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Directed Acyclic Graphs stand as one of the prevailing approaches for representing causal relationships within a set of variables. With observational or interventional data, certain undirected edges within a causal DAG can be oriented. Performing intervention can be done in two different settings, passive and active. Here, we prove that an optimal intervention set can be obtained based on the minimum vertex cover of a graph. We propose an algorithm that efficiently identifies such an optimal intervention set for chordal graphs within polynomial time. Performing intervention on this optimal set recovers all the undirected edges in graph G, regardless of the underlying ground truth DAG. Furthermore, we present an algorithm for evaluating the performance of passive algorithms. This evaluation provides insights into how many intervention steps of a specific algorithm are required to recover all edges in the causal graph for any possible underlying ground truth in the equivalence class. Experimental findings underscore that the number of nodes in the optimal intervention set increases with growing the number of nodes in a graph, where the edge density is fixed, and also increases with the rising edge density in a graph with a fixed number of nodes. [ABSTRACT FROM AUTHOR]

Background: Poor intra-tumoural vascularity contributes to a lack of response to chemotherapy in pancreatic cancers. Preliminary data suggest that the addition of endoscopic ultrasound (EUS)-guided intra-tumoural injection of phosphorus-32 ( 32 P) microparticles to standard chemotherapy is potentially beneficial in locally advanced pancreatic cancer (LAPC). We aimed to assess changes in pancreatic tumour vascularity following 32 P implantation, using contrast-enhanced EUS (CE-EUS)., Methods: This was a prospective single-centre trial from January 2022 to 2024 of patients with unresectable, non-metastatic LAPC undergoing standard FOLFIRINOX chemotherapy and 32 P implantation. We performed CE-EUS pre-implantation after two chemotherapy cycles and 4 and 12 weeks after implantation. Time-intensity curves were analysed for 90 s after IV contrast bolus to ascertain peak intensity and intensity gain., Results: A total of 20 patients underwent 32 P implantation, with 15 completing 12-week follow-up. The technical success of 32 P implantation was 100%. The median primary tumour size reduced from 32 mm (IQR 27.5-38.75) pre-implantation to 24 mm (IQR 16-26) 12 weeks post-implantation ( p < 0.001). Five patients (25%) had tumour downstaging, and four underwent resections. The baseline (pre-implantation, post-chemotherapy) median intensity gain of contrast enhancement within the tumour was 32.15 (IQR 18.08-54.35). This increased to 46.85 (IQR 35.05-76.6; p = 0.007) and 66.3 (IQR 54.7-76.3; p = 0.001) at 4 weeks and 12 weeks post-implantation, respectively. Over a median follow-up of 11.2 months (IQR 7.8-12.8), 15/20 (75%) of patients remained alive, with 3/20 (15%) demonstrating local disease progression. Overall survival was not significantly different between patients with or without an increased intensity of 10 a.u. or more at 12 weeks post-implantation., Conclusion: This is the first clinical study to demonstrate treatment-induced increased vascularity within pancreatic primary tumours, which followed 32 P implantation and FOLFIRINOX chemotherapy. Larger comparative trials are warranted.

