomy and improvement in lipid profile (p < 0.05). No significant detectable effect of post-gastrectomy weight loss on patients with diabetes mellitus, hypertension, or obstructive sleep apnea. As regards the hormonal profile, sex hormone binding globulin, total and free testosterone improved significantly after 12- and 18-months following sleeve gastrectomy. There was a significant increase in sperm count and total sperm number during the follow-up after sleeve gastrectomy (p < 0.05), however, there were no significant changes in other semen parameters. Concerning sexual function, sexual desire, erectile function, and satisfaction improved significantly at 12 and 18 months after surgery., Conclusion: Weight loss through sleeve gastrectomy surgery significantly improves testosterone deficiency, sexual performance, and Sperm count in obese infertile men., (© 2023. The Author(s).)

Student engagement is a complex multidimensional construct that has attained great interest in health professions education (HPE). Definition and conceptualization of student engagement is an important step that should drive the development of the instruments for its measurement. We have recently proposed a comprehensive framework for student engagement in HPE with a definition of engagement as student investment of time and energy in academic and non-academic experiences that include learning, teaching, research, governance, and community activities. The dimensions of student engagement in this framework included the cognitive, affective, behavioral, agentic, and socio-cultural. Guided by the student engagement framework, this non-systematic review aims to identify, critically appraise, and summarize the existing methods for measuring student engagement in HPE. Extrapolating from higher education literature, we attempted to link the theoretical perspectives of student engagement with the published methods of its measurement in HPE context. In addition, we have described the different methods of measuring student engagement including self-report surveys, real time measures, direct observation, interviews/focus groups, and the use of multiple instruments. The span of engagement dimensions measured by self-report surveys ranges from one to five dimensions. However, measurement of agentic and sociocultural dimensions of engagement in HPE is still limited and further research is required. We have also reflected on the existing methods of measuring engagement of students as active partners in HPE. The review also describes the advantages, limitations, and psychometric properties of each method for measuring student engagement. We ended the review with a guiding conclusion on how to develop and select an instrument for measuring student engagement in HPE. Finally, we addressed the gaps in the literature about measuring engagement of HPE students and future research plans., (© 2023. The Author(s).)

Background: The genus Nebo has been identified as a medically important scorpion species distributed across Arabia and the Middle East. However, its taxonomic status remains unclear., Aim: The molecular phylogeny of two Nebo species from Saudi Arabia and comparative sequences from Palestine is presented based on the mitochondrial cytochrome oxidase subunit I (COI) gene., Methodology: Scorpion specimens were collected from two different localities, mainly the Southern part of Saudi Arabia. Then, DNA was extracted, amplified using invertebrate universal primers, and sequenced to identify the COI gene. The obtained sequences were analyzed, and phylogenetic trees based on maximum parsimony, neighbor-joining, and Bayesian inference were constructed., Results: The inferred phylogeny indicates the monophyletic status of the family Diplocentridae and its subfamily Nebinae and Diplocentrinae. Also, the phylogenetic analyses support the existence of interspecific and intraspecific variations among/ within Nebo hierichonticus and Nebo yemenensis which may indicate distinct species., Conclusion: Further morphological studies with additional specimens from the Arabian Peninsula may reveal possible undiscovered and cryptic species., (© 2023. The Author(s).)

Neurotoxicity is a severe side effect of platinum compounds used for cancer chemotherapy such as Cisplatin. This neurotoxicity leads to severe cognitive and nervous dysfunction, therefore, limiting the dose of Cisplatin and compromising the treatment protocol.The present study investigates the neuroprotective effect of Sea Urchins which is a marine animal known for its rich bioactive compounds. Male Sprague Dawley rats received Cisplatin (2 mg/kg body weight) for 4 weeks, two times per week, followed by Sea Urchin extracts (50 and 100 mg/kg body weight) twice weekly for 4 weeks.Results show that rats treated with Urchin's extracts showed a significant improvement in the thermal (heat and cold) sensitivity compared to untreated rats. Liver enzymes Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) and Urea levels were also significantly decreased back to normal following treatment with sea urchin extracts. Brain tissue oxidative stress marker Nitric oxide (NO) and lipid peroxidation marker Malondialdehyde (MDA) increased significantly in the cisplatin-treated rats while the reduced glutathione levels (GSH) and catalase activity (CAT) showed a significant decrease. Treatment with sea Urchin extracts reversed these changes.Histological and immunohistochemical examination of the cerebral cortex reveled degenerative changes such as karyopyknosis and shrunken necrotic ghost like neurons in the cisplatin treated groups. There was also strong positive Glial fibrillary acidic protein (GFAP) reactivity and a negative B-cell leukemia/lymphoma 2 protein (Bcl2) reaction in most apparent neurons, indicating strong apoptotic changes. Treatment with Urchin extracts reversed these changes. Quantification of cerebral cortex neurons also revealed the strong effect of the extracts. Cisplatin treated groups showed 3708 cells/ mm3 compared to 8091 cells/mm 3 in the normal rats. Extract treatment increased the neuronal numbers to almost normal levels. Quantification of the Immuno-histochemical expression of GFAP showed an increase by 10-folds after cisplatin administration. A remarkable decline from the cisplatin group was seen in the extract treated groups.In Conclusion, Sea Urchins extracts possess a strong neuroprotective activity and could provide a novel therapeutic method to prevent Cisplatin-induced neurotoxicity., (© 2023. The Author(s).)

Background: IgG4-related disease (IgG4-RD) is a progressive and sometimes fatal disease that rarely affects pediatric age group. It may affect the orbits, lacrimal and salivary glands, pancreas, kidneys, peritoneum and other organs. Lung and pleura are not commonly reported in IgG4-RD. We here present a rare case of pediatric IgG4-RD with rare involvement of pericardium, pleura and lungs., Case Presentation: A 13-year-old girl presented with intrathoracic IgG4-RD with pleuropericardial involvement. She showed initial improvement on prednisolone. Azathioprine and then mycophenolate failed to control relapses during steroid tapering. Her last relapse was treated by rituximab however, the patient developed acute fatal massive hemoptysis., Conclusions: Pediatric IgG4-RD is a rare entity with pericardio-pulmonary affection as the rare of the rare. Usual treatment of prednisolone and steroid sparing agents should be used, with rituximab used as a rescue therapy, but fatal complications may occur., (© 2023. The Author(s).)

