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Background: Composite polymerization creates internal stresses that cause bond loss at the tooth composite interface, cuspal deflection, and enamel crack formation; that are potential restoration failure. Aims: The aim of the present study was to evaluate micro-tensile bond strength of bulk-fill resin composite to human dentine of extracted teeth using nanoclay modified adhesive system (with and without organic modifier). Materials and Methods: A total of 120 caries-free permanent human posterior teeth were used and classified three groups according to adhesive system (each with 40 teeth); including Prime&Bond universalTM, Dellite®43B and Dellite®LVF modified adhesive systems. Each group was subdivided into two equal subgroups whether thermocycling was conducted or not. Results: Result revealed that there was a significant difference in mean microtensile bond strength of the three tested materials The best results achieved by Dellite®43B followed by Dellite®LVF modified adhesive system finally conventional Prime&Bond universal adhesive system. Difference in Microtensile bond strength between thermocycled and Nonthermocycled was highly significant. Conclusion: Addition of Nanoclay (montmorillonite) with organic modifier to universal adhesive material is valuable to augment the bond strength of bulk fill resin composite to human dentition. (2) Thermocycling adversely affect the bond strength of nanoclay /adhesive system complex to tooth tissue.

Introduction Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI). Methods PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded. Findings Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case–control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p Conclusion Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

ObjectiveGlobally, South Asia has the highest proportion of disabling hearing loss. There is a paucity of data exploring the associated hearing loss and disability caused by chronic middle-ear disease in South Asia in the setting of surgical outreach. This study aimed to measure disability using the World Health Organization Disability Assessment Schedule 2.0 in patients undergoing ear surgery for chronic middle-ear disease in an ear hospital in Nepal.MethodThe World Health Organization Disability Assessment Schedule 2.0 was translated into Nepali and administered by interview to patients before ear surgery, and results were correlated with pre-operative audiograms.ResultsOut of a total of 106 patients with a mean age of 23 years, the mean World Health Organization Disability Assessment Schedule 2.0 score was 17.7, and the highest domain scores were for domain 6 ‘participation in society’ at a score of 34. There was a positive correlation of World Health Organization Disability Assessment Schedule 2 score with hearing level (r = 0.46).ConclusionPatients with ear disease in Nepal have had their disability measured using the World Health Organization Disability Assessment Schedule 2.0. Our study demonstrated a correlation between impaired hearing and disability in a surgical outreach context, which was an expected but not previously reported finding.

Outcomes for patients with heart failure (HF) remain suboptimal worldwide, despite the national and international guidelines. A disease management program such as a multidisciplinary (MD) team HF clinic proved to be one of the effective strategies to improve patients’ outcomes. In June 2018, the first MD-HF clinic was opened at Ahmed Gasim Cardiac Surgery and Renal Transplantation Center, Khartoum, Sudan. This focused report aims to share our experience and pave the way for such an approach for cardiac and other specialty services that may require MD-specialized clinics. We provide a detailed report of the MD team, structure, facilities, and plans of the HF clinic, which may be considered as a nucleus for an advanced HF program and heart transplant in Sudan. Keywords: multidisciplinary, heart failure clinic, Sudan

Introduction Anterior skull base cerebrospinal fluid (CSF) leaks are managed successfully with endonasal surgery. Endoscopic closure of CSF leaks from posterior table of the frontal sinus remains challenging. Vascularized Hadad-Bassagasteguy flap (HBF) reconstruction of the skull base has increased CSF closure rates but does not extend to frontal sinus. We describe our technique using septal flap pedicled by anterior ethmoid artery (AEA) for repairing frontal defects. Method Retrospective review of cases of frontal CSF leak repair using the AEA flap reconstruction. Flap design: an anterior vertical septal mucosa incision at posterior border of the frontal sinusotomy is made and extended to nasal floor. Posterior vertical incision is made 1 cm posterior to the projection of the axilla of the middle turbinate on the septum and extended to nasal floor. A horizontal incision along the nasal floor joins the two incisions. The flap is raised and rotated into the frontal sinus over the posterior table reconstructed defect. Results Three patients identified. Two males, one female, aged 11, 33 and 56. Patient histories included recurrent bacterial meningitis following head trauma, recurrent sinusitis and fronto-ethmoidal osteoma, with intraoperative CSF leak and CSF rhinorrhea due to meningoencephalocele. The three posterior wall defects were successfully repaired endoscopically with multilayer reconstruction and the AEA septal flap. Conclusions The anterior ethmoid artery septal flap can be successfully utilised for frontal CSF leak repair. Flap is conveniently located for frontal sinus defects. When the septum is intact it provides an excellent final layer as part of multilayer reconstruction.

