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Aims The aim of this systematic review and meta-analysis is to compare outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis. Methods A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis and trial sequential analysis of outcomes were conducted. Post-operative pain at 12-h, cosmesis, need for an additional port(s), operative time, port-site hernia, ileus, surgical site infection (SSI), intra-abdominal collection, length of hospital stay (LOS), readmission, and reoperation were the evaluated outcome parameters. Results Sixteen RCTs with total number of 2017 patients who underwent SPLA (n = 1009) or CLA (n = 1008) were included. SPLA was associated with a significantly higher cosmetic score (MD 1.11, P= 0.03) but significantly longer operative time (MD 7.08, P = 0.00001) compared to CLA. However, the difference was not significant between SPLA and CLA in the post-operative pain score at 12-h (MD −0.13, P = 0.69), need for additional port(s) (RR0.03, P = 0.07), port-site hernia (RD: 0.00, P = 0.68), ileus (RR 0.74, P = 0.51), SSI (RR 1.38, P = 0.28), post-operative intra-abdominal collection (RR 0.00, P = 0.62), LOS (MD −2.41, P = 0.16), readmission to the hospital (RR 0.45, P = 0.22), and return to theatre (RR 0.00, P = 0.49). Trial sequential analysis demonstrated that the meta-analysis is conclusive for most of the outcomes, except LOS and intra-abdominal collection. Conclusion Although SPLA is associated with a slightly longer operative time, its efficacy and safety are comparable to CLA in management of uncomplicated appendicitis. Moreover, it offers improved post-operative cosmesis. The available evidence is conclusive, and further trials may not be required.

A meta-analysis was conducted to determine the significant risk alleles which increase the risks of gestational diabetes mellitus (GDM) in Asian to help in decision-making for genotyping of women at risk. PubMed, Science Direct and HuGE navigator were used to identify relevant studies from January 2000 to November 2018. Data extraction was done by five reviewers. Using Review Manager 5.3, association between 11 SNPs and risks of GDM was determined. Odds ratios (ORs) with 95% confidence intervals (95% CI), test of heterogeneity and publication bias were calculated. The result was considered significant if p-value ≤ 0.05. Twenty-one studies were identified based on the inclusion and exclusion criteria. From 11 genetic variants studied, 9 were found to have significant association with GDM susceptibility with different heterogeneity. Allelic, dominant and recessive genetic models show MTNR1B (rs138753, rs10830963) and CDKAL1 (rs7754840) are significantly associated with GDM. IGF2BP2 (rs4402960) was found to have significant association with GDM using allelic and recessive models. For TCF7L2 (rs7903146), significant association was found using allelic, dominant and over dominant models. KCNQ1 (rs2237892) showed association with GDM in dominant model only. Strong associations with increased susceptibility for GDM were also found for GSTM1 (deletion), GSTT1 (deletion) and GSTP1 (rs1695). However, MTNR1B (rs10830962) and PPARγ2 are lack of association with GDM risk in Asian population. Nine genetic variants were associated with increased GDM risk in Asian population. Screening of these polymorphisms to identify pregnant women at risk is recommended for prevention and personalised intervention.

The novel coronavirus (COVID-19) pandemic has affected the community at large. It has affected almost everyone and every aspect of social, economic and educational activities. Training in reproductive medicine has not been spared, as training in this field requires a combination of clinical interaction with patients, procedural experience, constant discussions and the element of research. The changes to numbers of new infections or active cases dictate the restrictions placed on the community and health care services alike. At the beginning of the pandemic, both the patients’ fear of going to a health care facility and movement restrictions had caused a significant reduction in the number of COVID-19 cases. Furthermore, the Ministry of Health (MOH) Malaysia’s recommendation to withhold all non-essential medical services, including those related to reproductive medicine, falls under this category. Therefore, it could negatively impact the quality of training and lead to an extension of training duration in reproductive medicine. Thus, the procedural experience could be supplemented with simulator training, teleconsultation could replace standard clinic sessions and online meeting platforms could replace routine academic meetings. Any modifications must be adaptable or flexible, as similar infectious pandemics and restrictions could recur from time to time.

Glutamic aciduria Type II is an uncommon inborn error of metabolism. It has a rare late-onset variant that can present in adulthood with recurrent lethargy, vomiting, metabolic acidosis, and myopathy. This is a case of a 27-year-old previously healthy gentleman who presented with complains of daily vomiting and generalized body aches that started 3 days after initiation of strenuous exercise and poor oral intake. Initially found to have high anion gap metabolic acidosis, elevated creatinine kinase levels and hypoglycaemia that improved with intravenous fluids. He later deteriorated and he was transferred to the intensive care unit for intubation and monitoring of his mental status. Labs were evident of hyperammonaemia not responding to lactulose. Further management with continuous venovenous hemodialysis (CVVHD) for ammonia clearance was required. This presentation raised the suspicion for metabolic disease and work up done was suggestive of Type II glutaric aciduria. After a long stay of 28 days in the hospital the patient recovered his mental status and was discharged home on carnitine and riboflavin. The diagnosis was confirmed with further genetic testing. He was later found to have concurrent celiac disease that was confirmed by duodenal biopsy.

To evaluate vascular endothelial growth factor (VEGF) levels in serum and urine among diabetic nephropathy (DN) patients with and without diabetic retinopathy (DR). This is a cross-sectional study involving stage 3 and 4 DN patients. A fundus examination was done to determine the DR status. VEGF levels were measured using VEGF-A ELISA kits. Serum creatinine, glycated hemoglobin (HbA1c), and urine protein creatinine index (UPCI) were analyzed per laboratory protocol. Clinical data collected includes height, weight, visual acuity, fundus photo, and macula thickness measured by the optical coherence tomography. Seventy-nine patients were divided into group 1: DN with no DR (n = 45.57%) and group 2: DN with DR (n = 34.43%). The two groups were equally distributed in age, gender, ethnicity, duration of diabetes, and smoking status. Mean serum VEGF (244.9 pg/mL), urine VEGF (230.4 pg/mL), and HbA1c (7.6%) were significantly higher in group 2. Mean serum to urine VEGF ratios were 0.72 in group 1 and 1.06 in group 2. Poorer renal function was seen in group 2, although the UPCI was not significantly different. There was no significant correlation between serum and urine VEGF levels and between serum VEGF and other parameters. The occurrence of DR in patients with DN is associated with higher mean serum than urine VEGF levels, as compared to lower serum to urine ratio of VEGF levels in DN patients without DR.