Background: Multiple sclerosis (MS) is the most frequent non-traumatic neurological debilitating disease among young adults with no cure. Over recent decades, efforts to treat neurodegenerative diseases have shifted to regenerative cell therapy. Adipose tissue-derived stromal vascular fraction (SVF) comprises a heterogeneous cell population, considered an easily accessible source of MSCs with therapeutic potential in autoimmune diseases. This study aimed to assess the regenerative capacity of low-level laser-activated SVF in an MS cat model., Methods: Fifteen adult Persian cats were used in this study: Group I (control negative group, normal cats), Group II (EB-treated group, induced for MS by ethidium bromide (EB) intrathecal injection), and Group III (SVF co-treated group, induced for MS then treated with SVF on day 14 post-induction). The SVF was obtained after digesting the adipose tissue with collagenase type I and injecting it intrathecal through the foramen magnum., Results: The results showed that the pelvic limb's weight-bearing locomotion activity was significantly (P ≤ 0.05) recovered in Group III, and the Basso, Beattie, and Bresnahan (BBB) scores of hindlimb locomotion were significantly higher in Group III (14 ± 0.44) than Group II (4 ± 0.31). The lesion's extent and intensity were reduced in the magnetic resonance imaging (MRI) of Group III. Besides, the same group showed a significant increase in the expression of neurotrophic factors: BDNF, SDF and NGF (0.61 ± 0.01, 0.51 ± 0.01 and 0.67 ± 0.01, respectively) compared with Group II (0.33 ± 0.01, 0.36 ± 0.006 and 0.2 ± 0.01, respectively). Furthermore, SVF co-treated group revealed a significant (P ≤ 0.05) increase in oligodendrocyte transcription factor (Olig2) and myelin basic protein (4 ± 0.35 and 6 ± 0.45, respectively) that was decreased in group II (1.8 ± 0.22 and 2.9 ± 0.20, respectively). Moreover, group III showed a significant (P ≤ 0.05) reduction in Bax and glial fibrillary acidic protein (4 ± 0.53 and 3.8 ± 0.52, respectively) as compared with group II (10.7 ± 0.49 and 8.7 ± 0.78, respectively). The transmission electron microscopy demonstrated regular more compact, and markedly (P ≤ 0.05) thicker myelin sheaths (mm) in Group III (0.3 ± 0.006) as compared with group II (0.1 ± 0.004). Based on our results, the SVF co-treated group revealed remyelination and regeneration capacity with a reduction in apoptosis and axonal degeneration., Conclusion: SVF is considered an easy, valuable, and promising therapeutic approach for treating spinal cord injuries, particularly MS., (© 2022. The Author(s).)

Background: Access to electronic (E) resources has become an indispensable requirement in medical education and practice., Objective: Our objective was to assess the effect of E-resources access during examination on end-course-exam scores of medical and dental students., Methods: A quasi-experimental study which included two cohorts of medical (n = 106 & 85) and three cohorts of dental students (n = 66, 64 and 69) who took end-course- exams. Each exam was composed of two- parts (Part I and II), that encompassed equal number of questions and duration. Access to E-resources was allowed in part-II only. Items Difficulty Index (DI), Discrimination Index, (DisI), Point Biserial, (PBS) and cognitive level were determined., Results: The study included 390 students. The proportion of items at various levels of DI, DisI, and PBS and the average values for item DI, DisI in both parts of each exam were comparable. The average scores in part-II were significantly higher than part-I (P < 0.001, < 0.001 and 0.04) and lower-order cognitive-level items scores were higher in three exams (P < 0.0001, 0.0001, 0.0001). Higher- order cognitive level items scores were comparable between part I and II in all courses. The significant factor for change in marks were questions cognitive level and type of the course., Conclusion: Access to E-resources during examination does not make a significant difference in scores of higher-order cognitive level items. Question cognitive level and course type were the significant factors for the change in exam scores when accessing E-resources. Time-restricted E-resources accessed tests that examine higher cognitive level item had no significant academic integrity drawback., (© 2022. The Author(s).)

Objective: To evaluate and compare the outcome of ECIRS in the treatment of partial staghorn renal calculi in both prone split-leg positions versus GMSV positions with regard to; technical aspects, success rate, operative time, complications, safety, and effectiveness of both approaches., Patients and Methods: Between October 2018 and August 2021, 66 patients with partial staghorn calculi were enrolled in this prospective comparative study. Patients were randomly divided according to a 1:1 ratio into two groups. Group A included 33 patients who were treated by (ECIRS) in the prone split-leg position, and group B included 33 patients who were treated by (ECIRS) in the Galdakao-modified supine Valdivia (GMSV) position., Results: No significant statistical difference between both groups regarding the mean age (p = 0.448), mean body mass index (BMI) (p = 0.137), mean stone burden (p = 0.435), mean operative time (p = 0.541) and the number of calyces located in branched stones (p = 0.628). The mean hospital stay was 6.71 ± 1.12 days for group A and 6.66 ± 1.10 days for group B patients (p = 0.724). The final SFR was achieved in (29)87.87% and (30)90.9% of group A & B patients, respectively (p = 0.694). No significant difference was detected between both groups in perioperative complication rates., Conclusion: ECIRS is safe and effective in treating partial staghorn calculi either in the prone split-leg position or in the Galdakao-modified supine Valdivia position, with comparable outcomes and no statistically significant difference between both positions., (© 2022. The Author(s).)

Background: Multiple sclerosis (MS) is a progressive autoimmune demyelinating disease of the central nervous system. To date, there is no effective therapy for it. Our study aimed to determine the potential role of platelet-rich plasma (PRP) in the treatment of MS in cats., Methods: The current study was conducted on 15 adult Persian cats that were divided into three groups: control negative, control positive (ethidium bromide (EB)-treated group), and PRP co-treated group (EB-treated group intrathecally injected with PRP on day 14 post-spinal cord injury). PRP was obtained by centrifuging blood on anticoagulant citrate dextrose and activating it with red and green laser diodes. The Basso-Beattie-Bresnahan (BBB) scores were used to assess the motor function recovery on days 1, 3, 7, 14, 20, and 28 following 14 days from EB injection. Moreover, magnetic resonance imaging (MRI) analysis, histopathological investigations, transmission electron microscopy (TEM) studies, and immunohistochemical analysis were conducted, and the gene expressions of nerve growth factors (NGFs), brain-derived neurotrophic factors (BDNF), and stromal cell-derived factors (SDF) were evaluated., Results: Our results indicated that PRP had a significant ameliorative effect on the motor function of the hindlimbs as early as day 20 and so on. MRI revealed that the size and intensity of the lesion were significantly reduced in the PRP co-treated group. The histopathological and TEM investigations demonstrated that the PRP co-treated group had a significant improvement in the structure and organization of the white matter, as well as a high remyelination capacity. Furthermore, a significant increase in myelin basic protein and Olig2 immunoreactivity as well as a reduction in Bax and glial fibrillar acidic protein immune markers was observed. NGFs were found to be upregulated by gene expression., Conclusion: As a result, we concluded that the intrathecal injection of PRP was an effective, safe, and promising method for the treatment of MS., (© 2022. The Author(s).)

Background: Introducing radiological anatomy in the preclinical curriculum can increase the understanding of Anatomy. Regardless of the integration when teaching anatomy, it is essential to maintain oversight as to what and how much is being taught. In addition, the knowledge requirements for preclinical students should be considered. The purpose of this kind of integration is that the student should be able to apply the knowledge which can help them better understand anatomy and not to make the course more challenging. This study aimed to understand whether adding radiological images would increase the difficulty level of the questions., Methods: We introduced radiological images, including X Rays, CT scans and MRIs, when teaching anatomy in the preclinical curriculum. A class of 99 students were tested using A-type MCQs (n = 84). All 84 questions were categorized on whether they were case-based with or without a radiological image. The item analysis of both groups of test questions was then compared based on their difficulty and discrimination index. A qualitative student perception regarding the inclusion of radiological images in anatomy was also measured using a questionnaire with a 5-point Likert scale., Results: The results showed that the performance level of the students was similar when comparing the test questions in both groups. The item analysis of the MCQs in the two groups revealed that by integrating radiological images when teaching anatomy, the various parameters in both groups of test questions were in the same range. More than 80% of the students felt that radiological images facilitate the achievement of learning outcomes and help to apply their knowledge in clinical contexts. The study's findings reported that the rate of satisfaction by including radiological images when teaching anatomy is high., Conclusion: Recognition and interpretation of images are essential in an undergraduate medical program. Students found it helpful when radiological images were introduced to them when teaching anatomy. Since the students' performance in summative exams in both groups of questions was in the same range, the findings also point out that adding radiological images when teaching anatomy does not increase the difficulty of the subject., (© 2022. The Author(s).)