In the absence of rapid on-site evaluation (ROSE), it is not clear which method of tissue preparation is best to process tissue obtained from EUS guidance. Cytological smearing (CS), cell block (CB), and direct histology (DH) are the available techniques., Aim: To compare the diagnostic yield of three techniques of tissue preparation for EUS-guided tissue acquisition without ROSE., Methods: Patients who were referred for EUS-FNA of peri-gastrointestinal masses were recruited. Without ROSE, each lesion was biopsied with three needle passes, and the order in which tissue is prepared was randomized to either (i) CS + CB, (ii) CB only, or (iii) DH only. The prepared specimens were reviewed., Results: A total of 243 specimens were taken from 81 patients. Tissue diagnosis was achieved in 78/81 (96.3%) of patients, including 63 neoplasms (PDAC [n = 45], pancreatic neuroendocrine tumors [PNET; n = 4], cholangiocarcinoma [n = 5], metastatic disease [n = 4], lymphoma [n = 1], linitis plastica [n = 2], leiomyoma [n = 2]) and 15 benign pathologies (chronic pancreatitis [n = 8], reactive nodes [n = 5], inflammatory biliary stricture [n = 1], and pancreatic rest [n = 1]). The three non-diagnostic cases were found to be PDAC (n = 2) and PNET (n = 1). Sensitivity and diagnostic accuracy was highest with DH (94 and 95%), which was significantly better than that by CS + CB (43 and 54%; P = 0.0001) and CB-only preparations (32 and 48.6%; P < 0.0001). There was no significant difference between the CS + CB and CB-only arms (P > 0.22)., Conclusion: Without ROSE, our findings suggest that with just a single pass, DH should be the tissue preparation method of choice given its significantly higher diagnostic accuracy compared with CS and/or CB techniques., (© 2023 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aim: Eosinophilic esophagitis (EoE) is a chronic disease which may progress to a fibro-stenotic phenotype due to esophageal sub-epithelial fibrosis. Esophageal wall thickening in patients with EoE has been demonstrated in a few studies using endoscopic ultrasound (EUS). The aim of this study was to longitudinally assess the endoscopic appearance, wall thickness, histology, and dysphagia score of EoE patients., Methods: Patients with EoE were recruited and studied between February 2012 and April 2021. Patients were evaluated on two separate occasions at least 12 months apart with endoscopy, EUS, and esophageal mucosal biopsies. The dysphagia score and epidemiology data were also assessed., Results: A total of 16 EoE patients were included with a mean follow-up duration of 2.2 ± 1.2 years. In 14/16 (88%) patients, the total wall thickness of the distal esophagus significantly increased ( P  = 0.0012) as a result of thickening of the muscularis propria ( P  = 0.0218). However, only 1/14 (7%) patient had an increase in the dysphagia score, while 8/14 (57%) and 5/14 (36%) had a stable and reduced dysphagia score, respectively. No differences were found in the total thickness of other esophageal regions, dysphagia score, endoscopic appearance, and eosinophil count over time., Conclusion: Distal esophageal wall thickness increases with time in EoE patients, independent of the dysphagia score and eosinophil count., (© 2023 The Authors. JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Thickening of the esophageal wall in patients with eosinophilic esophagitis (EoE) and gastro-esophageal reflux disease (GERD) has been shown in studies using endoscopic ultrasound (EUS). We hypothesise that transmural inflammation in EoE results in prominent esophageal wall thickening compared with the mucosal inflammation in GERD. The aim of this study was to compare the relationship among dysphagia, endoscopic appearance, wall thickness, histology, and motility in EoE and GORD., Methods: EoE and GERD patients were prospectively studied between February 2012 and April 2021. Patients were studied on 2 separate occasions with endoscopy, EUS and mucosal biopsies, followed by high-resolution manometry. Epidemiology and dysphagia data were obtained., Results: A total of 45 patients (31 EoE, 14 GERD) were included. There were no significant differences in age, sex, duration of disease and presence of esophageal motility disorders. EoE patients had a higher dysphagia score (P < 0.001), EREFS score (P < 0.001) and peak eosinophil count (P < 0.001) compared with GERD patients. Thickness of the submucosa in the distal esophagus in EoE was significantly higher than GERD (P = 0.003) and positively correlated with duration of disease (P = 0.01, R = 0.67). Positive correlation was also found between dysphagia score and distal total esophageal wall thickness (P = 0.03, R = 0.39) in EoE patients. No correlation was found between these variables in GERD patients., Conclusion: Distal esophageal wall thickness positively correlates with dysphagia score in EoE but not GERD. This appears to be related to the composition of the submucosa which can be identified using EUS., (© 2022. Crown.)