BackgroundCT-guided biopsy is a commonly used diagnostic procedure for spinal lesions. This meta-analysis aims to investigate its diagnostic performance and complications, as well as factors influencing outcomes.MethodsA systematic review of the literature was performed to identify studies reporting outcomes of CT-guided biopsies for spinal lesions. Diagnostic yield (ie, the rate of procedures resulting in a specific pathological diagnosis) and diagnostic accuracy (ie, the rate of procedures resulting in the correct diagnosis) were the primary outcomes of interest. Complications following biopsy procedures were also included.ResultsThirty-nine studies with 3917 patients undergoing 4181 procedures were included. Diagnostic yield per procedure was 91% (95% CI 88% to 94%) among 3598 procedures. The most common reason for non-diagnostic biopsies was inadequacy of sample. No difference in diagnostic yield between different locations and between lytic, sclerotic, and mixed lesions was found. Diagnostic yield did not differ between procedures using ≤13G and ≥14G needles. Diagnostic accuracy per procedure was 86% (95% CI 82% to 89%) among 3054 procedures. Diagnostic accuracy among 2426 procedures that yielded a diagnosis was 94% (95% CI 92% to 96%). Complication rate was 1% (95% CI 0.4% to 1.9%) among 3357 procedures. Transient pain and minor hematoma were the most common complications encountered.ConclusionIn our meta-analysis of 39 studies reporting diagnostic performance and complications of CT-guided biopsy, we found a diagnostic yield of 91% and diagnostic accuracy of 86% with a complication rate of 1%. Diagnostic yield did not differ between different locations, between lytic, sclerotic and mixed lesions, and between wide- and thin-bore needles.

Objective: The aim of this study was to investigate scuba diving induced exercise response in novice divers as required in open water scuba diving certification. Methods: Maximal cardiopulmonary exercise test (CPET) was performed in 30 novice divers before and within 24 hours after a standard scuba diving open water certification diving protocol of four open water dives. Results: A significant increase in maximal oxygen consumption (VO2max) in mL·kg-1·min-1 after scuba diving training [25.84 (6.0) vs. 27.04 (7.0)] (p

Objectives To compare the effect of Iberet Folic® and Zincofer® on haemoglobin (Hb) and serum ferritin level; and its adverse effect. Methods This randomised controlled trial conducted from January 2018 until December 2018. Pregnant women below 34 weeks of gestation, with Hb concentration less than 11 g/dL and serum ferritin level less than 12 ug/L were randomised to receive either one tablet Zincofer® or one tablet Iberet Folate® daily for four weeks. Both groups were compared in terms of effect on Hb level, serum ferritin level, and other haematological indices adverse effect related to treatment, and treatment cost. Results Hundred and thirty patients were recruited in this study with 68 patients in Iberet Folic group and 62 patients in Zincofer group. The change in the Hb and serum ferritin level from baseline to day 30 did not differ significantly between treatment groups. The mean (±SD) change from baseline to day 30 was 2.15 (±0.59) g/dL in the Iberet Folic group, and 1.98 (±0.49) in the Zincofer (p value = 0.08). Mean serum ferritin at day 30 was 17.2 (±3.68) ug/L and 16.7 (±4.28) ug/L with 8.44 (±3.41) and 8.55 (±3.50) difference, respectively (p = 0.86). Adverse events were comparable in between groups, with p value >0.05. GI intolerance and constipation were among the common side effects, occurred in 34.6 and 29.2% cases, respectively. Conclusions Zincofer® offers equivalent efficacy and side effect profile in comparison with Iberet Folic® for the treatment of iron deficiency anaemia (IDA) during pregnancy, but with lower cost.

Endometriosis is an inflammatory condition characterised by the presence of endometrial growth beyond the uterine cavity. It is a debilitating disease requiring multiple modalities of treatment. In considering surgery as the option of treatment, the benefits should outweigh the risk. Besides direct surgical risk, intervention may lead to a reduction of ovarian reserve, in addition to premature menopause and low fecundity. To date, there is an inconclusive evidence to support any specific parameters in monitoring disease progression following surgical intervention. Serum cancer antigen (CA)-125 is expressed by coelomic epithelium and has been extensively studied as a biomarker for endometriosis. Elevated expression of CA-125 has been shown in endometrial tissues and the marker increased indirectly from peritoneal irritation that accompanies an extensive form of endometriosis. Additionally, the visual analogue scale (VAS) scores have been used as an objective measurement for measuring pain, especially in a complex disease such as endometriosis. This review aims to consolidate a series of clinical trials that utilised CA-125 level and VAS score as tools for monitoring patients undergoing surgery for endometriosis.

To evaluate comparative outcomes of single-port laparoscopic appendicectomy (SPLA) and conventional three-port laparoscopic appendicectomy (CLA) in the management of acute appendicitis in children. A comprehensive systematic review of randomised controlled trials (RCTs) with subsequent meta-analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. Operative time, surgical site infection, intra-abdominal collection, incisional hernia, length of hospital stay (LOS), additional port/s and conversion to open were the evaluated outcome parameters. Four RCTs reporting a total number of 520 patients who underwent SPLA (n = 260) or CLA (n = 260) were included. There was no difference between SPLA and CLA group in post-operative collection (risk difference (RD) − 0.00, P = 0.94), surgical site infection (RD 0.02, P = 0.25), incisional hernia (RD 0.00 P = 1), LOS (mean difference (MD) 0.73 P = 0.93), need for additional port/s (RD 0.04, P = 0.24) and conversion to open (RD 0.00, P = 1). However, there was a significantly longer operative time in the SPLA group (MD 9.80, P = 0.00001). The certainty of the evidence was judged to be moderate for all outcomes. SPLA and CLA seem to have comparable efficacy and safety in children with acute appendicitis although the former may be associated with longer procedure time. Future high-quality RCTs with adequate sample sizes are required to provide stronger evidence in favour of an intervention.