Background: To date, only few studies have investigated ghrelin levels in bipolar disorders, and all have exclusively measured acylated ghrelin, with none investigating total ghrelin (acylated and des-acylated). We aimed to investigate peripheral levels of acylated and total ghrelin in subjects experiencing a manic episode of bipolar disorder., Methods: Peripheral levels of acylated and total ghrelin were measured in hospitalised medicated individuals recovering from a manic episode. Enzyme-linked immunosorbent assays (ELISA) were used to measure ghrelin levels in patients and compared with healthy controls. The relationship between ghrelin levels in bipolar disorder, self-reported hunger measures, demographic and clinical parameters was investigated with correlational analyses., Results: Twenty-four subjects (15 males, 9 females) recovering from mania and 27 matched healthy controls (13 males, 14 females) were recruited for the study. Mean values of both acylated (187 vs.520 pg/mL) and total ghrelin (396 vs. 648 pg/mL) were significantly reduced in bipolar disorder (p = 0.001). Ghrelin levels correlated positively with markers of illness severity and negatively with prescribed mood stabilizers, second-generation antipsychotics, weight and body mass index., Conclusion: Peripheral measurements of acylated and total ghrelin were both reduced in bipolar disorder patients compared to healthy controls. Whilst illness severity promotes higher ghrelin levels, pharmacological treatment and weight gain exercise the opposite effect., (© 2022. The Author(s).)

Background: This is a practice guide for the evaluation tool specifically created to objectively evaluate longitudinal faculty development programs (FDP) using the "5×2 -D backward planning faculty development model". It was necessary to create this tool as existing evaluation methods are designed to evaluate linear faculty development models with a specific endpoint. This backward planning approach is a cyclical model without an endpoint, consisting of 5 dynamic steps that are flexible and interchangeable, therefore can be a base for an evaluation tool that is objective and takes into account all the domains of the FDP in contrast to the existing, traditional, linear evaluation tools which focus on individual aspects of the program. The developed tool will target evaluation of longitudinal faculty development programs regardless of how they were planned., Methodology: Deductive qualitative grounded theory approach was used. Evaluation questions were generated and tailored based on the 5 × 2-D model followed by 2 Delphi rounds to finalize them. Based on the finalized evaluation questions from the results of the Delphi rounds, two online focus group discussions (FGDs) were conducted to deduce the indicators, data sources and data collection method., Results: Based on the suggested additions, the authors added 1 new question to domains B, with a total of 42 modifications, such as wording changes or discarding or merging questions. Some domains received no comments, therefore, were not included in round 2. For each evaluation question, authors generated indicators, data sources and data collection methods during the FGD., Conclusion: The methodology used to develop this tool takes into account expert opinions. Comprehensiveness of this tool makes it an ideal evaluation tool during self-evaluation or external quality assurance for longitudinal FDP. After its validation and testing, this practice guide can be used worldwide, along with the provided indicators which can be quantified and used to suit the local context., (© 2022. The Author(s).)

Objectives: There has been increasing interest in the management of oropharyngeal swallowing dysfunction (SwD). Its prevalence, particularly in otherwise healthy infants and toddlers (OHITs), is underappreciated. As the standard diagnostic tests are either invasive or scarce, valid parent-reported outcome (PRO) questionnaires could play a pivotal role in the understanding and managing SwD in this group. This article reviewed the literature on PRO questionnaires pertaining to SwD in OHITs., Data Source: A librarian searched Prospero, Cochrane Library, Embase, Medline, PsycINFO, HaPI, CINAHL, and SCOPUS until February 2021 using the MeSH terms for deglutition and screening methods., Review Method: Questionnaires that examined disease-specific or eating and feeding concerns or difficulties were excluded. Two reviewers independently identified PRO questionnaires for SwD that were used in OHITs and extracted the author names, publication year, questionnaire name, the studied population, and the reported psychometric assessments. A quality assessment was performed based on consensus-based standards for the selection of health measurement instruments (COSMIN) and updated criteria for good measurement properties., Results: Of the 3488 screened articles, we identified only two questionnaires, the pediatric version of the Eating Assessment Tool (PEDI-EAT-10) and the PRO questionnaire for Swallowing Dysfunction in OHITs. The PEDI-EAT-10 authors assessed the validity and reliability on children with cerebral palsy. However, concerns were identified regarding the developmental process and the internal structure validity. The PRO questionnaire for SwD in OHITs meets criteria but has not yet been validated in the population of interest nor its psychometric properties assessed., Conclusion: Two instruments were identified. The PED-EAT-10 exhibits methodological flaws, while Edmonton PRO questionnaire for SwD in OHITs awaits construct validation and could fill the current knowledge gap., (© 2021. The Author(s).)

Background: To evaluate the clinical management of choanal atresia (CA) in tertiary centers across Canada., Methods: Multi-centre case series involving six tertiary care pediatric hospitals across Canada. Retrospective chart review of patients born between 1980 and 2010 diagnosed with choanal atresia to a participating center., Results: The health charts of 215 patients (59.6% female) with choanal atresia (CA) were reviewed. Mean age of initial surgical repair was 0.8 months for bilateral CA, and 48.6 months for unilateral CA. Approaches of surgical repair consisted of endoscopic transnasal (31.7%), non-endoscopic transnasal (42.6%), and transpalatal (25.2%). Stents were used on 70.7% of patients. Forty-nine percent of patients were brought back to the OR for a planned second look; stent removal being the most common reason (86.4%). Surgical success rate of initial surgeries was 54.1%. Surgical technique was not associated with rate of restenosis [χ 2 (2) = 1.6, p = .46]., Conclusions: The present study is the first national multi-institutional study exploring the surgical outcomes of CA over a 30-year period. The surgical repair of CA presents a challenge to otolaryngologists, as the rate of surgical failure is high. The optimal surgical approach, age at surgical repair, use of stents, surgical adjuncts, and need for planned second look warrant further investigation., (© 2021. The Author(s).)

Background: To evaluate the clinical presentation of choanal atresia (CA) in tertiary centers across Canada., Methods: Multi-centre case series involving six tertiary care pediatric hospitals across Canada. Retrospective chart review of patients born between 1980 and 2010 diagnosed with CA at a participating center., Results: The health charts of 215 patients (59.6% female) with CA were reviewed and included in this study. The mean age of patients at time of CA presentation was 0.4 months (range 0.1 to 7.2 months) for bilateral CA and 37.8 months (range 0.1 to 164.1 months) for unilateral cases. The most common presenting symptoms for bilateral CA in decreasing order were respiratory distress (96.4%), feeding difficulties (68.2%), and rhinorrhea (65.5%), and for unilateral cases in decreasing order were rhinorrhea (92.0%), feeding difficulties (24.7%), and respiratory distress (18.0%). For the majority of patients (73.2%), the obstruction comprised mixed bony and membranous tissue, with only 10.5% presenting with a purely membranous obstruction. Familial history of CA was confirmed in only 3.3% of cases. One half of patients with CA presented with one or more associated anomalies and 30.6% had a syndrome., Conclusions: The present investigation is the first national multi-institutional study evaluating the clinical presentation of CA over three decades. The present cohort of CA patients presented with a breadth of co-morbidities with highly variable presentations, with bilateral cases being more severely affected than unilateral cases. Further investigation into hereditary linkages to CA development is warranted., (© 2021. The Author(s).)