Statement of the Problem: Orthodontic removable appliances can facilitate the accumulation of certain microorganisms and microbial plaque on tooth surfaces and appliance components. Since long-term use of chemical agents is not recommended, an alternative option would be medicinal plants for disinfection of the oral cavity., Purpose: The aim of this study was to assess the efficacy of thymus vulgaris (T. vulgaris) essential oil to decrease the count of candida albicans (C. albicans) accumulated on removal orthodontic appliances., Materials and Method: In this 2-arm parallel controlled clinical trial, forty-four patients whose removable orthodontic appliances were contaminated with C. albicans were randomly divided into two groups by electronic random sampling. In the first group, T. vulgaris essential oil spray and in the second group, 0.2% chlorhexidine (CHX) spray was applied to the appliances. Thereafter, the C. albicans colony count was measured at baseline (T0) and at 2 (T1) and 5 (T2) days after the intervention. Microbial samples were collected by a sterile swab from 3 spots on the internal surface of orthodontic appliances. The Friedman test was used for within-group comparisons and the Mann Whitney test was employed to compare the efficacy of T. vulgaris essential oil with CHX., Results: The results of this study revealed that continuous use of 2%T. vulgaris essential oil or 0.2% CHX significantly decreased the colony count of C. albicans on removable orthodontic appliances; Howevere, no significant difference was noted in the efficacy of 2% T. vulgaris essential oil and 0.2% CHX in decreasing the C. albicans colony count., Conclusion: T. vulgaris essential oil and CHX have favorable antimicrobial activity against C. albicans. Moreover, 2% T. vulgaris essential oil can be considered as an alternative to 0.2% CHX to eliminate fungal contamination of orthodontic appliances., (Copyright: © Journal of Dentistry.)

Background: This study evaluated clinical outcomes of combined chemotherapy and endoscopic ultrasound (EUS)-guided intratumoral radioactive phosphorus-32 ( 32 P) implantation in locally advanced pancreatic adenocarcinoma (LAPC)., Methods: Consecutive patients with newly diagnosed LAPC were recruited over 20 months. Baseline computed tomography and 18 F-2-fluoro-2-deoxy-D-glucose ( 18 FDG) positron emission tomography-computed tomography were performed and repeated after 12 weeks to assess treatment response. Following two cycles of conventional chemotherapy, patients underwent EUS-guided 32 P implantation followed by six chemotherapy cycles., Results: 12 patients with LAPC (median age 69 years [interquartile range 61.5-73.3]; 8 male) completed treatment. Technical success was 100 % with no procedural complications. At 12 weeks, median reduction in tumor volume was 8.2 cm 3 (95 % confidence interval 4.95-10.85; P  = 0.003), with minimal or no 18 FDG uptake in nine patients (75 %). Tumor downstaging was achieved in six patients (50 %), leading to successful resection in five (42 %), including four R0 resections (80 %)., Conclusions: EUS-guided 32 P implantation was feasible, well tolerated, and resulted in a 42 % surgical resection rate. Further evaluation in a larger randomized multicenter trial is warranted., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Aims: Making a dry surgical field during functional endoscopic sinus surgery (FESS) is a challenge for anesthetists. This study was conducted to evaluate the pre-emptive hemostatic effects of a single dose of an intranasal spray of desmopressin (DDAVP) in sinus surgery., Material and Methods: Sixty consecutive patient's as first-time candidates for FESS due to chronic sinusitis were enrolled. They were randomly allocated to receive either a nasal spray of DDAVP 20 μg or sterile water before induction of anesthesia. Management of anesthesia was achieved with propofol and remifentanil infusions. Blood loss, quality of the surgical field, and surgeon's satisfaction were compared between the two groups., Results: Blood loss in the DDAVP group was 147 ± 43 mL and in the placebo group 212 ± 64 mL (mean ± SD, P < 0.01). The quality of the surgical field in the DDAVP group was better than the placebo group. (median score, 1 (1-2) vs. 2 (1-3), P = 0.017). Surgeons were more satisfied with the surgical field in the DDAVP group than in the control group (median score, 4 (2.8-5) vs. 3 (2-3), P = 0.04)., Conclusion: Premedication with nasal spray DDAVP 20 μg effectively reduces bleeding and improves the surgical field during FESS., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology.)