Introduction Although the therapeutic effects of probiotics in atopic dermatitis (AD) are known, the limited findings in adults are inconsistent. Lactobacillus plantarum (LP) IS-10506 was found to improve AD symptoms due to its immunomodulatory effects. Objective To assess the Scoring Atopic Dermatitis Index (SCORAD), the serum immunoglobulin E (IgE), interleukin (IL)-4, interferon-gamma (IFN-γ), forkhead box P3 (Foxp3+), and IL-17 levels in adults with mild and moderate AD after LP IS-10506 supplementation. Methods A randomized double-blind placebo-controlled trial comparing the microencapsulated probiotic (2 × 1010 CFU/day) and placebo (skim milk-Avicel) was conducted at an outpatient clinic on 30 adults with mild and moderate AD. The patients were divided into 2 groups with 15 patients each: intervention and control. Result The SCORAD score was significantly lower in the probiotic than the placebo group on the 8th week. The IL-4 and IL-17 levels were significantly lower in the probiotic than the placebo group. The IFN-γ and Foxp3+ levels were significantly higher in the probiotic than the placebo group. However, the IgE levels remained significantly unchanged. Conclusion The administration of LP IS-10506 is effective for alleviating AD symptoms in adults owing to its immunomodulatory effects.

The objective of this study was to highlight the emergence of COVID-19 bacteria pneumonia co-infections in patients infected with SARS-Cov-2 and risk factors related to its incidence and outcomes. We reported two cases of elderly patients with multiple comorbidities infected with SARS-Cov-2 and developed COVID-19 bacterial pneumonia requiring admission to intensive care unit (ICU) with one mortality preceded by septicemic shock and multi-organ failures. Observing the potential risk factors for being infected with SARS-Cov-2 and developing COVID-19 bacterial pneumonia we strongly advocate for rapid detection of COVID-19 bacterial pneumonia in SARS-Cov-2 infected patients and rapidly characterized the bacterial involved for a better outcome and importantly for efficient antimicrobial stewardship. COVID-19 bacterial pneumonia is an emerging disease requiring rapid detection and bacterial characterization with the ongoing management for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 Keywords: COVID-19, bacterial pneumonia, acute respiratory syndrome

The aim of this study is to measure the reliability and validity of the Family Satisfaction in the Intensive Care Unit (FS-ICU) Malay language version of family member’s satisfaction with care (19 items) during their stay at the intensive care units. A cross sectional study was conducted among 196 respondents. The self-administered FS-ICU comprises of three domains with a total of 19 items. Descriptive analysis, Cronbach’s alpha and Exploratory Factor Analysis (EFA) were performed on the Malay language version of FS-ICU. The final model EFA on the Malay language version of the FS-ICU indicated Bartlett’s Test of Sphericity was significant (Chi Square= 2321.013, p value

Purpose Malnutrition is a common problem among hospitalized patients, especially among traumatic brain injury (TBI) patients. It is developed from hypermetabolism and the condition may worsen under the circumstance of underfeeding or incompatible dietary management. However, the data of nutrient intake especially calorie and protein among TBI patients were scarce. Hence, this study aimed to determine the calorie and protein intake among acute and sub-acute TBI patients receiving medical nutrition therapy in hospital Sultanah Nur Zahirah, Terengganu. Methods This observational study involved 50 patients recruited from the neurosurgical ward. Method of 24 h dietary recall was utilized and combined with self-administered food diaries for 2–8 days. Food consumptions including calorie intake and protein intake were analyzed using Nutritionist PRO™ (Woodinville, USA) and manual calculation based on the Malaysian food composition database (2015). Results Patients consisted of 56% males and 44% females with the median age of 28.0 (IQR = 22.8-36.5) years, of which 92% were diagnosed as mild TBI and the remaining (8%) as moderate TBI. The Glasgow coma scale (GCS) was adopted to classify TBI severity with the score 13–15 being mild and 9–12 being moderate. The median length of hospital stay was 2 (IQR = 2.0–3.3) days. Calorie and protein intake improved significantly from day 1 to discharge day. However, the intake during discharge day was still considered as suboptimal, i.e. 75% of calorie requirement, whilst the median protein intake was only 61.3% relative to protein requirement. Moreover, the average percentages of calorie and protein intakes throughout hospitalization were remarkably lower, i.e. 52.2% and 41.0%, respectively. Conclusion Although the calorie and protein intakes had increased from baseline, hospitalized TBI patients were still at a risk to develop malnutrition as the average intakes were considerably low as compared to their requirements. Optimum nutrient intakes especially calorie and protein are crucial to ensure optimum recovery process as well as to minimize risks of infection and complications.

Background: With the advancement of technology, Computed Tomography (CT) scan imaging can be used to gain deeper insight into the cause of death. Aims: The purpose of this study was to perform a systematic review of the efficacy of Post- Mortem Computed Tomography (PMCT) scan compared with the conventional autopsies gleaned from literature published in English between the year 2009 and 2016. Methodology: A literature search was conducted on three databases, namely PubMed, MEDLINE, and Scopus. A total of 387 articles were retrieved, but only 21 studies were accepted after meeting the review criteria. Data, such as the number of victims, the number of radiologists and forensic pathologists involved, causes of death, and additional and missed diagnoses in PMCT scans were tabulated and analysed by two independent reviewers. Results: Compared with the conventional autopsy, the accuracy of PMCT scans in detecting injuries and causes of death was observed to range between 20% and 80%. The analysis also showed that PMCT had more advantages in detecting fractures, fluid in airways, gas in internal organs, major hemorrhages, fatty liver, stones, and bullet fragments. Despite its benefits, PMCT could also miss certain important lesions in a certain region such as cardiovascular injuries and minor vascular injuries. Conclusion: This systematic review suggests that PMCT can replace most of the conventional autopsies in specific cases and is also a good complementary tool in most cases.

