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Introduction: Medical simulation is a technique that allows interactive and immersive activity by recreating all or part of a clinical experience without exposing the patients to the antecedent risks. High-fidelity patient simulation-based teaching is an innovative and efficient method to address increasing student enrolment, faculty shortages and restricted clinical sites. Objective: To assess the effectiveness of high-fidelity patient simulation (HFPS) as compared to video-assisted lecture-based teaching method (VALB) among undergraduate medical students. Methods: The study was a Randomized Controlled Trial which involved 56 final year undergraduate medical students. The effectiveness of teaching based on HFPS (intervention group) and VALB (control group), on acquisition of knowledge, was assessed by multiple choice questions (MCQs) in the first and fourth week. Similarly, the skills competency was assessed by objective structured clinical examination (OSCE) in the second and fourth week. Mean and standard deviation (SD) for total score of knowledge and skills assessments were used as outcome measures. P value < 0.05 was considered to be statistically significant. Results: In both groups, students had significant higher mean MCQ scores at Post-tests. The intervention group had higher mean change score of MCQ marks than the control group but the difference was not statistically significant. In both the first and second skills assessments, mean OSCE scores for intervention group were higher than control group but this difference was not statistically significant. Conclusion: There was significant gain in knowledge in both methods of teaching but did not reach statistical difference in terms of skills enhancement in the intervention group as compared to the control group.

Herpes simplex encephalitis (HSE) is a medical emergency associated with high mortality and morbidity. Definitive diagnosis is established by history, clinical examination, neuroimaging studies, supportive electroencephalogram (EEG) findings, and cerebrospinal fluid (CSF) analysis. A 7-year-old Malay girl with known case of right hemiplegia secondary to herpes encephalitis presented to the neuropediatric ward, in General Hospital with refractory seizure. She had a moderate learning disability and diagnosed as right hemiparesis secondary to herpes encephalitis complicated with epilepsy. She was planned for the positron emission tomography (PET) scan and to undergo operation if PET scan was feasible (Hemispherectomy). However, the patient refused for operation. Prompt clinical recognition is important in the HSE to prevent progressive brain tissue damage, haemorrhagic changes, and worsening of the encephalitis. Diagnosis is usually confirmed through an extensive evaluation, including a thorough clinical examination with attention to findings on mental status changes, cerebrospinal fluid (CSF) analysis, electroencephalogram (EEG) testing and findings on neuroimaging. Once HSE is suspected, high-dose acyclovir should be started immediately before lumbar puncture (LP), and only stopped once a definitive alternate diagnosis has been established. This case is reported because the patient has generalized epilepsy with right hemiparesis secondary to herpes encephalitis. Herpes encephalitis with right hemiparesis cases are quite rare.

Nonunion of intertrochanteric fracture is uncommon because there are excellent blood supply and good cancellous bone in the intertrochanteric region of the femur. A diagnosis of primary intertrochanteric nonunion is made when at least 15 weeks after the fracture there is radiological evidence of a fracture line, with either no callus (atrophic) or with callus that does not bridge the fracture site (hypertrophic). The patient was subsequently treated successfully with an open reduction procedure. Open reduction and internal fixation with right DHS (Dynamic Hip Screw) with 8 screw holes plate inserted first and then 6 screws inserted under the guidance of Image Intensifier (C Arm). We would like to report a case of right intertrochanteric fracture with non-union. A 60 years old patient presented with the history of pain in the right hip, off and on for many years after the operation. The pain was associated with stiffness of the right hip joint. This case is selected for reporting because it’s a relatively rare incidence.