Objectives: Coronavirus disease 2019 (COVID-19) represents a major pandemic threat that has spread to more than 212 countries with more than 432,902 recorded deaths and 7,898,442 confirmed cases worldwide so far (on June 14, 2020). It is crucial to investigate the spatial drivers to prevent and control the epidemic of COVID-19., Methods: This is the first comprehensive study of COVID-19 in Iran; and it carries out spatial modeling, risk mapping, change detection, and outbreak trend analysis of the disease spread. Four main steps were taken: comparison of Iranian coronavirus data with the global trends, prediction of mortality trends using regression modeling, spatial modeling, risk mapping, and change detection using the random forest (RF) machine learning technique (MLT), and validation of the modeled risk map., Results: The results show that from February 19 to June 14, 2020, the average growth rates (GR) of COVID-19 deaths and the total number of COVID-19 cases in Iran were 1.08 and 1.10, respectively. Based on the World Health Organisation (WHO) data, Iran's fatality rate (deaths/0.1M pop) is 10.53. Other countries' fatality rates were, for comparison, Belgium - 83.32, UK - 61.39, Spain - 58.04, Italy - 56.73, Sweden - 48.28, France - 45.04, USA - 35.52, Canada - 21.49, Brazil - 20.10, Peru - 19.70, Chile - 16.20, Mexico- 12.80, and Germany - 10.58. The fatality rate for China is 0.32 (deaths/0.1M pop). Over time, the heatmap of the infected areas identified two critical time intervals for the COVID-19 outbreak in Iran. The provinces were classified in terms of disease and death rates into a large primary group and three provinces that had critical outbreaks were separate from the others. The heatmap of countries of the world shows that China and Italy were distinguished from other countries in terms of nine viral infection-related parameters. The regression models for death cases showed an increasing trend but with some evidence of turning. A polynomial relationship was identified between the coronavirus infection rate and the province population density. Also, a third-degree polynomial regression model for deaths showed an increasing trend recently, indicating that subsequent measures taken to cope with the outbreak have been insufficient and ineffective. The general trend of deaths in Iran is similar to the world's, but Iran's shows lower volatility. Change detection of COVID-19 risk maps with a random forest model for the period from March 11 to March 18 showed an increasing trend of COVID-19 in Iran's provinces. It is worth noting that using the LASSO MLT to evaluate variables' importance, indicated that the most important variables were the distance from bus stations, bakeries, hospitals, mosques, ATMs (automated teller machines), banks, and the minimum temperature of the coldest month., Conclusions: We believe that this study's risk maps are the primary, fundamental step to take for managing and controlling COVID-19 in Iran and its provinces., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Congenital hearing loss is associated with cardiac rhythm disturbances namely long Q-T syndrome. This study was designed to investigate the effect of anti-emetic doses of ondansetron and dexamethasone on ECG recordings in children undergoing cochlear implant surgery., Methods: Sixty-three pediatric patients scheduled for elective cochlear implantation were enrolled in the study. Two patients were excluded as their baseline ECG showed long QT syndrome. Anesthesia was induced with fentanyl, propofol and atracurium and maintained with propofol. Dexamethasone 0.1 mg.kg -1 or ondansetron 0.2 mg.kg -1 was randomly administered for the participants approximately 30 min before the end of surgery. ECG recording was performed 15 min after induction of anesthesia and 15 min after dexamethasone/ondansetron administration. RR interval, QRS duration, QT interval, and Tp-e interval were measured by a blinded cardiologist., Results: Ondansetron resulted in no significant changes in RR, JTc and QTc intervals; while prolongedTp-e interval. Multivariable logistic regression analysis showed that use of ondansetron was an independent predictor of QTc prolongation after adjustment for age, gender and baseline QTc (OR = 17.94, CI 95% 1.97-168.70, p = 0.011). The incidence of postoperative retching/vomiting in ondansetron group was significantly lower than dexamethasone group. (3.2% vs. 26.7%, p = 0.011)., Conclusion: The risk of arrhythmias with the use of ondansetron in otherwise healthy candidates of cochlear implant is very low. However, the drug may induce significant changes in ECG parameters. The clinical significance of these changes in patients with cardiac conduction abnormalities should be investigated in further studies., Competing Interests: Declaration of competing interest None