Background: Incidence of noncommunicable disease, specially cardiovascular diseases, is increasing in Bangladesh. Prevalence of risk factors in ischaemic heart disease (IHD) has been studied in different tertiary hospitals and institutes. This study was done in a secondary hospital with a patient population mainly of low socioeconomic condition and was compared with other patient groups of the country and Indian subcontinent. Methods: this cross sectional study was conducted in Manikganj Sadar Hospital from July 2019 to December 2019. All the patients admitted with the diagnosis of myocardial infarction (MI) were included. Cardiovascular risk factors, like smoking, diabetes mellitus (DM), hypertension (HTN), family history of premature cardiovascular diseases, dyslipidaemia and obesity, were evaluated among the patients. Results: This cross-sectional study showed most of the patients were in the age group of 50-59 years. 66% of the male patients and 2% of the female patients were smoker. 66% of the patients were hypertensive, 44% patients were diabetic, 28.5% patients were overweight, 60.4% patients had total cholesterol > 200mg/dl, 73.6% patients had LDL>130 mg/dl, 110 76.3% patients had HDL < 40 mg/ dl, 72.2% had triglyceride >150 mg/dl and 39% patients had family history of premature cardiovascular disease. Ninety (62.5%) patients had anterior MI, 50 (34.7%) patients had inferior MI and 4 (2.7%) patients had NSTEMI. 65 patients had no major risk factor and 57 % had three or more risk factors. Conclusion: The study population was more aged in comparison to other studies conducted in different parts of Bangladesh. Prevalence of smoking habit was lower but the prevalence of HTN, DM and dyslipidaemia were higher than the general population and other cohorts of MI patients. The prevalence of major risk factors was much higher than the general population of Bangladesh. Cardiovasc. j. 2020; 12(2): 96-101

Purpose: Conventional Laparoscopic Cholecystectomy (CLC) is the “gold standard” approach for patients with gallstones. Single-incision Laparoscopic Cholecystectomy (SILC) was an alternative technique, purportedly offering several postoperative benefits over CLC. Studies comparing short-term postoperative outcomes of SILC versus CLC have yielded conflicting results. Our paper aims to compare the long-term postoperative outcomes of patients undergoing SILC and CLC with a minimum follow up of seven years.

Objectives: To document the leptin level and its effect on obese and non-obese. Study Design: Observational comparative study. Setting: CMH Institute of Medical Sciences Bahawalpur, Sharif Medical and Dental College and Sharif College of Nursing Lahore. Period: From 1st January 2018 to 1st January 2019. Material & Methods: Ninety healthy obese and non-obese subjects who were selected by non-probability consecutive sampling technique included in study. Ethical approval was obtained before start of study. SPSS version 23 was used for data analysis; main variables of study were age, BMI and leptin resistance. P value ≤0.05 was considered as significant. Results: The mean leptin level in obese and non-obese was 53.75±7.54 and 50.62±7.18, respectively. There difference was statistically significant among the groups, (p=0.000). Conclusion: Results of our study reveal that leptin level is a related factor in the pathogenesis of obesity.

The aims of the present systematic review and meta-analysis were to compare non-mesh Desarda technique with standard mesh-based Lichtenstein technique for inguinal hernia repair. A systematic literature search for RCTs comparing between DT and LT was conducted using electronic databases and Google scholar service. Studies were evaluated for recurrence and post-operative complications. We pooled the data using fixed effects model and random effects model after assessing the heterogeneity among the included studies. A total number of 8 RCTs studies were included in this meta-analysis with total number of 3177 patients divided between Desarda group and Lichtenstein group as follows: 1551 patients and 1,626 patients, respectively. There was no difference in terms of recurrence between the Desarda repair and Lichtenstein repair groups [P = 0.44]. There was a lower rate of overall post-operative complications [P = 0.003], seroma [P = 0.0004] and surgical site infections (SSIs) [P = 0.04] in the Desarda group. DT and LT were found to have comparable results in terms of recurrence rate, haematoma formation, testicular atrophy and time to return to normal daily activity/work. DT is superior to LT in terms of reducing post-operative mesh-attributed complications, such as SSI and Seroma formation.

Background: Moringa oleifera Lam. has been used traditionally for the treatment of different cardio-metabolic disorders. So, the aim was to assess its leaf extracts in metabolic syndrome rat model.Methods: Out of the total 36-rats, 6 rats were given normal matched diet (NMD) while the rest were provided high-fat diet and 20% fructose (HFD-20%F). Moringa oleifera leaf extracts were administered orally for 30 days. Body weight, blood glucose, BMI, blood pressure, lipids, insulin, insulin resistance, MCP-1, visceral fat and liver weight were evaluated.Results: Sixty-days feeding with HFD-20%F produced the metabolic syndrome features like hyperinsulinemia, insulin resistance, and increase in low-density lipoprotein (LDL), visceral fat, and liver weight significantly (p

Perkembangan anak tidak luput dari peran serta orang tua yang hakikatnya berkewajiban memberikan yang terbaik bagi perkembangan fisik maupun psikis anak. Nutrisi makanan dan lingkungan juga memegang peranan penting bagi tumbuh kembang anak, selain itu dibutuhkan instansi pendidikan Pra Sekolah yang dapat membantu tugas orang tua mengontrol dan memperhatikan perkembangan anak. Anamnesa (pemeriksaan subyekti) adalah salah satu cara pengumpulan data status pasien yang didapat dengan cara operator mengajukan pertanyaan-pertanyaan yang berhubungan dengan keadaan pasien (anak pra sekolah). Salah satu metode yang dapat digunakan untuk mengetahui gangguan perkembangan anak adalah Denver Developmental Screening Test. Denver Developmental Screening Test adalah salah satu dari metode skrining terhadap kelainan perkembangan anak, tes ini bukanlah tes diagnostic atau tes IQ. Denver Developmental Screening Test memenuhi semua persyaratan yang diperlukan untuk metode skrining yang baik. Tes ini mudah dan cepat (15-20 menit), dapat diandalakan dan menunjukkan validitas tinggi. Karena kebutuhan pelaksanaan test yang komplit kemudian metode ini dikembangkan dalam Sistem pakar yang dapat mewakili pakar mentransformasikan pengetahuannya. Sedangkan Forward Chaining adalah suatu metode dalam sistem pakar yaitu pencocokan fakta atau pernyataan dimulai dari bagian sebelah kiri (IF). Dengan kata lain, penalaran dimulai dari fakta terlebih dahulu untuk menguji kebenaran hipotesis. Dari hasil uji coba sistem didapatkan cara pelaksanaan test skrining yang lebih mudah, efektif dan efisien.