Background: Neonatal jaundice is a common condition that sometimes lead to devastating neurological consequence such as kernicterus. Aim: This study was aimed to find out the clinical features and etiology of neonatal jaundice in term newborn admitted to Ratchaburi Hospital. Study Design: Hospital-based retrospective study Methodology: The study was conducted by reviewing 117 medical records of neonatal jaundice who were admitted at Ratchaburi Regional Hospital, Bangkok, Thailand from 1st October 2007 to 30th September 2008. Both the patient’s and their mother’s profiles, etiology and clinical features of jaundice were extracted. Results: The results showed that the most common etiology was inconclusive jaundice (64.9%) followed by ABO incompatibility (17.9%) and breast feeding jaundice (10.2%). Other less common causes were G6PD deficiency, minor blood group incompatibility and cephalhematoma. The onset of the neonatal jaundice usually occurred on the 2nd to the 4th day of life and almost all newborns responded well to phototherapy. Most of interventions were started on the 2nd day of life. Moreover, exchange transfusion was needed in four cases. The maximum and minimum haematocrit was significantly lower while Nucleated Red Cell (NRC) count and percent of reticulocytes counts were significantly higher in haemolysis group than in non-haemolysis group,. Conclusion: From our study, the most common etiology was inconclusive jaundice which is followed by ABO incompatibility but non-immune hemolysis and polycythemia were not encountered. There was significant difference of hematocrit, NRC and reticulocytes between hemolytic and non-hemolytic groups. Detailed approach of history taking and physical examination, early investigations of jaundice work up and septic work up are recommended in eliciting various etiologies and preventing complications.

Background: Periodontitis is a public health concern since it is a major factor in tooth loss worldwide and has association with many systemic diseases. Sleep is a complex and essentially biological process and a critical factor for maintaining mental and physical health. Since inflammation is characteristic of both chronic periodontitis and sleep deprivation, few studies in recent years present the contradictory results regarding this potential association. The objective of the present study was to investigate the association between quality of sleep and chronic periodontitis. Materials and Methods: A total of 200 individuals participated in this study. All participants underwent a comprehensive clinical periodontal examination. case–control were identified using the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions for periodontal disease. The quality of sleep was assessed by Pittsburgh Sleep Quality Index. The univariate and multivariate logistic regression analysis was used to test the influence of variables (quality of sleep, age, sex, ethnicity, education, and socioeconomic status), in the occurrence of periodontitis. Odds ratio (OR) and respective confidence intervals (CIs) were calculated and reported. P ≤0.05 was considered statistically significant. Results: The prevalence of poor quality of sleep was 56.75% in cases (periodontitis group) and 43.24% in control group. There was positive association between quality of sleep and chronic periodontitis (OR = 3.04; 95% CI = 1.42–6.5; P = 0.004). In multivariate logistic regression analysis, only the age was significantly related to the periodontitis (OR = 1.11; 95% CI = 1.07–1.41; P < 0.001) , other variables failed to reach the significant level. Conclusion: Poor quality of sleep was significantly associated with chronic periodontitis. Only the age was significantly related to periodontitis among the other covariable measured. Key Words: Chronic periodontitis, periodontal medicine, quality of sleep, sleep deprivation

Background COVID-19 pandemic reached a public health emergency status of international concern. The impacts and events associated with this were associated with adverse psychological impacts among the general public globally. This cross sectional study aimed to determine the prevalence of psychological distress and to identify predictors associated with psychological distress due to the COVID-19 pandemic among the population in Myanmar. Design and methods A cross-sectional survey was conducted from March to April 2020 among adults, 18 years old and above, who reside in Myanmar through a structured questionnaire distributed in social media platforms. Univariate and bivariate analyses were used to estimate the prevalence of COVID-19 Peritraumatic Distress Index (CPDI) symptoms and to test the associations between CPDI and the exposure variables. Logistic Regression Analysis was done to identify significant predictors of distress. The statistical analysis used was Chi-square test and Multiple Logistic Regression Analysis. Results There were 530 participants in this study.37.4% of them did not have psychological distress, 55.6% experienced mild to moderate psychological distress, and 7% experienced severe psychological distress due to COVID-19 pandemic. Simple and Multiple Logistic Regression Analyses were performed to determine the factors associated with psychological distress due to COVID-19. Conclusions It was shown that the self-employed group and age group older than 45 years old had more psychological distress than others. However, Buddhists and people from the capital city had less distress than other religions and districts. This study recommends the government to develop better strategies for self-employed groups, elders, and the poor for a support, relief, and resettlement of their ruined status.