Objectives: To describe indications for injection augmentation (IA), endoscopic repair (ER) and conservative methods for the management of type 1 laryngeal cleft (LC1) and propose a management algorithm. We also aimed to compare success of IA and ER and determine independent predictors of treatment failure., Methods: Retrospective study of patients diagnosed with LC1 at a Pediatric Otolaryngology referral centre between 2004 and 2016. All had pre-operative instrumental swallowing evaluation (VFSS/FEES), and were managed with a combination of conservative measures, IA and/or ER. We collected demographics, symptoms, comorbidities, VFSS/FEES results, and operative details. The primary outcome was symptom resolution by parental report. The secondary outcome was predictors of treatment failure., Results: 88 patients were included in the analysis, with mean age 26 ± 25 months. Most presented with choking events (68%) or recurrent pneumonias (48%). In total, there were 55 IA performed and 45 ER. Of the patients who received IA, 19 required subsequent ER. 95% had symptom improvement, 67% had complete resolution. IA had a 56% long-term success rate, whereas that for ER was 85%. Tube feeding at initial evaluation was an independent predictor of treatment failure (HR 11.33 [1.51-84.97], p = 0.018)., Conclusions: LC1 can be effectively managed with a combination of IA and ER with favorable results. Failure to respond to IA does not preclude ER, and both have their role in management. Patients who are tube fed have a higher probability of treatment failure. We propose a management algorithm that includes reasoning for conservative approaches, and reduces exposure to general anesthesia.

Background: Inferior turbinoplasty (IT) and adenoidectomy (Ad) are frequently resorted to in children with chronic rhinitis (CR) refractory to medical therapy. The aim of this study is to document the long-term improvement in quality of life (QOL) in children with CR following endoscopic IT with or without Ad., Methods: A retrospective case series study was conducted. We searched a prospectively kept surgical database for children ≤18 years old who had CR who underwent endoscopic IT with or without Ad between 2009 and 2016 at a tertiary care children's center. Patients with sinonasal pathologies other than CR, had craniofacial syndromes or dysmorphism and had other sinonasal procedures or trauma were excluded. Collected data included demographics, secondary diagnoses, duration of follow-up, and complications of procedures. The Glasgow Children's Benefit Inventory (GCBI) was administered by phone to assess QOL improvement., Results: One hundred sixty-five eligible subjects were identified. Eighty-nine subjects met the inclusion criteria. Data was collected for the 60 subjects that were reached. Forty-two patients had IT only while 18 had IT and Ad. The mean age was 10.7 ± 2.7 years, with 31 males and 29 females. The median duration of follow-up (25th, 75th percentile) was 38.1 months (24.6, 55.8). The median GCBI score (25th, 75th percentile) was 22.9 (6.3, 39.6) revealing an overall positive benefit in all domains. There was only one complication., Conclusions: This study validates prior findings regarding improvement of QOL and safety of IT with or without Ad for children with CR and indicates it is maintained in the long term.

Background: Ensuring universal access to malaria diagnosis and treatment is a key component of Pillar 1 of the World Health Organization Global Technical Strategy for Malaria 2016-2030. To achieve this goal it is essential to know the types of facilities where the population seeks care as well as the malaria service readiness of these facilities in endemic countries., Methods: To investigate the utilization and provision of malaria services, data on the sources of advice or treatment in children under 5 years with fever from the household-based Demographic and Health Surveys (DHS) and on the components of malaria service readiness from the facility-based Service Provision Assessment (SPA) surveys were examined in Malawi, Senegal and Tanzania. Facilities categorized as malaria-service ready were those with: (1) personnel trained in either malaria rapid diagnostic testing (RDT), microscopy or case management/treatment of malaria in children; (2) national guidelines for the diagnosis and treatment of malaria; (3) diagnostic capacity (available RDT tests or microscopy equipment as well as staff trained in its use); and, (4) unexpired artemisinin-based combination therapy (ACT) available on the day of the survey., Results: In all three countries primary-level facilities (health centre/health post/health clinic) were the type of facility most used for care of febrile children. However, only 69% of these facilities in Senegal, 32% in Malawi and 19% in Tanzania were classified as malaria-service ready. Of the four components of malaria-service readiness in the facilities most frequented by febrile children, diagnostic capacity was the weakest area in all three countries, followed by trained personnel. All three countries performed well in the availability of ACT., Conclusions: This analysis highlights the need to improve the malaria-service readiness of facilities in all three countries. More effort should be focused on facilities that are commonly used for care of fever, especially in the areas of malaria diagnostic capacity and provider training. It is essential for policymakers to consider the malaria-service readiness of primary healthcare facilities when allocating resources. This is particularly important in limited-resource settings to ensure that the facilities most visited for care are properly equipped to provide diagnosis and treatment for malaria.

Background: Identification and assessment of professional competencies for medical students is challenging. We have recently developed an instrument for assessing the essential professional competencies for medical students in Problem-Based Learning (PBL) programs by PBL tutors. This study aims to evaluate the reliability and validity of professional competency scores of medical students using this instrument in PBL tutorials., Methods: Each group of seven to eight students in PBL tutorials (Year 2, n = 46) were assessed independently by two faculty members. Each tutor assessed students in his/her group every five weeks on four occasions. The instrument consists of ten items, which measure three main competency domains: interpersonal, cognitive and professional behavior. Each item is scored using a five-point Likert scale (1 = poor, 5 = exceptional). Reliability of professional competencies scores was calculated using G-theory with raters nested in occasions. Furthermore, criterion-related validity was measured by testing the correlations with students' scores in written examination., Results: The overall generalizability coefficient (G) of the professional competency scores was 0.80. Students' professional competencies scores (universe scores) accounted for 27% of the total variance across all score comparisons. The variance due to occasions accounted for 10%, while the student-occasion interaction was zero. The variance due to raters to occasions represented 8% of the total variance, and the remaining 55% of the variance was due to unexplained sources of error. The highest reliability measured was the interpersonal domain (G = 0.84) and the lowest reliability was the professional behavior domain (G = 0.76). Results from the decision (D) study suggested that an adequate dependability (G = 0.71) can be achieved by using one rater for five occasions. Furthermore, there was a positive correlation between the written examination scores and cognitive competencies scores (r = 0.46, P < 0.01), but not with the other two competency domains (interpersonal and professionalism)., Conclusions: This study demonstrates that professional competency assessment scores of medical students in PBL tutorials have an acceptable reliability. Further studies for validating the instrument are required before using it for summative evaluation of students by PBL tutors.