Aim Survival is the most consistently captured outcome across countries for out-of-hospital cardiac arrests (OHCA), with return of spontaneous circulation (ROSC) representing the earliest endpoint for ‘unbiased’ initial resuscitation success. The ROSC after cardiac arrest (RACA) score was developed to predict ROSC and has been validated in several European countries. In this study, we aimed to evaluate the performance of RACA in a Pan-Asian population. Methods We conducted a retrospective analysis of data collected in the Pan-Asian Resuscitation Outcomes Study (PAROS) registry. We included OHCA cases from seven communities (Japan, South Korea, Malaysia, Singapore, Taiwan, Thailand, and United Arab Emirates) between January 2009 and December 2012. Paediatric cases, cases that were conveyed by non-emergency medical services (EMS), and cases with incomplete records were excluded from the study. Results The RACA score showed similar discrimination performance as the original German study and various European validation studies. However, it had poor calibration with the original constant regression coefficient, which was primarily due to the low ROSC rate (8.2%) in the PAROS cohort. The calibration performance of RACA significantly improved after the constant coefficient was modified to adjust for the disparity in ROSC rates between Asia and Europe. Conclusion This is the largest validation study of the RACA score. RACA consistently performs well in both Pan-Asian and European communities and can thus be a valuable tool for evaluating EMS systems. However, to implement it, the constant coefficient has to be modified in the RACA formula with local historical data.

Introduction Long-acting recombinant factor IX (FIX) products may simplify the surgical treatment of haemophilia B patients. The impact of rIX-FP, a recombinant FIX fused to recombinant albumin, on FIX consumption and surgical management was assessed in patients with haemophilia B. Materials and methods Male patients, ≤65 years old with severe haemophilia B (FIX activity ≤2%) requiring non-emergency surgery were enrolled in the surgical substudy of PROLONG-9FP. Dosing was based on World Federation of Hemophilia guidelines and patients' pharmacokinetics. Haemostatic efficacy was assessed on a 4-point scale. rIX-FP consumption and safety were monitored throughout the perioperative period. Results This updated dataset reports on thirty (8 minor and 22 major) surgeries conducted in 21 patients. A single preoperative bolus was used in 96.7% (n = 29) of surgeries. After minor surgery, patients received a median (range) of 0 (0–3) infusions with a median (range) consumption of 0 (0–178.89) IU/kg in the 14-day postoperative period. In patients who underwent major surgery (including 15 patients undergoing joint replacement surgery), the median (range) number of infusions in the 14-day postoperative period was 5 (0−11) and median consumption was 221.7 (0–444.07) IU/kg. Haemostatic efficacy was rated as excellent or good in 87.5% (7/8) of minor surgeries and 95.5% (21/22) of major surgeries. Conclusion Surgical procedures can be performed using a single preoperative bolus of rIX-FP in nearly all patients. During postoperative care, use of rIX-FP necessitated infrequent infusions and low FIX consumption. Overall, data suggest rIX-FP simplifies perioperative care in patients with haemophilia B.

Health literacy is a very important concept linked to the wellbeing of a nation. A healthy nation is a progressive nation when they can make informed decisions about their health. The concept means one’s cognitive and social ability to gain access, to understand and use health information to make wise decisions to maintain and promote good health on oneself (Nutbeam, 1998). The level of health literacy among rural population in Malaysia is found to be 2.3 percent, lower than urban population according to the 2015 National Health & Morbidity Survey by the Institute for Public Health Malaysia (2015). Hence, a study was undertaken in Sabah to further investigate health literacy rate among rural communities there. Drawing data collected from both survey and semi-structured interviews, rural communities’ health literacy is found to be problematic because it is hampered by problems of accessibility to health information and lack of literacy in searching for health information through the new media. Health information is only accessible through non-media communications like health talks where 70 percent respondents found public health talks to be most useful. On the other hand, findings from semi-structured interviews with 42 informants from four districts in Sabah found that the concept of health literacy as being individually-construct is problematic and needs to be seen from a broader context of socio-economic factor, living conditions of the individuals as well as the quality of health information disseminated in the media. Keywords: Health literacy, rural communities, cultural capital, accessibility, health information.

Summary: Background: We aimed to evaluate and improve the accuracy of the ultrasound scan in estimating gestational age in late pregnancy (ie, after 24 weeks' gestation) in low-income and middle-income countries (LMICs), where access to ultrasound in the first half of pregnancy is rare and where intrauterine growth restriction is prevalent. Methods: This prospective, population-based, cohort study was done in three LMICs (Bangladesh, Pakistan, and Tanzania) participating in the WHO Alliance for Maternal and Newborn Health Improvement study. Women carrying a live singleton fetus dated by crown-rump length (CRL) measurements between 8+0–14+6 weeks of gestation, who were willing to return for two additional ultrasound scans, and who planned on delivering in the study area were enrolled in the study. Participants underwent ultrasonography at 24+0–29+6 weeks and at 30+0–36+6 weeks' gestation. Birthweights were measured within 72 h of birth, and the proportions of infants who had a small-for-gestational-age birthweight (ie, a birthweight

INTRODUCTION: Football and futsal were the main sports in the Malaysian Games. However, they were associated with a risk of injury. The purpose of the study was to analyse the incidence, circumstances, and characteristics of football and futsal injuries during the Malaysian Games of 2018. MATERIALS AND METHODS: During the tournament, 14 teams participated in men's football, 12 teams in men's futsal and 11 teams in women's futsal. The biannual event involved athletes aged under 21 years. A medical report form used by FIFA Medical Assessment and Research Centre (F-Marc), was provided to the physiotherapists and team doctors of all the teams to report all injuries after each match. RESULTS: The response rate was 84.62% in football and 59.76% in futsal. A total of 48 injuries were reported from 26 football matches, equivalent to 64.64 injuries per 1000 match hours (95%CI 46.35 to 82.93). In futsal, a total of 48 injuries from 41 matches were reported, equivalent to 292.42 injuries per 1000 match hours (95% CI 209.7 to 375.14). The rate of injury in women futsal players was higher compared to men: 358.21 versus 247.04 injuries per 1000 match hours (p=0.224). Futsal recorded higher injuries per 1000 match hours than football (p