BACKGROUND: The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. OBJECTIVES: To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. DATA COLLECTION AND ANALYSIS: We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. MAIN RESULTS: We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. AUTHORS' CONCLUSIONS: We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed.

Background: Sickle cell disease (SCD) is a group of disorders that affects haemoglobin, which causes distorted sickle‐ or crescent‐shaped red blood cells. It is characterized by anaemia, increased susceptibility to infections and episodes of pain. The disease is acquired by inheriting abnormal genes from both parents, the combination giving rise to different forms of the disease. Due to increased erythropoiesis in people with SCD, it is hypothesized that they are at an increased risk for folate deficiency. For this reason, children and adults with SCD, particularly those with sickle cell anaemia, commonly take 1 mg of folic acid orally every day on the premise that this will replace depleted folate stores and reduce the symptoms of anaemia. It is thus important to evaluate the role of folate supplementation in treating SCD. Objectives: To analyse the efficacy and possible adverse effects of folate supplementation (folate occurring naturally in foods, provided as fortified foods or additional supplements such as tablets) in people with SCD. Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also conducted additional searches in both electronic databases and clinical trial registries. Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 17 November 2017. Selection criteria: Randomised, placebo‐controlled trials of folate supplementation for SCD. Data collection and analysis: Four review authors assessed We used the standard Cochrane‐defined methodological procedures. Four review authors independently assessed the eligibility and risk of bias of the included trials and extracted and analysed the data included in the review. The quality of the evidence was assessed using GRADE. Main results: One trial, undertaken in 1983, was eligible for inclusion in the review. This was a double‐blind placebo‐controlled quasi‐randomised triaI of supplementation of folic acid in people with SCD. A total of 117 children with homozygous sickle cell (SS) disease aged six months to four years of age participated over a one‐year period (analysis was restricted to 115 children). Serum folate measures, obtained after trial entry at six and 12 months, were available in 80 of 115 (70%) participants. There were significant differences between the folic acid and placebo groups with regards to serum folate values above 18 μg/L and values below 5 μg/L (low‐quality evidence). In the folic acid group, values above 18 μg/L were observed in 33 of 41 (81%) compared to six of 39 (15%) participants in the placebo (calcium lactate) group. Additionally, there were no participants in the folic acid group with serum folate levels below 5 μg/L, whereas in the placebo group, 15 of 39 (39%) participants had levels below this threshold. Haematological indices were measured in 100 of 115 (87%) participants at baseline and at one year. After adjusting for sex and age group, the investigators reported no significant differences between the trial groups with regards to total haemoglobin concentrations, either at baseline or at one year (low‐quality evidence). It is important to note that none of the raw data for the outcomes listed above were available for analysis. The proportions of participants who experienced certain clinical events were analysed in all 115 participants, for which raw data were available. There were no statistically significant differences noted; however, the trial was not powered to investigate differences between the folic acid and placebo groups with regards to: minor infections, risk ratio (RR) 0.99 (95% confidence interval (CI) 0.85 to 1.15) (low‐quality evidence); major infections, RR 0.89 (95% CI 0.47 to 1.66) (low‐quality evidence); dactylitis, RR 0.67 (95% CI 0.35 to 1.27) (low‐quality evidence); acute splenic sequestration, RR 1.07 (95% CI 0.44 to 2.57) (low‐quality evidence); or episodes of pain, RR 1.16 (95% CI 0.70 to 1.92) (low‐quality evidence). However, the investigators reported a higher proportion of repeat dactylitis episodes in the placebo group, with two or more attacks occurring in 10 of 56 participants compared to two of 59 in the folic acid group (P < 0.05). Growth, determined by height‐for‐age and weight‐for‐age, as well as height and growth velocity, was measured in 103 of the 115 participants (90%), for which raw data were not available. The investigators reported no significant differences in growth between the two groups. The trial had a high risk of bias with regards to random sequence generation and incomplete outcome data. There was an unclear risk of bias in relation to allocation concealment, outcome assessment, and selective reporting. Finally, There was a low risk of bias with regards to blinding of participants and personnel. Overall the quality of the evidence in the review was low. There were no trials identified for other eligible comparisons, namely: folate supplementation (fortified foods and physical supplementation with tablets) versus placebo; folate supplementation (naturally occurring in diet) versus placebo; folate supplementation (fortified foods and physical supplementation with tablets) versus folate supplementation (naturally occurring in diet). Authors' conclusions: One doubIe‐blind, placebo‐controlled triaI on folic acid supplementation in children with SCD was included in the review. Overall, the trial presented mixed evidence on the review's outcomes. No trials in adults were identified. With the limited evidence provided, we conclude that, while it is possible that folic acid supplementation may increase serum folate levels, the effect of supplementation on anaemia and any symptoms of anaemia remains unclear. If further trials were conducted, these may add evidence regarding the efficacy of folate supplementation. Future trials should assess clinical outcomes such as folate concentration, haemoglobin concentration, adverse effects and benefits of the intervention, especially with regards to SCD‐related morbidity. Such trials should include people with SCD of all ages and both sexes, in any setting. To investigate the effects of folate supplementation, trials should recruit more participants and be of longer duration, with long‐term follow‐up, than the trial currently included in this review. However, we do not envisage further trials of this intervention will be conducted, and hence the review will no longer be regularly updated. Funding: This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the Cochrane Cystic Fibrosis and Genetic Disorders Group. Declaration of Interest: Ruchita Dixit: none known. Sowmya Nettem: none known. Simerjit S Madan: none known. Htoo Htoo Kyaw Soe: none known Adinegara BL Abas: none known Leah Vance: has undertaken a research year that allowed for her participation in this review was supported by Grant 2014086 from the Doris Duke Charitable Foundation. She has no other conflicts to disclose. Patrick Stover: none known.