The Arabian Peninsula is recognized as an arid area dominated by deserts and poor biodiversity. However, the Kingdom of Saudi Arabia (henceforth abbreviated into KSA) has a wide range of flora, consisting of different species of trees, herbs, and shrubs and containing numerous edible and medicinal plants. The KSA is characterized by its vast area of diverse geographical landscapes and climates. Consequently, there is enormous variation in the distribution of plants across the Kingdom. The traditional use of ethnomedical plants in the KSA represents a strong interconnection among familiar remedies, health, diet, and traditional healing practices characterized by specific cultures. The present paper reviews a collection of medicinal plants in KSA used in ethnomedicine. This review might be useful in developing strategies for the sustainable use of medicinal plants which are among the threatened important natural resources in folk medicine in the KSA. The present study reports 309 genera which cover 471 species from a total of 2253 known species belonging to 89 families. The most dominating families are Asteraceae, Fabaceae, Lamiaceae, Euphorbiaceae, Solanaceae, Apiaceae, Brassicaceae, Chenopodiaceae, Poaceae, Amaranthaceae, Boraginaceae, Apocynaceae, Convolvoulaceae, Asclepiadaceae, Capparaceae, Polygonaceae, and Zygophyllaceae.

Background: Seroma is the most frequent postoperative complication following breast cancer surgery. Our aim was to evaluate the effect of the harmonic focus scalpel versus electrocautery in reducing seroma formation post-mastectomy and axillary clearance., Methods: A prospective randomized controlled trial study was conducted at the Department of Surgery of Suez Canal University Hospital from April 26th 2014 to 30th June 2016. Seventy-two women, in whom a mastectomy and axillary clearance for breast cancer were performed, were randomly allocated to either harmonic dissection ( n  = 36) or electrocautery ( n  = 36)., Results: The mean operative time was significantly longer for harmonic dissection compared with electrocautery (2.63 ± 0.41 vs. 1.75 ± 0.26 h; p  < 0.0001). In addition, a significantly smaller amount of intraoperative blood loss (69.4 ± 25.1 vs. 255.5 ± 41.6 ml; p  = 0.002) and total drainage volume (1277.8 ± 172.5 ml vs. 3300 ± 167.5 ml; p  = 0.002) were found in the harmonic group. Moreover, there was a significant reduction in the time of drain removal (10.9 ± 1.12 vs. 15.9 ± 1.44; p  = 0.001) and the incidence of seroma formation after drain removal [8.3% vs 33.3%; p  = 0.003] in the harmonic group compared with those in the electrocautery group., Conclusion: Harmonic dissection technique leads to significant decreases in intraoperative blood loss, total drainage volume and postoperative seroma in terms of shorter drain duration with a minimal increase in the operative time and better quality of life. Here, we recommend the use of the harmonic dissection technique in mastectomy and axillary clearance., Competing Interests: The study was approved by the Hospital Ethics Committee and written informed patient consent was obtained after providing an explanation of the purpose, methods, effects and complications of the intervention.We have consent to publish case reports through our institutional consent form.The authors declare that no competing interests exist. None of the authors had any commercial bias related to the product analyzed in this study, including consulting fees, reimbursement for travel and lodging costs, speaking fees, stocks, grants, and any other financial interest with the company and the product.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Distally impacted chronic tracheobronchial sharp foreign bodies in children are a management challenge that presents with clinical subtlety and extreme variability. The use of image guided techniques, imaginative instrumentation, tracheotomy, thoracotomy, and even extracorporeal membrane oxygneation have been reported. Endoscopy is made difficult by the distal location, inflammatory reaction with granulation tissue formation, and bleeding obscuring the foreign body. Our aim is to describe our experience with two children who had removal of aspirated impacted sharp metallic foreign bodies from the distal airway using rigid bronchoscopy, preceded by maximal medical therapy.

Background: Epistaxis is the most common emergent consultation to otolaryngology-head & neck surgery (OHNS) and with 60% of the population having experienced an episode and 1.6 in 10,000 requiring hospitalization in their lifetime. In preliminary studies Floseal® (Baxter, USA) Hemostatic Matrix has shown efficacy in up to 80% of persistent anterior epistaxis. We sought to evaluate the clinical efficacy and cost-effectiveness of Floseal® (Baxter, USA) compared to traditional nasal packing for persistent epistaxis., Methods: A prospective, randomized controlled trial was conducted on all adult patients consulted to the OHNS service at the tertiary referral centers of the University of Alberta Hospital and Royal Alexandra Hospital for persistent epistaxis. Patients were randomized to the Floseal® (Baxter, USA) or traditional packing study arms. Our main clinical outcome measures were: 1) Hemostasis directly following treatment and at 48 h post-treatment, and 2) self-reported patient comfort at 48 h post-treatment. Further, trial data was used for a formal cost-effectiveness analysis to determine incremental cost-effectiveness ratio (ICER). Univariate sensitivity analysis and uncertainty analysis were performed., Results: There were no significant differences between groups for initial hemostasis (76.9% vs. 84.6%, p = 1.000) or, hemostasis at 48 h (76.9% vs. 69.2%, p = 1.000), requirement for admission (15.4% vs. 46.1%, p = 0.2016) or 30-day re-presentation rates (15.4% vs. 46.1%, p = 0.2016). Floseal® (Baxter, USA) was superior for decreased pain during placement (2.42 vs. 7.77, p = 0.0022), treatment (0.50 vs. 4.46, p = 0.0007) and removal (0 vs. 3.85, p = 0.0021). Floseal® (Baxter, USA) provides an average $1567.61 per patient savings from the single-payer system point of view and has an ICER of - $11,891 per re-bleed prevented (95% CI: -$37,658 to +$473). Uncertainty analysis shows that Floseal® has >90% chance of not only being cost-effective, but the dominant (preferred) treatment., Conclusions: Floseal® (Baxter, USA) was demonstrated to be an effective, comfortable and cost-effective alternative treatment of persistent epistaxis when compared to traditional packing methods for patients referred to OHNS with a normal coagulation profile., Trial Registration: Trial registration number: NCT02488135 . Date registered: June 26, 2015.

Background: Adenotonsillectomy (AT) is the most commonly performed procedure for sleep disordered breathing (SDB) in pediatrics. However, 20-40% of patients will have persistent signs and symptoms of SDB after AT. Drug-induced sleep endoscopy (DISE) has the potential to individualize surgical treatments and avoid unnecessary or unsuccessful surgeries. The objective of this study was to determine the predictors of failure of DISE-directed adenoidectomy and/or tonsillectomy in otherwise healthy children with SDB., Methods: We retrospectively reviewed a prospective database of children who presented with SDB. All patients underwent preoperative pulse oximetry (PO), followed by DISE with T ± A, The variables documented included demographics, ethnicity, co-morbidities, family history, McGill Oximetry Score (MOS) on PO, as well as findings of collapse and or obstruction on DISE and symptom resolution based on modified Pediatric Sleep Questionnaire (PSQ). The primary outcome was the independent predictors of treatment failure based on multivariate binary logistic regression., Results: Three hundred eighty-two patients satisfied the inclusion criteria. Based on post-operative modified PSQ, SDB resolved in 259 patients (68%), whereas 123 (32%) had persistent symptoms. On bivariate analysis, neuropsychiatric diagnosis (r = 0.286, p = 0.042), history of sleepwalking or enuresis (r = 0.103, p = 0.044), MOS (r = 0.123, p = 0.033), presence of DNS (r = 0.107, p = 0.036), and presence of laryngomalacia (r = 0.122, p = 0.017) all positively correlated with treatment failure. Small tonsil size on DISE correlated with treatment failure (r = -0.180, p < 0.001). Multivariate analysis identified age greater than 7 years (OR = 1.799, [95% CI 1.040-3.139], p = 0.039), obesity (OR = 2.032, [95% CI 1.043-3.997], p = 0.040), chronic rhinitis (OR = 1.334, [95% CI 1.047-1.716], p = 0.025), deviated nasal septum (OR = 1.745, [95% CI 1.062-2.898], p = 0.031) and tonsil size (OR = 0.575, [95% CI 0.429-0.772], p < 0.01) as independent predictors of treatment failure., Conclusions: Obese, asthmatic, and children older than seven years are at increased risk of treatment failure after DISE-directed AT. Several DISE findings can independently predict AT failure, including tonsil size, degree of chronic rhinitis, and the presence of a deviated nasal septum, and can be addressed at a second stage. Further research is needed into the role of DISE in surgically naïve patients with SDB, and to compare DISE-directed surgery with the current standard of care.