Objectives: To assess the association between enlarged adenoid and otitis media with effusion in children. Methods: This cross sectional comparative study was carried out in the Department of Otolaryngology-Head & Neck Surgery in Bangabandhu Sheikh Mujib Medical University, from July 2013 to June 2015. Thirty children with enlarged adenoids (case) and 30 children without enlarged adenoids (control) were included in this study. All patients subjected for history, local physical examination and evaluation of adenoid size by lateral X-ray of post nasal space. Tympanometry and pure tone audiometry are also done. Information’s recorded on a specially designed data sheet. Result: Among 30 case and 30 control, 12 (40.0%) and 2 (6.7%) patient had OME in case and control group respectively, mean age was 9.5 (2.76%) years and 9.96 (2.95%) in case and control group respectively. Male were predominant (70%) than female (30.0%) in cases. Among cases, grade- I was 20.0%, grade II- was 33.3% and grade-III was 46.7%. Hearing loss was found in 14 (46.7%) children. According to tympanometry, type A curve was in 17 (56.7%) children, type B in 9 (30.0%) and type C in 4 (13.3%) cases. Conclusion: Enlarged adenoids can be relevant in the pathogenesis of otitis media with effusion. Bangladesh J Otorhinolaryngol; April 2019; 25(1): 47-53

Objectives: To determine the best surgical approach of myringoplasty regarding healing of tympanic membrane and improvement of hearing. Methods: This was a cross sectional comparative study carried out in the departments of Otolaryngology and Head-Neck Surgery of Bangabandhu Sheikh Mujib Medical University, Dhaka Medical College Hospital, Sir Salimullah Medical college Mitford Hospital and Shaheed Suhrawardy Medical College Hospital during the period of July’2009 to March 2011. A total number of 75 patients of age 15-45years having inactive mucosal chronic otitis media with central perforation were included in this study. All patients has undergone myringoplasty and patients were divided into three groups according to surgical approach such as postaural, transcanal and endaural. All patients were followed up postoperatively and all postoperative findings were recorded. The three groups were compared with regard to healing of tympanic membrane and improvement of hearing. Results: The success rate in this study was 80% . graft take rate in postaural, transcanal and endaural approaches were 92.5%, 66.67% and 63.64% respectively. Improvement of mean airbone gap in postaural, transcanal and endaural approaches were 19.04dB, 10.02dB and 11.36dB Conclusion: Graft take rate and hearing improvement is significantly higher in postaural approach than other approaches. Bangladesh J Otorhinolaryngol; April 2016; 22(1): 21-25

The presence of atypical endometrial cells in the Papanicolaou (Pap) test has been associated with an increased rate of endometrial malignancy, with reported rates ranging from 14% to 47%. However, most reported studies have focused on patients who were aged40 years. The purpose of the present study was to investigate the clinical significance of identifying atypical endometrial cells in Pap test samples in women aged40 years of age.A search of the cytology Pap test database was performed from 2000 to 2014 using the keywords "atypical endometrial cells" or "atypical glandular cells favor endometrial origin" in women aged40 years. The available ThinPrep slides were reviewed. The patients' clinical presentation, follow-up endometrial biopsy findings, treatment, and clinical follow-up data were recorded. Endometrial carcinoma tissue sections were screened for Lynch syndrome.The database search yielded 63 study cases. Of these 63 patients, 52 had subsequently undergone endometrial biopsy. Of the 52 patients with follow-up biopsy findings available, 9 (17.3%) had premalignant (5 with atypical hyperplasia) or malignant (4 with endometrioid adenocarcinoma) lesions. In addition, 16 patients (30.8%) had other endometrial pathologic features. The 9 patients with premalignant or malignant endometrial lesions (8 white, 1 black) were overweight or obese; 3 of the patients did not have any clinical symptoms. All 4 patients with endometrioid adenocarcinoma had negative Lynch syndrome screening findings.Our results suggest that it is important to recognize the presence of atypical endometrial cells in the Pap tests from young patients, given its association with the finding of premalignant and malignant pathologic features in subsequent endometrial biopsies.

Studies on the anthropometric, physical and physiological characteristics among Malaysian Paralympic powerlifters are limited. This study examined the sociodemographic, clinical information and anthropometric physical parameters of Paralympic powerlifters in Malaysia. A cross-sectional study was conducted during a Powerlifting Workshop and National Championship in 2016. A structured questionnaire was used to collect data on athlete’s sociodemographic, sports participation history and medical information. All participants underwent a structured physical medical examination and anthropometric assessments. Fifty-two powerlifters took part in this study. Mean age of participants was 24.50±SD8.25 year. Majority of participants were men (82.7%) and most had spinal cord injury (34.6%) or amputation of the lower limb (26.9%). Most powerlifters competed at district and state level championships and 42.3% had represented Malaysia at international competitions. Women powerlifters had a significantly higher amount of body fat compared to men (35.61% vs 19.80%; p=0.003). Men power-lifters had significantly longer arm and forearm length (30.10±IQR3.00 cm vs 23.00±IQR2.13 cm; p=0.020).

Summary Background Whole breast irradiation delivered once per day over 3–5 weeks after breast conserving surgery reduces local recurrence with good cosmetic results. Accelerated partial breast irradiation (APBI) delivered over 1 week to the tumour bed was developed to provide a more convenient treatment. In this trial, we investigated if external beam APBI was non-inferior to whole breast irradiation. Methods We did this multicentre, randomised, non-inferiority trial in 33 cancer centres in Canada, Australia and New Zealand. Women aged 40 years or older with ductal carcinoma in situ or node-negative breast cancer treated by breast conserving surgery were randomly assigned (1:1) to receive either external beam APBI (38·5 Gy in ten fractions delivered twice per day over 5–8 days) or whole breast irradiation (42·5 Gy in 16 fractions once per day over 21 days, or 50 Gy in 25 fractions once per day over 35 days). Patients and clinicans were not masked to treatment assignment. The primary outcome was ipsilateral breast tumour recurrence (IBTR), analysed by intention to treat. The trial was designed on the basis of an expected 5 year IBTR rate of 1·5% in the whole breast irradiation group with 85% power to exclude a 1·5% increase in the APBI group; non-inferiority was shown if the upper limit of the two-sided 90% CI for the IBTR hazard ratio (HR) was less than 2·02. This trial is registered with ClinicalTrials.gov , NCT00282035 . Findings Between Feb 7, 2006, and July 15, 2011, we enrolled 2135 women. 1070 were randomly assigned to receive APBI and 1065 were assigned to receive whole breast irradiation. Six patients in the APBI group withdrew before treatment, four more did not receive radiotherapy, and 16 patients received whole breast irradiation. In the whole breast irradiation group, 16 patients withdrew, and two more did not receive radiotherapy. In the APBI group, a further 14 patients were lost to follow-up and nine patients withdrew during the follow-up period. In the whole breast irradiation group, 20 patients were lost to follow-up and 35 withdrew during follow-up. Median follow-up was 8·6 years (IQR 7·3–9·9). The 8-year cumulative rates of IBTR were 3·0% (95% CI 1·9–4·0) in the APBI group and 2·8% (1·8–3·9) in the whole breast irradiation group. The HR for APBI versus whole breast radiation was 1·27 (90% CI 0·84–1·91). Acute radiation toxicity (grade ≥2, within 3 months of radiotherapy start) occurred less frequently in patients treated with APBI (300 [28%] of 1070 patients) than whole breast irradiation (484 [45%] of 1065 patients, p Interpretation External beam APBI was non-inferior to whole breast irradiation in preventing IBTR. Although less acute toxicity was observed, the regimen used was associated with an increase in moderate late toxicity and adverse cosmesis, which might be related to the twice per day treatment. Other approaches, such as treatment once per day, might not adversely affect cosmesis and should be studied. Funding Canadian Institutes for Health Research and Canadian Breast Cancer Research Alliance.