Aim: The purpose of our research was to investigate the effect of different body positions on lungs volume by conducting pulmonary function test (PFT) values of the asthmatic patients. The objectives were (1) to assess the correlation between pulmonary function and posture in adult patients with asthma, (2) to determine the best position with higher lungs volume that was preferable for the asthmatic patients to relieve the asthma attack and for rehabilitation approach. Study Design: Cross-sectional study. Place and Duration of Study: This study was conducted in the Reconstructive and Rehabilitative Center at University Malaysia Sarawak (UNIMAS) between December 2015 and June 2016. Methodology: The total of 30 participants was recruited in this study. Among them, 15 participants were asthmatic patients and 15 participants were non-asthmatic, control persons. All the participants were between 19-25 years of age and they were enrolled after they had signed a written consent. Participants were selected using the inclusion criteria and Spiro Excel PC based pulmonary function test (PFT Medicaid Systems) were administered. Spirometer measurements (FVC, FEV1) were taken in the standing, sitting and supine positions. Each measurement was taken two times and the average values were analyzed. The order of the body positions was randomized. Results: In the asthmatic group, the best position was supine with a mean±standard deviation (SD) of FEV1/FVC, 77.93±17.37. Whereas, in control group, the best position was standing with a mean±SD of FEV1/FVC, 90.12±5.97. The second best positions were sitting position in the asthmatic group (75.37±16.37) and supine position in control group (89.70±8.79). Finally, the standing position had the lowest lungs function in the asthmatic group (73.63±17.08) and sitting position in control group (88.53±11.17). Conclusion: Our study showed that supine was the best position for measuring FEV1 and FVC of asthmatic participants. Therefore, supportive positions such as supine or leaning to the wall are suggested to improve pulmonary function of the patients, especially during asthmatic attack.