Introduction Choanal atresia (CA) is a congenital obstruction of the posterior nasal aperture due to nasal cavity canalisation failure. Endoscopic endonasal surgery has led to successful CA repair and fewer complications compared to open surgery. We describe our surgical technique that uses septal mucosal flaps without need for stenting or subsequent intubation. Method A multicentre retrospective review of patients who underwent surgery using the cross over septal technique. Patient demographics and outcomes were recorded. Flap design: bilateral vertical septal mucosa incisions are performed on either side of the posterior third of the septum to form two mucoperiosteal flaps. The posterior vomer and atretic plates are removed. One flap is pedicled superiorly and rotated over the bare sphenoid rostral bone. The contralateral flap is pedicled inferiorly and rotated to cover exposed bone of nasal cavity floor. Lateral nasal wall mucosal integrity is maintained. This technique is used both for unilateral and bilateral atresia. Results Twelve patients from 2013 to 2020 were included. Age range was 0.07-50 years, male to female ratio of 1:5. Ten patients had unilateral CA, two had bilateral. Nine had bony CA, the remainder mixed. 5 patients (mean age 2.8 years) underwent second-look endoscopy under sedation an average 36 days following primary surgery. Conclusions The cross over technique for CA has low morbidity and 100% success in our multicentre series. Use of mucoperiosteal flaps to cover the exposed bone, removal of vomer and minimal instrumentation to the lateral nasal wall are the best ways to avoid postoperative stenosis.

Background Noise has been recognised to have a negative impact on performance and wellbeing in many settings. Average noise levels have been found to range between 51-79 dB in operating theatres. Despite this, there is little research investigating the effect of noise on surgical team functioning. Method A literature review to look at the impact of noise in the operating theatre was performed on MEDLINE which included the search terms ‘noise’ OR ‘distraction’ AND ‘technical skill’ OR ‘Surgical skill’ OR ‘Operating Room’. 10 of 307 articles identified were deemed relevant. Results 8 of 10 studies found noise to be detrimental to communication and surgical performance, particularly regarding total errors and time to task completion. No studies found noise to be beneficial. Two studies found case irrelevant verbal communication to be a frequent form of noise pollution in operating theatres; this is both perceived by surgeons to be distracting and delays patient care. Noise was most harmful to trainees. Conclusions Noise and irrelevant verbal communications were both found to be harmful to surgical performance, surgeon experience and team functioning. The worsened effect on the trainee exposes an urgent need to address noise pollution in the training environment.

Introduction Noise has been recognised to have a negative impact on performance and wellbeing in many settings. Average noise levels have been found to range between 51dB and 79dB in operating theatres. Despite these levels of noise, there is little research investigating their effect on surgical team functioning. Methods A literature review to look at the impact of noise in the operating theatre was performed on MEDLINE, which included the search terms ‘noise’ OR ‘distraction’ AND ‘technical skill’ OR ‘Surgical skill’ OR ‘Operating Room’. Only 10 of 307 articles identified were deemed relevant. Findings Eight of ten studies found noise to be detrimental to communication and surgical performance, particularly regarding total errors and time to task completion. No studies found noise to be beneficial. Two studies found case-irrelevant verbal communication to be a frequent form of noise pollution in operating theatres; this is both perceived by surgeons to be distracting and delays patient care. Conclusion Noise and irrelevant verbal communications were both found to be harmful to surgical performance, surgeon experience and team functioning.