to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Children with sensorineural hearing loss are at risk of cardiac electrophysiologic abnormalities. Inhalational Sevoflurane induction in these children can cause QT prolongation., Objectives: In order to evaluate the safety of inhalational induction of anesthesia with sevoflurane in children with sensorineural hearing loss, who are candidates for cochlear implant, its electrophysiologic effects was compared with intravenous induction of anesthesia with propofol., Methods: In this double-blind randomized clinical trial, 61 children aged between one and eighteen years old, who were candidates for cochlear implantation, were randomly allocated to groups receiving anesthesia with sevoflurane (n = 32) or propofol (n = 29) for induction of anesthesia. Two 12-leads ECG were taken from all of patients before and after induction and QTc, Tp-e interval, and JTc were measured and compared., Results: Two cases, who had pre-induction QTc longer than 500 ms were excluded from the study. Patients had similar age (102.58 ± 87 versus 101.46 ± 67 months, P = 0.95) and gender (males: 48.3% versus 56.3%, P = 0.53) distribution. The researchers observed significant post induction difference in QTc values between these groups (propofol 422.5 ± 40, sevoflurane 445.0 ± 29, P = 0.016). There was no significant difference in the percent QTc and Tp-e changes in propofol and sevoflurane groups. Greater percentage of patients with increased Tp-e interval (> 100 ms) in the sevoflurane group than the propofol group was also seen. There was no significant long QTc difference (QTc > 500 ms or more than 60 ms increase from baseline) after induction of anesthesia in the sevoflurane group compared to the propofol group (15.6% versus 13.8%, P = 0.84)., Conclusions: After electrophysiological evaluations in children with sensorineural hearing loss, in patients whose pre-induction QTc is not longer than 500 ms, propofol seems safer than inhalational sevoflurane for induction of anesthesia., Competing Interests: Conflict of Interests: The authors declare that there was no conflict of interest., (Copyright © 2019, Author(s).)

Objective: Ulcerative colitis (UC) is characterized by mucosal inflammation and ulceration of the large intestine. Emu Oil (EO) has been reported to protect the intestine against mucositis, NSAID-enteropathy, UC-associated colorectal cancer and acute UC. We aimed to determine whether EO could reduce the severity chronic UC in mice. Methods: Female C57BL/6 mice ( n  = 10/group) were orally administered (gavage) water (Groups 1-2) or EO (Groups 3: low dose-80 µl and 4: high dose-160 µl), thrice weekly. Group 1 mice consumed plain drinking water throughout the trial. Groups 2-4 mice underwent two cycles [each consisting of seven days dextran sulfate sodium (DSS; 2% w/v) and 14 days water], followed by a third DSS week. All mice were euthanized two days later (day 51). Bodyweight, disease activity index (DAI), burrowing activity, myeloperoxidase activity, crypt depth and histologically assessed damage severity were assessed. p  < .05 was considered significant. Results: DSS decreased bodyweight and increased DAI compared to normal controls ( p  < .05), which was partially attenuated by both EO doses ( p  < .05). Burrowing activity was impaired in DSS-controls compared to normal controls (days 27 and 40); an effect prevented by both EO doses ( p  < .05). DSS increased colonic myeloperoxidase activity and crypt depth compared to controls ( p  < .05), with no significant EO effect. Moreover, DSS increased colonic damage severity compared to normal controls ( p  < .001). Importantly, both EO doses decreased distal colonic damage severity compared to DSS-controls ( p  < .001). Conclusions: Emu Oil attenuated clinically- and histologically-assessed disease severity in a mouse model of chronic UC. Emu Oil demonstrates promise as an adjunct to conventional treatment options for UC management.

BACKGROUND Diaphragmatic rupture can be seen in up to 5% of car accidents, and 80%-100% of diaphragmatic hernias are associated with other vital organ injuries. Brain, pelvis, long bones, liver, spleen, and aorta are some other organs that can be severely damaged and need different anesthetic managements. CASE REPORT A 37-year-old male victim of a head-on collision who was suffering diaphragmatic rupture and corneal laceration was prepared for an emergency operation 11 hours after the car accident. Gastric decompression, pre-oxygenation, rapid sequence induction with succinylcholine, immediate use of non-depolarizing muscle relaxant, and mechanical ventilation with low tidal volume after intubation were used in anesthetic management of the patient. CONCLUSIONS Because of the high prevalence of coexisting pathologies with traumatic diaphragmatic hernia, anesthetic management must be tailored to the associated pathologies.