BACKGROUND: Sickle cell disease is an autosomal recessive inherited haemoglobinopathy which causes painful vaso‐occlusive crises due to sickle red blood cell dehydration. Vaso‐occlusive crises are common painful events responsible for a variety of clinical complications; overall mortality is increased and life expectancy decreased compared to the general population. Experimental studies suggest that intravenous magnesium has proven to be well‐tolerated in individuals hospitalised for the immediate relief of acute (sudden onset) painful crisis and has the potential to decrease the length of hospital stay. Some in vitro studies and open studies of long‐term oral magnesium showed promising effect on pain relief but failed to show its efficacy. The studies show that oral magnesium therapy may prevent sickle red blood cell dehydration and prevent recurrent painful episodes. There is a need to access evidence for the impact of oral and intravenous magnesium effect on frequency of pain, length of hospital stay and quality of life. This is an updated version of the review. OBJECTIVES: To evaluate the effects of short‐term intravenous magnesium on the length of hospital stay and quality of life in children and adults with sickle cell disease. To determine the effects of long‐term oral magnesium therapy on the frequency of painful crises and the quality of life in children and adults with sickle cell disease. SEARCH METHODS: We searched the Cochrane Haemoglobinopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group’s Haemoglobinopathies Trials Register: 03 February 2019. Date of last search of other resources (clinical trials registries): 04 April 2019. SELECTION CRITERIA: We searched for published and unpublished randomized controlled studies of oral or intravenous magnesium compared to placebo or no magnesium. DATA COLLECTION AND ANALYSIS: Authors independently assessed the study quality and extracted the data using standard Cochrane methodologies. MAIN RESULTS: We included five randomized placebo‐controlled studies with a total of 386 participants (aged three to 53 years). Of these, two shorter parallel studies (n = 306) compared intravenous magnesium sulphate to placebo (normal saline) for admission to hospital due to a vaso‐occlusive crisis, for which we were able to analyse data. The quality of evidence was moderate for studies in this comparison, mainly due to limitations due to risk of bias and imprecision. Two of the three longer‐term studies comparing oral magnesium pidolate to placebo had a cross‐over design. The third was a parallel factorial study which compared hydroxyurea and oral magnesium to each other and to placebo over a longer period of time; we only present the comparison of oral magnesium to placebo from this study. The quality of evidence was very low with uncertainty of the estimation. The eight‐hourly dose levels in the two studies of intravenous magnesium were different; one used 100 mg/kg while the second used 40 mg/kg. Only one of these studies (n = 104) reported the mean daily pain score while hospitalised (a non‐significant difference between groups, moderate quality evidence). The second study (n = 202) reported a number of child‐ and parent‐reported quality of life scores. None of the scores showed any difference between treatment groups (low quality evidence). Data from one study (n = 106) showed no difference in length of stay in hospital between groups (low quality evidence). Both studies reported on adverse events, but not defined by severity as we had planned. One study showed significantly more participants receiving intravenous magnesium experienced warmth at infusion site compared to placebo; there were no differences between groups for other adverse events (low quality evidence). Three studies (n = 80) compared oral magnesium pidolate to placebo. None of them reported data which we were able to analyse. One study (n = 24) reported on the number of painful days and stated there was no difference between two groups (low quality evidence). None of the studies reported on quality of life or length of hospital stay. Two studies (n = 68) reported there were no differences in levels of magnesium in either plasma or red blood cells (moderate quality evidence). Two studies (n = 56) reported adverse events. One reported episodes of mild diarrhoea and headache, all of which resolved without stopping treatment. The second study reported adverse events as gastrointestinal disorders, headache or migraine, upper respiratory infections and rash; which were all evenly distributed across treatment groups (moderate quality evidence). AUTHORS' CONCLUSIONS: Moderate to low quality evidence showed neither intravenous magnesium and oral magnesium therapy has an effect on reducing painful crisis, length of hospital stay and changing quality of life in treating sickle cell disease. Therefore, no definitive conclusions can be made regarding its clinical benefit. Further randomized controlled studies, perhaps multicentre, are necessary to establish whether intravenous and oral magnesium therapies have any effect on improving the health of people with sickle cell disease.