This study aims to determine the presence or absence of protein in urine in patients with chronic renal failure. From the results of the study it was found that patients with chronic kidney failure in Martha Friska Multatuli General Hospital Medan from the 80 most patients in positive +++. Many patients with chronic kidney failure are male patients (62.5%) compared to female patients (37.5%) and the results of the examination based on age increase with age, ie at the age of 45 years and above. This type of research is descriptive analytic. Data is taken by recording medical record data of patients with chronic kidney failure based on age, sex and year. The study was conducted from January 2015 to December 2016. The place for conducting the research was conducted at Martha Friska Multatuli General Hospital (RSU) Medan. The study sample was urine samples from all patients with chronic renal failure. It can be concluded that the picture of protein in urine in patients with chronic kidney failure increases every year.

Tuberculosis is a serious threat to humankind. Every year millions of people are dying as it remains challenging to public health & care. The diversity of healthcare epidemiological settings has aggravated the situation. Third-world countries apply conventional methods to diagnose TB. They take a long time to give a result. Mainly blood, culture, sputum, and biopsies are examined. WHO has marked TB as a serious cause of death among ten other top life-threatening issues globally. The shortage of better healthcare services has worsened the situation in rural India. Recent advancements in medical sciences have proven significant success in controlling this contagious disease after being framed with artificial intelligence. There is a need for cost-effective screening and diagnosis at the initial stage of TB. To hold active TB cases demands new diagnostic approaches. The AI advancement during the last 10 years has been reviewed and analyzed in this paper.

Aims To evaluate comparative outcomes of laparoscopic versus open hepatectomy for malignant liver tumours in elderly patients. Methods A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies comparing laparoscopic (LH) versus open hepatectomy (OH) for both primary and metastatic malignant liver tumours in the elderly were included. Total operative time (minutes), need to perform Pringle’s manoeuvre, blood loss (ml), requirement for blood transfusion intra-operatively/post-operatively, post-operative complications, R0 resection rate, specimen resection margin (mm), re-operation rate, length of hospital stay (LOS), and 90-day mortality were the evaluated outcome parameters. Results Twelve studies reporting a total number of 1762 patients who underwent laparoscopic (n = 831) or open (n = 931) hepatectomy were included. OH group was associated with a significantly higher number of post-operative complications compared to LH (P = 0.00001). Complications such as post-operative liver failure (P = 0.02), ascites formation (P = 0.002), surgical site infection (P = 0.02), blood loss (P = 0.03), blood transfusion rate (P = 0.05) and LOS (P = 0.00001) were significantly higher in the OH group when compared to LH. There was no significant difference between the two groups in terms of total operative time (P = 0.53), bile leak (P = 0.12), R0 resection rate (P = 0.36), re-operation (P = 0.70) and 90-day mortality (P = 0.11). Conclusion Laparoscopic liver resections are safe with at least equal or superior peri-operative outcomes in the elderly population. Importantly, oncological outcomes are also comparable with open surgery. This approach needs to be utilised wherever possible to provide optimal healthcare in an aging population.

Tuberculosis is a serious threat to humankind. Every year millions of people are dying as it remains challenging to public health & care. The diversity of healthcare epidemiological settings has aggravated the situation. Third-world countries apply conventional methods to diagnose TB. They take a long time to give a result. Mainly blood, culture, sputum, and biopsies are examined. WHO has marked TB as serious cause of the death among 10 others top life threatening issues globally. The shortage of better healthcare services has worsened the situation in rural India. Recent advancements in Medical sciences have proven significant success in controlling this contagious disease after framed with artificial intelligence. There is a need for cost-effective screening and diagnosis at the initial stage of TB. To hold active TB cases demands new diagnostic approaches. The AI advancement during the last 10 years has been reviewed and analyzed in this paper.

Background Rathke cleft cysts (RCCs) are known sellar/suprasellar lesions that can grow and become symptomatic. For most asymptomatic lesions, stability is a typical outcome of surveillance; however, random relapse or cyst size fluctuation may also be observed. The conventional treatment for growing cysts is transsphenoidal removal. Methods A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. For significance, all journals were screened. Only records of tissue diagnosed RCCs with changes in size were included. Age and sex at diagnosis, size of the lesion, symptoms (if any), pituitary dysfunction, follow-up period, and size reduction were included in the data items. Results A total of 4 articles where selected after the second exclusion method. Three articles where case series and one was a case report. Eight total patients where histologically proven to have Rathke cleft cysts which fluctuated in size without intervention. Conclusion This review shows that RCCs can decrease or fluctuate in size following a dynamic process that is not fully understood. In the absence of symptoms, a larger cyst or an absolute increase in a cyst size, which may traditionally provoke an early surgical intervention, should be assessed and managed carefully to avoid potentially unneeded surgical morbidity.