Background: Supraglottic devices could be used to reduce postoperative respiratory complications, but there are few studies focused on their use in more prolonged surgeries., Objectives: In this study, we compared postoperative respiratory complications in patients with prolonged ear, nose and throat (ENT) surgeries, whose airways were controlled with tracheal tube or laryngeal mask airway (LMA)., Materials and Methods: In a randomized control trial (RCT), 171 candidates of prolonged ENT surgeries were randomly assigned into two groups. In group one (n = 85) LMA and in group two (n = 86) endotracheal tube were used for airway control. The incidences of four postoperative respiratory complications including sore throat, hoarseness, cough and shortness of breath in immediate postoperative period were measured and compared among patients of each group., Results: Sore throat was recorded in 32.9% of patients with LMA and 44.2% of intubated patients, but it was not statistically significant (Fisher's Exact test = 0.158). Hoarseness was recorded in 3.5% of patients with LMA and 24.4% of intubated patients (Fisher's Exact test = 0.000). In 1.2% of patients with LMA cough was recorded; it was also seen in 7% of the intubated patients (Fisher's Exact test = 0.005). Shortness of breath was mentioned by two intubated patients (2.3%) and in patient with LMA we did not record this complication., Conclusions: LMA in prolonged ENT surgeries was associated with reduced respiratory complications.

Background: Although controversial, many studies have shown effectiveness of colloid loading as a substitute for crystalloids on reducing the incidence of hypotension in spinal anesthesia. This study was conducted to compare the effects of three intravenous fluid regimens on hemodynamic changes following spinal anesthesia in cesarean section. The regimens included 6% Hydroxyethylstarch 130/0.4 (HES) as a colloid and two crystalloids (lactated ringer's solution and sodium chloride 0.9%)., Material & Method: In a double-blind clinical trial, 90 otherwise healthy parturients candidate of elective caesarean section were randomly allocated to receive lactated ringer's solution (1000 ml), sodium chloride 0.9% (1000 ml) or HES (7.5 mL/Kg) as preloading before spinal anesthesia. Hemodynamic parameters including blood pressure and heart rate, umbilical cord blood pH and the neonatal Apgar score were compared among the three groups., Results: There was no difference in the basic hemodynamic measurements among the three groups. The incidence of hypotension and required dose of ephedrine was lower in HES group (p=0.008). There was no significant difference in umbilical cord blood PH or Apgar scores among intervention groups., Conclusion: Preloading with HES is more effective than crystalloids in prevention hypotension after spinal anesthesia without significant difference in Apgar score and umblical cord blood pH.

Background: Hemodynamic stability and blood loss reduction are subjects to further consideration in patients undergoing percutaneous nephrolithotomy (PNCL)., Objectives: This study compared the preference of spinal anaesthesia (SA) or general anaesthesia (GA) in respect to mentioned concerns., Patients and Methods: In this randomized clinical trial, 59 patients who underwent PCNL divided into SA and GA groups. 15-20 mg from intra-thecal bupivacaine 0.5%, and premedication of 0.01-0.02 mg from midazolam, were given to patients in SA group (n = 29). Patients in GA group (n = 30) received premedication of 1-2 µg/kg from fentanyl and 0.01-0.02 mg/kg from midazolam, and intravenously anaesthetized with 100 µg/kg/min of propofol and 0.5 mg/kg of atracurium, given by continuous infusion and N2O/O2 50%. Mean arterial pressure (MAP) and heart rate were recorded intra-operatively and during recovery., Results: MAP and heart rate show no significant differences at designated time points between two groups (P > 0.05). Surgery time, anesthesia time, bleeding volume, and analgesic intake were significantly reduced in SA group (P < 0.05)., Conclusions: It seems that, in patients undergoing PNCL, SA is as effective and safe as GA. Patients who undergo PNCL under SA require smaller amounts of analgesic dose and show hemodynamic stability during surgery and recovery time. Also, SA technique provides decreased blood loss and shortened surgery as well as anesthesia times compared to GA.