Background Sickle cell disease is a genetic chronic haemolytic and pro-inflammatory disorder. The clinical manifestations of sickle cell disease result from the presence of mutations on the beta globin genes that generate an abnormal haemoglobin product (called haemoglobin S) within the red blood cell. Sickle cell disease can lead to many complications such as acute chest syndrome, stroke, acute and chronic bone complications (including painful vaso-occlusive crisis, osteomyelitis, osteonecrosis and osteoporosis). With increased catabolism and deficits in energy and nutrient intake, individuals with sickle cell disease suffer multiple macro- and micro-nutritional deficiencies, including vitamin D deficiency. Since vitamin D maintains calcium homeostasis and is essential for bone mineralisation, its deficiency may worsen musculoskeletal health problems encountered in sickle cell disease. Therefore, there is a need to review the effects and the safety of vitamin D supplementation in sickle cell disease. Objectives To investigate the hypothesis that vitamin D supplementation increases serum 25-hydroxyvitamin D level in children and adults with sickle cell disease. To determine the effects of vitamin D supplementation on general health such as growth status and health-related quality of life; on musculoskeletal health including bone mineral density, pain crises, bone fracture and muscle health; on respiratory health which includes lung function tests, acute chest syndrome, acute exacerbation of asthma and respiratory infections; and the safety of vitamin D supplementation in children and adults with sickle cell disease. Search methods We searched the Cochrane Haemoglobinopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched database such as PubMed, clinical trial registries and the reference lists of relevant articles and reviews. Date of last search: 15 December 2016. Selection criteria Randomised controlled studies and quasi-randomised controlled studies (controlled clinical studies) comparing oral administration of any form of vitamin D supplementation to another type of vitamin D or placebo or no supplementation at any dose and for any duration, in people with sickle cell disease, of all ages, gender, and phenotypes including sickle cell anaemia, haemoglobin sickle cell disease and sickle beta-thalassaemia diseases. Data collection and analysis Two authors independently extracted the data and assessed the risk of bias of the included study. They used the GRADE guidelines to assess the quality of the evidence. Main results One double-blind randomised controlled study including 46 people with sickle cell disease (HbSS, HbSC, HbSβ+thal and HbSβ0thal) was eligible for inclusion in this review. Of the 46 enrolled participants, seven withdrew before randomisation leaving 39 participants who were randomised. Only 25 participants completed the full six months of follow up. Participants were randomised to receive oral vitamin D3 (cholecalciferol) (n = 20) or placebo (n = 19) for six weeks and were followed up to six months. Two participants from the treatment group have missing values of baseline serum 25-hydroxyvitamin D, therefore the number of samples analysed was 37 (vitamin D n = 18, placebo n = 19). The included study had a high risk of bias with regards to incomplete outcome data (high dropout rate in the placebo group), but a low risk of bias for other domains such as random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, selective outcome reporting; and an unclear risk of other biases. Compared to the placebo group, the vitamin D group had significantly higher serum 25-hydroxyvitamin D (25(OH)D) levels at eight weeks, mean difference 29.79 (95% confidence interval 26.63 to 32.95); at 16 weeks, mean difference 12.67 (95% confidence interval 10.43 to 14.90); and at 24 weeks, mean difference 15.52 (95% confidence interval 13.50 to 17.54). We determined the quality of the evidence for this outcome to be moderate. There was no significant difference of adverse events (tingling of lips or hands) between the vitamin D and placebo groups, risk ratio 3.16 (95% confidence interval 0.14 to 72.84), but the quality of the evidence was low. Regarding the frequency of pain, the vitamin D group had significantly fewer pain days compared to the placebo group, mean difference -10.00 (95% confidence interval -16.47 to -3.53), but again the quality of the evidence was low. Furthermore, the review included physical functioning PedsQL scores which was reported as absolute change from baseline. The vitamin D group had a lower (worse) health-related quality of life score than the placebo group but this was not significant at eight weeks, mean difference -2.02 (95% confidence interval -6.34 to 2.30). However, the difference was significant at both 16 weeks, mean difference -12.56 (95% confidence interval -16.44 to -8.69) and 24 weeks, mean difference -12.59 (95% confidence interval -17.43 to -7.76). We determined the quality of evidence for this outcome to be low. Authors' conclusions We included only one low-quality clinical study which had a high risk of bias with regards to incomplete outcome data. Therefore, we consider that the evidence is not of sufficient quality to guide clinical practice. Until further evidence becomes available, clinicians should consider the relevant existing guidelines for vitamin D supplementation (e.g. the Endocrine Society Clinical Practice Guidelines) and dietary reference intakes for calcium and vitamin D (e.g. from the USA Institute of Medicine). Evidence of vitamin D supplementation in sickle cell disease from high quality studies is needed. Well-designed, randomised, placebo-controlled studies of parallel design, are required to determine the effects and the safety of vitamin D supplementation in children and adults with sickle cell disease.