Background: The surgical excision of anatomic obstructions such as adenoids, palatine or lingual tonsils are commonly performed in children with sleep disordered breathing (SDB). Imaging studies measuring airway changes post-surgery in the SDB pediatric population are scarce, rarely addresses the nasal cavity, and are based on global measures (e.g. volume) that do not represent the complexity of the upper airway anatomy. The purpose of this pilot is to test the feasibility in using cone beam CT (CBCT) to analyze the nasal and pharyngeal airway space post-surgery using meaningful methods of analyses, and correlating imaging findings with clinical outcomes in children with SDB symptoms and maxillary-mandibular disproportion., Methods: Twelve non-syndromic children with SDB symptoms and jaw disproportions were evaluated by interdisciplinary airway team before and after upper airway surgery. CBCT and OSA-18 quality of life questionnaire pre and post-operatively were completed. Conventional and new airway variables were measured based on 3D models of the upper airways and correlated with OSA-18. Conventional measures include volume, surface area, and cross-sectional area. New airway measures include constriction and patency; point-based analyses., Results: Eight females and four males were 8.8 ± 2 years with mean BMI of 18.7 ± 3. OSA-18 improved, median (lower quartile-upper quartile) from 64.2 (54.7-79.5) to 37.6 (28.7-43) postoperatively, p < 0.001. The median of all airway measures improved however with very wide range. Subjects with the smallest amounts of constriction relief and/or gain in airway patency presented with least improvement in OSA-18. New airway measures show strong correlation with changes in OSA-18 (ρ = 0.44 to 0.71) whereas conventional measures showed very weak correlation (ρ = -0.04 to 0.37)., Conclusions: Using point-based analyses, new airway measures better explained changes in clinical symptoms compared to conventional measures. Airway patency gained by at least 150% and constriction relief by at least 15% showed marked improvement in OSA-18 by 40-55%, after surgery in the tested cohort.

Background: Adenotonsillectomy is the most commonly performed operation for pediatric snoring/sleep disordered breathing (S/SDB). However, 20-40% of patients will fail to improve. Drug-induced sleep endoscopy (DISE) may provide a more individualized surgical plan and limit unsuccessful surgeries. The aim of this study was to assess the impact of DISE on surgical decision-making in surgically naïve children with S/SDB., Methods: A retrospective observational cohort study was undertaken at the Stollery Children's Hospital. Patients 3-17 years of age who underwent DISE-directed surgery for S/SDB between January 2009 and December 2015 were eligible. We excluded other indications for tonsillectomy and syndromic children. The primary outcome was the level of agreement between a DISE-based surgical decision and the reference standard based on the American Academy of Pediatrics (AAP) guidelines via un-weighted Cohen's kappa. Secondary outcomes included the frequency and type of alternate surgical targets identified by DISE. The agreement on tonsil size between in-office physical assessment and DISE was also calculated. The effectiveness of DISE-directed surgery on postoperative S/SDB was not investigated., Results: Five hundred fifty-eight patients were included. DISE changed the surgical plan in 35% of patients. Agreement between DISE-based and AAP clinical practice guidelines-based management was low (κ = 0.354 +/- 0.021 [95% CI 0.312-0.395]). An alternate diagnosis or surgical target was identified by DISE in 54% of patients. There was moderate agreement on tonsil size (κ = 0.44 [0.33-0.55]) between DISE and in-office clinical assessment., Conclusions: This is a first phase diagnostic study, which demonstrates that DISE affects decision-making in surgically naïve children with S/SDB in up to 35% of patients. It has utility in individualizing first stage surgical treatments as well as identifying alternate targets for further surgical or medical therapy, while potentially limiting unsuccessful surgeries. Further studies to examine the effect of DISE on surgical outcomes are required.

Background: As minimally invasive cardiac and vascular procedures are on the rise, the incidence of iatrogenic acute aortic dissection (IAAD) will increase. Cardiovascular professionals should be aware about the risk factors, means of prevention and best management options for IAAD in the perioperative setting., Case Presentation: We present the successful clinical management of a complicated case of IAAD after minimally invasive aortic valve replacement., Conclusion: High index of suspicion is required for prompt diagnosis of IAAD; collaboration of the whole perioperative team is imperative for management of this catastrophe.

Background: Nasal obstruction is a common complaint seen by otolaryngologists. The internal nasal valve (INV) is typically the narrowest portion of the nasal cavity, and if this area collapses on inspiration the patient experiences significant symptoms of nasal obstruction. The nasal obstruction is further compounded if the INV is narrower than normal. Previous studies have evaluated the effectiveness of techniques to alleviate structural nasal obstruction, but none have looked specifically at spreader grafts measured by acoustic rhinometry or validated grading assessment of dynamic INV collapse. Our objective was to evaluate the application of acoustic rhinometry coupled with visual endoscopic grading of the INV, and validated subjective measurements, in patients undergoing endonasal spreader graft surgery with septoplasty and turbinoplasty., Methods: This is a prospective clinical study conducted within a tertiary care rhinoplasty practice. Patients undergoing septoplasty and bilateral inferior turbinoplasty with bilateral endonasal spreader graft placement for observed internal nasal valve collapse were recruited. Baseline, early and intermediate postoperative measures were obtained. The primary outcome was grading of the INV collapse on video endoscopy. Secondary outcomes included cross-sectional area at the INV measured by acoustic rhinometry, subjective Nasal Obstruction Symptom Evaluation (NOSE) and Sino-Nasal Outcome Tool (SNOT-22) scores., Results: A total of 17 patients, average age of 34.5 ± 12.2 years, undergoing septoplasty, bilateral endonasal spreader grafts, and bilateral turbinoplasty were included in the study. Postoperative measurements were performed at an average of 8.1 ± 1.6 weeks and 17.7 ± 4.2 weeks. Patients had significant improvement for INV collapse grading, cross-sectional area, NOSE and SNOT-22 scores in both the early and intermediate follow up. Endoscopic grading had moderate inter-rater agreement (κ = 0.579) and average intra-rater agreement (κ = 0.545)., Conclusions: This study is the first to demonstrate a statistically significant improvement of objective measurement of internal nasal valve function, both static and dynamic, and subjective improvements. This supports endonasal cartilagenous spreader grafts with septoplasty and inferior turbinoplasty for patients with nasal obstruction with internal nasal valve collapse.