Background CMV infection prevalence in kidney transplant recipients (KTR) is reported to be high in the literature, reaching rates of over 80%. Objectives The primary endpoints were the evaluation of the prevalence, the risks factors, and the effects of CMV infection on graft function and survival, as well as patient survival at three years after kidney transplantation. Material and methods We retrospectively reviewed the medical records of 288 kidney transplant patients operated in three Lebanese transplant centers between 1998 and 2017 with three years of follow-up. The patients were divided into two groups: those free of any CMV infection (271 patients (94%); Group I) and those who suffered from CMV infection (17 patients (6%); Group II). Results Baseline demographics of the two groups were similar, including recipient and donor gender and age, cause of renal disease, recipient body mass index, pre-transplant fasting blood sugar and dialysis duration, HLA matching between donor and recipient, degree of sensitization in the recipient, type of CMV prophylaxis, maintenance immunosuppression and immunological characteristics. The prevalence of CMV infection is 5.9% among KTR. There were significant differences between the two groups concerning the type of induction therapy and the duration of anti-CMV prophylaxis. The rate of infected patients and infectious episodes were significantly higher in Group II. At 3-years, graft function and survival, patient survival, and the rate of new-onset diabetes were similar between the two groups. Conclusion The present study is the first to explore the incidence and risk factors of CMV in kidney transplant patients in Lebanon. Comprehensive nationwide studies are therefore necessary to determine the epidemiology and risk factors of CMV infection after kidney transplantation in Lebanon.

There are several previous studies on the association of vitamin E with prevention of stroke but the findings remain controversial. We have conducted a systematic review, meta-analysis together with trial sequential analysis of randomised controlled trials to evaluate the effect of vitamin E supplementation versus placebo/no vitamin E on the risk reduction of total, fatal, non-fatal, haemorrhagic and ischaemic stroke. Relevant studies were identified by searching online databases through Medline, PubMed and Cochrane Central Register of Controlled Trials. A total of 18 studies with 148 016 participants were included in the analysis. There was no significant difference in the prevention of total stroke (RR (relative risk)=0.98, 95% CI 0.92–1.04, p=0.57), fatal stroke (RR=0.96, 95% CI 0.77–1.20, p=0.73) and non-fatal stroke (RR=0.96, 95% CI 0.88–1.05, p=0.35). Subgroup analyses were performed under each category (total stroke, fatal stroke and non-fatal stroke) and included the following subgroups (types of prevention, source and dosage of vitamin E and vitamin E alone vs control). The findings in all subgroup analyses were statistically insignificant. In stroke subtypes analysis, vitamin E showed significant risk reduction in ischaemic stroke (RR=0.92, 95% CI 0.85–0.99, p=0.04) but not in haemorrhagic stroke (RR=1.17, 95% CI 0.98–1.39, p=0.08). However, the trial sequential analysis demonstrated that more studies were needed to control random errors. Limitations of this study include the following: trials design may not have provided sufficient power to detect a change in stroke outcomes, participants may have had different lifestyles or health issues, there were a limited number of studies available for subgroup analysis, studies were mostly done in developed countries, and the total sample size for all included studies was insufficient to obtain a meaningful result from metaanalysis. In conclusion, there is still a lack of statistically significant evidence of the effects of vitamin E on the risk reduction of stroke. Nevertheless, vitamin E may offer some benefits in the prevention of ischaemic stroke and additional well-designed randomised controlled trials are needed to arrive at a definitive finding. PROSPERO registration number: CRD42020167827.

Introduction Coronavirus disease-19 (COVID-19), which started in late December, 2019, has spread to affect 216 countries and territories around the world. Globally, the number of cases of SARS-CoV-2 infection has been growing exponentially. There is pressure on countries to flatten the curves and break transmission. Most countries are practicing partial or total lockdown, vaccination, massive education on hygiene, social distancing, isolation of cases, quarantine of exposed and various screening approaches such as temperature and symptom-based screening to break the transmission. Some studies outside Africa have found the screening for fever using non-contact thermometers to lack good sensitivity for detecting SARS-CoV-2 infection. The aim of this study was to determine the usefulness of clinical symptoms in accurately predicting a final diagnosis of COVID-19 disease in the Ghanaian setting. Method The study analysed screening and test data of COVID-19 suspected, probable and contacts for the months of March to August 2020. A total of 1,986 participants presenting to Tamale Teaching hospital were included in the study. Logistic regression and receiver operator characteristics (ROC) analysis were carried out. Results Overall SARS-CoV-2 positivity rate was 16.8%. Those with symptoms had significantly higher positivity rate (21.6%) compared with asymptomatic (17.0%) [chi-squared 15.5, p-value, Conclusion The use of fever alone or other symptoms individually [or in combination] as a screening tool for SARS-CoV-2 infection is not worthwhile based on ROC analysis. Use of temperature check as a COVID-19 screening tool to allow people into public space irrespective of the temperature cut-off is of little benefit in diagnosing infected persons. We recommend the use of facemask, hand hygiene, social distancing as effective means of preventing infection.

Background: The incidence of oropharyngeal carcinoma has been increasing in many parts of the world. The potential etiologic role of human papillomavirus (HPV) infection in head and neck squamous cell carcinomas has been recognized for more than 3 decades.Aim: To assess the frequency of human papilloma virus in oropharyngeal carcinoma.Methodology: This cross-sectional study has been conducted in a tertiary level hospital at the Department of Otolaryngology-Head & Neck Surgery, BSMMU, Dhaka, Bangladesh. 20 cases of oropharyngeal carcinoma enrolled as a sample in this study. PCR has performed to detect HPV DNA of those cases who were histologically proven oropharyngeal carcinoma. The results were expressed as percentage and p value

Background: Opportunistic bilateral salpingectomy is one of the primary strategies available for preventing epithelial ovarian cancer. Case: An 81-year-old woman underwent a vaginal pelvic organ pr...

Objective:To highlight the importance of immediate initiation of perimortem caesarean delivery in maternal with sudden cardiac arrest. Case report: We reported the outcomes of three cases of perimortem caesarean delivery secondary to maternal cardiac arrest. A 28-year-old G3P2 at 36 weeks of gestation who developed severe hypoxaemia secondary to acute pulmonary oedema which was arise from pre-eclampsia related hypertensive crisis. The second case was a 29-year-old G1P0 at 38 weeks of gestation who developed severe hypoxaemia secondary to spinal anaesthesia complication (total spinal)and the third case was a 44-year-old G5P4 at 39 weeks of gestation who developed severe hypoxaemia secondary to failed intubation and ventilation during induction of anaesthesia. Observing the outcomes of the three maternal after post perimortem caesarean delivery, we are strongly agreed that the time from maternal cardiac arrest to the initiation of resuscitative hysterotomy should be shifted from 4 minute to immediately. Conclusion: Preparations for perimortem caesarean delivery should be made simultaneously with the initiation of maternal resuscitative efforts.