Purpose One of the major challenges lies in the use of strategies to assess students working in small groups. The assessment by tutors and peers, and self-assessment by students appear to be integral parts of problem-based-learning (PBL) tutorials. Our study aimed to analyze the formative assessment scores by students themselves, their tutor and peers during undergraduate ophthalmology tutorials. Design A cross sectional study. Methods One hundred undergraduate students' self-assessment made during ophthalmology PBL tutorials were compared with that made by their tutor and student peers. At the end of every session, each student and student peers were given an assessment form dealing with criteria like responsibility, information processing, communication, critical analysis and self-awareness. The questionnaires were filled using the 5-point Likert scale. The tutor's assessment was made using the same criteria. Results There were significant positive correlations between self-assessment and tutor assessment in regard to participation in PBL session (P = 0.01), punctuality for each session (P ≤ 0.001) and bring new information (P = 0.001). There was a positive correlation between self-assessment and peer assessment regarding active participation (P = 0.02) and bringing new information (P = 0.003). However, there was no significant correlation between the overall scores given by selves and those by peers and the tutor. Conclusions Students tended to overrate themselves. The self-assessment scores were generally higher than those given by their tutor and peers. To foster evidence-based practice of ophthalmology, the information acquisition skills need to be improved.

Abnormal liver function tests are not uncommon encounter in diabetes mellitus patients. The aim of this study was to find out the liver function test abnormalit ies in a group of d iabetic patients in Myan mar and to determine the factors associated with these biochemical changes. In this cross sectional study conducted at the diabetic clinic of Yangon General Hospital, Myan mar between March 2006 and February 2007, a total of 81 patients were included. The means of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), γ glutamyl transferase (γ GT), bilirubin and prothrombin time fall within normal range. Raised ALT and AST were noted in 18.5% and 14.8% respectively. 4.9% had high bilirubin and prolonged prothrombin time each, γGT was normal in all patients. The mean values of ALT and AST had no significant correlat ion with age, family h istory of diabetes, mode of therapy or type of diabetes. Although mean ALT had no correlation with gender of the d iabetes patients, AST was found to be significantly elevated in men. Values of ALT and AST were also significantly higher with increasing BMI. Hepatomegaly, increased liver echogenicity and presence of fatty liver were the factors significantly correlated with elevated A LT and AST values. In conclusion, abnormal liver function results are more co mmon among diabetes patients. Elevated ALT and AST are the markers for associated non alcoholic fatty liver disease in diabetes patients. Testing for A LT and AST, should be carried out to screen underlying fatty liver, especially in male diabetes patients with high BMI.