Surgical management of acute aortic infection is challenging, including excision of the infected segment and reconstruction either through extra-anatomical bypass or in situ graft replacement with higher risk of re-infection. Here in, we present a case of delayed paralysis developed after an extra-anatomic (axillary-bifemoral) bypass of infected thoracic aorta in a 51 year old Caucasian male. Reversal of paralysis was successfully achieved via larger extra-anatomical ascending aorta to infra-renal aorta bypass and cerebrospinal fluid (CSF) drainage.

Objective: To validate the pharyngeal findings in sleep nasopharyngoscopy (SNP) of children with snoring - sleep disordered breathing (S-SDB)., Design: Prospective agreement diagnostic study on retrospective data., Methods: We conducted an inter-and intra-rater agreement study on video documentations of SNP performed on children (non-syndromic, complex, or operated upon) who presented with S-SDB. The videos featured various pharyngeal findings (normal, collapse, mixed or obstruction). Three 'non-expert' raters at various stages in their otolaryngological careers rated the videos independently, and on two separate occasions following an instructional session. We calculated both weighted and non-weighted linear kappa., Results: Each independent observer rated sixty-one videos (2 weeks apart). Intra-observer agreement was 0.64 ± 0.08 (95% CI 0.48-0.81), 0.74 ± 0.07 (95% CI 0.60-0.88), 0.59 ± 0.08 (95% CI 0.43-0.74), for raters 1, two and three. Weighted kappa was 0.6 ± 0.1 (95% CI 0.41-0.79), 0.8 ± 0.06 (95% CI 0.7-0.92), 0.7 ± 0.07 (95% CI 0.57-0.83), respectively. Inter-rater agreements between raters one and two, two and three, three and four were 0.83 ± 0.06 (95% CI 0.71-0.95), 0.52 ± 0.08 (95% CI 0.36-0.70), and 0.53 ± 0.08 (95% CI 0.37-0.69), respectively. Weighted kappa was 0.83 ± 0.073 (95% CI 0.69-0.98), 0.68 ± 0.06 (95% CI 0.56-0.79), and 0.64 ± 0.07 (95% CI 0.49-0.78), respectively., Conclusions: This is the first validation of pharyngeal findings on SNP in children. It is based on a four types' classification. Overall reproducibility amongst the three raters and their agreement was moderate to good. Further work should be phase four trials investigating the impact on outcome.

Background: To better understand the genetic determination of udder health, we performed a genome-wide association study (GWAS) on a population of 2354 German Holstein bulls for which daughter yield deviations (DYD) for somatic cell score (SCS) were available. For this study, we used genetic information of 44 576 informative single nucleotide polymorphisms (SNPs) and 11 725 inferred haplotype blocks., Results: When accounting for the sub-structure of the analyzed population, 16 SNPs and 10 haplotypes in six genomic regions were significant at the Bonferroni threshold of P ≤ 1.14 × 10-6. The size of the identified regions ranged from 0.05 to 5.62 Mb. Genomic regions on chromosomes 5, 6, 18 and 19 coincided with known QTL affecting SCS, while additional genomic regions were found on chromosomes 13 and X. Of particular interest is the region on chromosome 6 between 85 and 88 Mb, where QTL for mastitis traits and significant SNPs for SCS in different Holstein populations coincide with our results. In all identified regions, except for the region on chromosome X, significant SNPs were present in significant haplotypes. The minor alleles of identified SNPs on chromosomes 18 and 19, and the major alleles of SNPs on chromosomes 6 and X were favorable for a lower SCS. Differences in somatic cell count (SCC) between alternative SNP alleles reached 14 000 cells/mL., Conclusions: The results support the polygenic nature of the genetic determination of SCS, confirm the importance of previously reported QTL, and provide evidence for the segregation of additional QTL for SCS in Holstein cattle. The small size of the regions identified here will facilitate the search for causal genetic variations that affect gene functions.

Background: This paper describes an assessment approach of clinical competencies which widens the number of problems and tasks evaluated using videos and images., Method: Clinical Image and Video Assessment (CIVA) was used to assess clinical reasoning and decision making of final year medical students. Forty to fifty clinical videos and images supported by rich text vignette and reviewed by subject matter experts were selected based on examination blueprints for analysis. CIVA scores were correlated with OSCE, Direct Observation Clinical Encounter Exam (DOCEE) and written exam scores, using the 2-sided Pearson correlation analysis, and their reliability was analyzed using Cronbach's Alpha Coefficient. Furthermore, students personally evaluated the CIVA using a 5- point Likert scale., Results: CIVA and OSCE scores showed a high correlation (r = 0.83) in contrast with the correlation scores of the written examination (r = .36) and the DOCEE (r = 0.35). Cronbach's Alpha for the OSCE and CIVA for the first batch was 0.71 and 0.78. As for the second batch it was 0.91 and 0.91 respectively. Eighty-two percent of students were very satisfied or satisfied with the CIVA process, contents and quality., Conclusions: A well constructed CIVA type assessment with a rich authentic vignette and good quality videos and images could be used to assess clinical reasoning and decision making of final year medical students. CIVA is an assessment tool which correlates well with OSCE, compliments the written and DOCEE and is easier to conduct at a possibly reduced cost.

Here we present our attempt at off pump HeartMate II left ventricular assist device (LVAD) implantation using the anticoagulant bivalirudin in a patient with heparin induced thrombocytopenia, which resulted in thrombosis within the LVAD device. This required that our procedure be converted to on pump, and a new HeartMate II LVAD device to be implanted. In our view, this thrombotic event may have been caused by a number of factors that include bivalirudin's (1) short half-life of about 20 minutes, (2) decreased activity with blood stasis, (3) inability to prevent clot propagation, and (4) uncertainty with real-time monitoring of therapeutic levels. To prevent future thrombotic events, it may be beneficial to immediately deair the LVAD device prior to the coring of the left ventricle during off pump LVAD placement. In addition, a solution other than blood may be used for priming. If blood is used for priming of the LVAD device, the duration of blood stasis should not exceed 20 minutes when bivalirudin is being used for anticoagulation. Furthermore, this case emphasizes the importance of having a backup LVAD device available and ready to use during surgical procedures.

Objective: Congenital tracheal stenosis (CTS) is challenging. Its natural history and epidemiology are poorly described. Information is scarce on cases not undergoing surgery., Methods: A retrospective review of patients with CTS in one pediatric otolaryngology practice was performed. A Medline search of English publications from 1966 to 2008 was conducted using the terms "CTS," "management of CTS," and "slide tracheoplasty.", Results: Four patients were diagnosed over 5.5 years. Diagnosis was achieved within 4 months of life in three and at 13 years of age in one. Three children presented with difficulty to ventilate in the neonatal intensive care unit. One was diagnosed with asthma early in life. Other congenital abnormalities were encountered in three patients. One child required a tracheostomy due to respiratory failure, for reasons other than CTS. None required surgical repair, and conservative management was pursued. Three patients were followed for 5 years. Our search yielded 20 relevant reports from 1996 to 2008. All were retrospective case series. A total of 310 patients with a mean age of 17.14 months (± 24.10) were used in our analysis. The male to female ratio of those reported was 1.7:1. The mean follow-up was 5.1 years. Thirty-five to 43% of patients had no qualified indications for their surgical management. Mortality and complication rates make tracheal repair a significant undertaking. Little is reported on the long-term outcomes, swallowing functions, and quality of life of patients repaired who did not require immediate interventions., Conclusion: There is a need to identify specific indications for surgery and a stratification of successful candidates by various disease-related factors. If the difficulties weaning from assisted ventilation or coping with growth and activity requirements are circumvented, children may be managed conservatively.