Background: There are few contemporary data on the mortality and morbidity associated with rheumatic heart disease or information on their predictors. We report the 2-year follow-up of individuals with rheumatic heart disease from 14 low- and middle-income countries in Africa and Asia. Methods: Between January 2010 and November 2012, we enrolled 3343 patients from 25 centers in 14 countries and followed them for 2 years to assess mortality, congestive heart failure, stroke or transient ischemic attack, recurrent acute rheumatic fever, and infective endocarditis. Results: Vital status at 24 months was known for 2960 (88.5%) patients. Two-thirds were female. Although patients were young (median age, 28 years; interquartile range, 18–40), the 2-year case fatality rate was high (500 deaths, 16.9%). Mortality rate was 116.3/1000 patient-years in the first year and 65.4/1000 patient-years in the second year. Median age at death was 28.7 years. Independent predictors of death were severe valve disease (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.80–3.11), congestive heart failure (HR, 2.16; 95% CI, 1.70–2.72), New York Heart Association functional class III/IV (HR, 1.67; 95% CI, 1.32–2.10), atrial fibrillation (HR, 1.40; 95% CI, 1.10–1.78), and older age (HR, 1.02; 95% CI, 1.01–1.02 per year increase) at enrollment. Postprimary education (HR, 0.67; 95% CI, 0.54–0.85) and female sex (HR, 0.65; 95% CI, 0.52–0.80) were associated with lower risk of death. Two hundred and four (6.9%) patients had new congestive heart failure (incidence, 38.42/1000 patient-years), 46 (1.6%) had a stroke or transient ischemic attack (8.45/1000 patient-years), 19 (0.6%) had recurrent acute rheumatic fever (3.49/1000 patient-years), and 20 (0.7%) had infective endocarditis (3.65/1000 patient-years). Previous stroke and older age were independent predictors of stroke/transient ischemic attack or systemic embolism. Patients from low- and lower-middle–income countries had significantly higher age- and sex-adjusted mortality than patients from upper-middle–income countries. Valve surgery was significantly more common in upper-middle–income than in lower-middle– or low-income countries. Conclusions: Patients with clinical rheumatic heart disease have high mortality and morbidity despite being young; those from low- and lower-middle–income countries had a poorer prognosis associated with advanced disease and low education. Programs focused on early detection and the treatment of clinical rheumatic heart disease are required to improve outcomes.

BackgroundMules and other equine species have been used in warfare for thousands of years to transport goods and supplies. Mules are known for ‘braying’, which is disadvantageous in warfare operations. This article explores the fascinating development of surgical techniques to stop military mules from braying, with particular emphasis on the key role played by the otolaryngologist Arthur James Moffett in devoicing the mules of the second Chindit expedition of World War II.MethodThe PubMed database (1900–2017) and Google search engine were used to identify articles related to devoicing mules in the medical and veterinary literature, along with information and images on the Chindit expedition.ResultsThis paper reviews the surgical techniques aimed at treating braying in mules, ranging from ventriculectomy and arytenoidectomy to Moffett's approach of vocal cordectomy.ConclusionMoffett's technique of vocal cordectomy provided a quick, reproducible and safe solution for devoicing mules. It proved to be advantageous on the battlefield and demonstrated his achievements outside the field of medicine.

Objective:Intranasal splints have long been utilised as a post-operative adjunct in septoplasty, intended to reduce the risk of adhesions and haematoma formation, and to maintain alignment during healing.Methods:A Medline literature review of the history and evolution of intranasal splint materials and designs was performed. Advantages and disadvantages of various splints are discussed.Results:Intranasal splints fashioned from X-ray film were first reported in 1955. Since then, a variety of materials have been utilised, including polyethylene coffee cup lids, samarium cobalt magnets and dental utility wax. Most contemporary splints are produced from silicon rubber or polytetrafluoroethylene (Teflon). Designs have varied in thickness, flexibility, shape, absorption and the inclusion of built-in airway tubes. Future directions in splint materials and designs are discussed.Conclusion:Intranasal splints have steadily evolved since 1955, with numerous novel innovations. Despite their simplicity, they play an important role in nasal surgery and will continue to evolve over time.

Objective:This systematic review aimed to establish that quinolones are as effective as aminoglycosides when used to treat chronic suppurative otitis media.Method:The review included good quality, randomised, controlled trials on human subjects, published in English, that compared topical aminoglycosides with topical quinolones for the treatment of chronic suppurative otitis media.Results:Nine trials met the criteria. Two studies showed a higher clinical cure rate in the quinolone group (93 per centvs71 per cent,p= 0.04, and 76 per centvs52 per cent,p= 0.009). Four studies showed no statistically significant difference in clinical outcome. A significant difference in microbiological clearance in favour of quinolones was shown in two studies (88 per centvs30 per cent,p< 0.001, and 88 per centvs30 per cent,p< 0.001).Conclusion:Topical quinolones do not carry the same risk of ototoxicity as aminoglycosides. Furthermore, they are equal or more effective in treating chronic suppurative otitis media and when used as prophylaxis post-myringotomy. Topical quinolones should be considered a first-line treatment for these patients.