Aims: To assess oral health-related quality of life (OHRQoL) in patients with malocclusion and to measure the association of OHRQoL with orthodontic treatment need. Materials and Methods: The study sample comprised 290 participants aged 13 to 30 years, attending orthodontic clinics at the Faculty of Dentistry, Melaka Manipal Medical College (MMMC). The participants were asked to complete the Oral Health Impact Profile-14 (OHIP-14), after which clinical examinations were conducted to assess normative orthodontic treatment needs using the Dental Health Component (DHC) of the Index of Orthodontic Treatment Need (IOTN). Results: A total of 290 adolescent and young adults participated in this study. The mean overall score for OHIP-14 was 11.8(±8.0). There was no significant association of oral health related quality of life (OHRQoL) between different age groups, gender, ethnicities and education levels. There was no significant association between age, gender, ethnicity, education level and orthodontic treatment need. Also, there was no significant association of OHIP-14 score between no treatment need and little treatment need. However, OHIP-14 score was significantly higher in borderline treatment need compared to no treatment need (6.06, 95% CI 1.07, 11.04), little treatment need (3.95, 95% CI 1.75, 6.16) while high treatment need had significantly higher OHIP-14 score than borderline treatment need (7.13, 95% CI 3.46, 10.80). Conclusion: Malocclusion has a significant negative impact on OHRQoL. There is a significant association in mean overall OHIP score when comparing high orthodontic treatment needs and with no treatment needs. This study did not find any significant association in orthodontic treatment needs in relation to age groups, gender, ethnicities and education level.

Background: Although lecture handouts are commonly given to students during theory lectures, students' perception, as well as their performance, can vary depending on the type of handouts they receive for information processing. Methodology: This is a quasi-experimental study involving 6 th semester medical students. The study was conducted during theory lectures on ophthalmology. The two types of notes given to the students were comprehensive handout and a skeleton handout, which included some lecture notes but required substantial annotation by the students. Pre-test and post-test in the form of multiple choice questions were conducted before and after the lecture session, respectively. Results: There was a significant difference of mean score of pre- and post-test between skeletal handout (pre = 1.85 ± 1.275, post = 4.85 ± 0.363) and full handout (pre = 1.92 ± 1.09 post = 2.61 ± 0.771) with P < 0.001. However, the students' responses to questionnaires indicated a strong preference for much detailed handouts as essential to preparation for examinations. Conclusion: The student can improve their performance during examination while working on skeletal handouts during theory lectures in spite of showing a preference for complete handouts.

Abdominal pregnancy is a rare form of ectopic pregnancy in which the zygote implanted within the peritoneal cavity exception at ovaries, fallopian tubes and intra ligament spaces. The diagnosis is challenging and can be missed especially when the imaging facilities are not available in remote areas.A 35 years old, G3P2+0 was admitted to the hospital at 38+2 weeks of pregnancy with the chief complaint of reduced foetal movement for three days. She was taking regular antenatal care with the midwife at the rural health centre and uneventful until 37 weeks of pregnancy. On physical examination, the abdomen was distended, the foetal parts were easily palpable, no visible foetal movement and the foetal heart sound was not audible. Abdominal ultrasound scan identified the term foetus of abdominal pregnancy without foetal cardiac activity. The patient underwent laparotomy and dead, male foetus was extracted uneventfully. The placenta was attached to intestines and mesentery so that which was removed with great caution and secured haemostasis. The mother’s condition was stable throughout the operation and did not need to give the blood transfusion. The sutures were removed after 7 days and the healthy patient discharged from the hospital.Abdominal pregnancy is a rare condition and the diagnosis can be missed during the antenatal period and hence it is crucial to raise the awareness of health care personals especially in remote areas. The suspicious case of abdominal pregnancy should be referred to the experienced clinicians in the centres with diagnosis facilities.

This is the protocol for a review and there is no abstract. The objectives are as follows: To analyze the efficacy and possible adverse effects of folate supplementation (folic acid supplements or folate supplementation through diet) in people with SCD.