Objective: To identify the pattern of upper airway endoscopic findings in Down syndrome (DS) children with sleep-disordered breathing (SDB) spectrum., Design and Setting: Retrospective case-control study in a tertiary pediatric centre., Methods: DS children presenting with persistent snoring or SDB who underwent sleep nasopharyngoscopy (SNP) were identified from a prospectively kept surgical database. All SNPs were performed using a uniform intravenous sedation technique. Controls with persistent snoring or SDB from the same database were identified and pair-matched for age, gender, and body mass index (BMI) percentiles. The video recordings of the SNP for all subjects were reviewed. A comparison of the proportions of obstruction (O), mixed (M), and collapse (C) findings in each group was performed., Results: Over a period of 4.5 years, 23 consecutive DS children were identified (7 girls, 16 boys; mean age 7.09 ± 4.37 years). They were matched with 23 controls (mean age 7.6 ± 4.14 years). The DS group exhibited significantly more pharyngeal collapses than the controls (O:C:M, 2:6:15 and 12:0:10, respectively; p < .005). Lingual collapses were also noted more in DS children (11 vs 4), and a more significant number of collapses were seen (p < .004). Whereas nearly equal numbers exhibited tonsillar obstruction, adenoidal obstruction was significantly less in DS children (p < .05)., Conclusion: Generalized pharyngeal collapse dominates in DS children who present with SDB and is independent of age, gender, and BMI. Adenoidal hypertrophy causing obstruction is much less encountered than in controls.

Objective: To determine quality of life (QOL) improvement, symptom control, and safety after inferior turbinoplasty (IT) with or without adenoidectomy (Ad) in children., Design: Retrospective uncontrolled cohort study., Setting: Tertiary care pediatric hospital., Methods: A prospective database was searched. The database contained information regarding age, gender, other diagnoses, and complications. Inclusion criteria were (1) children who presented with chronic rhinitis (CR) refractory to medical treatment and (2) children who underwent IT with or without Ad., Main Outcome Measures: The Glasgow Children's Benefit Inventory (GCBI) was used to assess QOL improvement. The GCBI calculates a score ranging from -100 (maximum harm) to +100 (maximum benefit), with 0 representing no change after surgery., Results: Eighty-seven patients were identified. Forty-one were excluded owing to concurrent lingual tonsillectomy or septal or sinus surgery. Forty-six consecutive patients were included. Data were obtained from all 46 patients (100%). The average age was 10 years, with 15 females and 31 males. One complication required admission. The GCBI scores showed that patients derived benefit in all domains (median GCBI 28.1, range -6.3 to 93.8)., Conclusion: Preliminary results indicate that IT with or without Ad is a safe, beneficial procedure for CR in children. The impact of IT on QOL is comparable to that of well-established operations in otolaryngology.

Background: An estimated up to 7% of high-risk cardiac surgery patients return to the operating room for bleeding. Aprotinin was used extensively as an antifibrinolytic agent in cardiac surgery patients for over 15 years and it showed efficacy in reducing bleeding. Aprotinin was removed from the market by the U.S. Food and Drug Administration after a large prospective, randomized clinical trial documented an increased mortality risk associated with the drug. Further debate arose when a meta-analysis of 211 randomized controlled trials showed no risk of renal failure or death associated with aprotinin. However, only patients with normal kidney function have been studied., Methods: In this study, we look at a single center clinical trial using patients with varying degrees of baseline kidney function to answer the question: Does aprotinin increase odds of death given varying levels of preoperative kidney dysfunction?, Results: Based on our model, aprotinin use was associated with a 3.8-fold increase in odds of death one year later compared to no aprotinin use with p-value = 0.0018, regardless of level of preoperative kidney dysfunction after adjusting for other perioperative variables., Conclusions: Lessons learned from our experience using aprotinin in the perioperative setting as an antifibrinolytic during open cardiac surgery should guide us in testing future antifibrinolytic drugs for not only efficacy of preventing bleeding, but for overall safety to the whole organism using long-term clinical outcome studies, including those with varying degree of baseline kidney function.

We present a case in which a patient with a previous sternotomy and left ventricular assist device (LVAD) implantation developed cardiac arrest during resternotomy for LVAD exchange. The surgeon refused chest compressions for fear of potential damage to the inflow cannula directly beneath the sternum. The perioperative team had no alternatives to external cardiac massage other than rapid deployment of extra-corporeal membrane oxygenation for mechanical support, so the anesthesiologist advised the nursing personnel to perform abdominal only cardiopulmonary resuscitation while the surgeon performed a femoral bypass to cannulate the groin for extra-corporeal membrane oxygenation support.

Background: We hypothesize that implantation of left ventricular assist device through off-pump technique is feasible and has a comparable result to implantation on cardiopulmonary bypass and could improve one-year survival., Methods: This retrospective, observational, single-center study was conducted on 29 consecutive patients at our institution who underwent off-pump left ventricular assist device implantation by a single surgeon., Results: Twenty-seven procedures were performed successfully using the off-pump technique. The survival rate was 92% at 30 days, 76% at 90 days, and 67% at one year. We compared the one-year survival of different implantation periods, and divided our study into three time intervals (2004-2005, 2006, and 2007). There was a trend in reduction in number of deaths over one year that demonstrated a decrease in death rate from 50% to 17%, as well as improvement in our experience over time. However, this trend is not statistically significant (p = 0.08) due to limited sample size., Conclusions: Based upon our findings, off-pump left ventricular assist device implantation is a feasible surgical technique, and combining this technique with improved device technology in the future may provide even greater improvement in patient outcomes.

Aims: PTMC produces significant changes in mitral valve morphology as improvement in leaflets mobility. The determinants of such improvement have not been assessed before., Methods and Results: The study included 291 symptomatic patients with mitral stenosis undergoing PTMC. Post-PTMC subvalvular splitting area was a determinant of post-PTMC excursion in both the anterior (B 0.16, 95% CI 0.03 to 0.30, p < 0.05) and the posterior (B 0.12, 95% CI 0.01 to 0.24, p < 0.05) leaflets. Another determinant was the post-PTMC transmitral pressure gradient for anterior (B -0.02, 95% CI -0.04 to -0.005, p < 0.01) and posterior (B -0.01, 95% CI -0.04 to -0.005, p < 0.05) leaflets excursion. The relationship between post-PTMC MVA and leaflet excursion was non-linear "S curve". There was a steep increase of both anterior (p, 0.02) and posterior (p, 0.03) leaflets excursion with increased MVA till the MVA reached a value of about 1.5 cm2; after which both linear and S curves became nearly parallel., Conclusion: The improvement in leaflets excursion after PTMC is determined by several morphologic and hemodynamic changes produced in the valve. The increase in MVA improves mobility within limit; after which any further increase in MVA is not associated by a significant improvement in mobility in both leaflets.