Oral Care and Research

Assessment of microsphere-controlled drug delivery for local control of tooth movement Erukala Srikanth, Eslavath Seena Naik, Malledi Narasimha Lakshmi, Devatha Ashok Babu, Rahul Goud Padala, Addu Aravind Kumar International Journal of Oral Care and Research 2020 8(4):71-73 Background: Orthodontics is a special discipline dedicated to the investigation and practice of moving teeth through the bone. This study was conducted to assess new methods to locally enhance orthodontic anchorage. Materials and Methods: A single injection of 1 mg/kg nonencapsulated or microsphere encapsulated osteoprotegerin (OPG) was delivered into the palatal mucosa mesial to the first maxillary molar 1 day prior to tooth movement. A positive control group received injections of 5 mg/kg nonencapsulated OPG every 3 days during tooth movement. After 28 days of tooth movement, hemi-maxillae and femurs were dissected. Molar mesial and incisor distal tooth movement was measured using stone casts that were scanned and magnified. Results: Maximum movement was obtained with an empty microsphere single injection as compared to 1 mg/kg nonencapsulated OPG, 1 mg/kg encapsulated OPG, and 5 mg/kg nonencapsulated OPG. Maximum movement 2.6 mm was obtained with an empty microsphere single injection as compared to 1 mg/kg nonencapsulated OPG (2.4 mm), 1 mg/kg encapsulated OPG (2.5 mm), and 5 mg/kg nonencapsulated OPG (1.2 mm). A significant difference was found in bone mineral content, bone mineral density, tissue mineral content, and tissue mineral density with encapsulated and encapsulated OPG and microspheres (P < 0.05). Conclusion: Authors found that microsphere encapsulation of OPG allows for controlled drug release and enhances site-specific orthodontic anchorage without systemic side effects.

Comparison of marginal accuracy and internal fit of cast nickel chromium and metal laser-sintered crowns: An in vitro study Priyanka Konin, Arvind Moldi, Nagesh Ingleshwar, Shalini Nawabadkar, Rajasekhara Subhashini, Mohamed Ghalib Ruqshan Anjum International Journal of Oral Care and Research 2020 8(4):74-77 Purpose: The aim of this study was to evaluate and compare the marginal accuracy and internal fit of crowns fabricated by direct metal laser sintering, induction casting, and centrifugal casting. Materials and Methods: An acrylic resin analog of the right maxillary first molar was prepared with a total convergence angle of 6° and an occlusal reduction of 1.5 mm and 0.8 mm shoulder finish line. Thirty impressions of the analog tooth were obtained from the definitive die, n = 10 for each group. Wax patterns were fabricated and casting was done using an induction casting machine and centrifugal gas torch method, and for the direct metal laser-sintering group the dies were scanned and crown fabricated using EOS sintering machine. The marginal and internal gaps were estimated by measuring the cement thickness using a stereomicroscope. The mean value was determined and P values were obtained using a one-way analysis of variance (ANOVA) test. Student’s t test was used to determine the differences between the three groups. Results: The mean marginal and internal gaps were 59.82 ± 5.21 μm and118.69 ± 20.23 μm in the direct metal laser-sintering group, 116.13 ± 7.88 μm and 136.94 ± 13.50 μm in induction casting group, and 116.87 ± 7.46 μm and 133.77 ± 10.63 μm in centrifugal casting group, respectively. Conclusion: Under the limitation of this in vitro study, the marginal and internal gaps of DMLS group are better than centrifugal and induction casting groups.

Prevalence of malocclusion and gingival diseases in tribal population Ujjwal Priyadarsi, Mohammad Shahbaz Alam, Abid Hussain, Farrukh Azam, Priyanka Kumari, Rahul Anand International Journal of Oral Care and Research 2020 8(4):78-79 Background: Jharkhand is home to many tribes, which have an interesting and varied history of origins, customs, and social practices. Oral health care in tribal areas is limited due to shortage of dental manpower, financial constraints, and the lack of perceived need for dental care among tribal masses. The main objective of this study was to find prevalence of malocclusion and gingival diseases in tribal population in Jharkhand. Materials and Methods: A cross-sectional house-to-house survey was carried out among 1000 tribal children aged 5–15 years among 10 tribes of Jharkhand residing in East Singhbhum and West Singhbhum districts. Permissions and consent were obtained from local administrative authorities, ethical committee, and parents, respectively. A structured proforma was used to record demographic data. Examination for malocclusion and gingival diseases was also carried out. Descriptive tables and analytical tests such as ANOVA, post hoc, and chi-square test were employed. Results: The mean age was 10.75 (±2.43) years. The tribal children had minor malocclusion with no or slight treatment need. Categorization of orthodontic treatment need according to malocclusion severity is particularly important for the planning of corresponding public policies. Gingivitis was found among majority of children. Conclusion: The isolation of the villages and lack of transportation options impose limitations on the availability of health professionals to provide dental services.

Evaluation of orthodontic retention protocol among general dentist: A cross-sectional study Bhuvaneswari Mani, Abhishek Janardhanam, Haritha Doraiswamy, Selvakumar Ramar, Anupama S Prakash, S Srinidhi International Journal of Oral Care and Research 2020 8(4):80-82 Aim: The current survey was conducted to explore the retention protocol, complication regarding retainers, and long-term follow-up regarding orthodontic retention among the general dentist in Tamil Nadu. Materials and Method: This was a cross-sectional web-based questionnaire survey conducted among general dentists in Tamil Nadu. The pilot study was conducted to estimate the sample size and the final sample size arrived was 500 participants. The predesigned and validated, self-administered, structured 10 questions related to retention protocol, complication regarding retainers, and long-term follow-up regarding orthodontic retention. The statistical analysis was done using Statistical Package for Social Sciences SPSS (V 22.0) The frequency distribution was computed. Result: The current survey revealed that 500 (100%) respondents had awareness about the retention protocol after orthodontic treatment. Out of all the respondents 33 (6.6%) chose for a removable retainer, 367 (73.4%) chose a fixed retainer,84 (16.8%) opted for an invisible retainer and the remaining practitioner chose a combination of removable and fixed retainer. Nearly 452 (90.4%) general practitioners advised their patients to contact their orthodontist in case of a broken retainer and the remaining 48(9.6%) general practitioners can make retainers by themselves. Out of all the respondents, nearly 54.6% general dentists gradually taking over the case during monitoring and follow-up phase. Conclusion: In conclusion, the current study showed that a vast majority of the dentists were aware of the retention protocol and they are confident enough to deal emergency situation like broken retainers and most of the dentist prefer fixed retainer over other types of retainer.

Anterior and posterior crowns in primary dentition: A contemporary review Dempsy Chengappa MM, Akshai Kannan, Dhruv Sharma International Journal of Oral Care and Research 2020 8(4):83-87 One of the most common problems faced by clinicians in pediatric dentistry is to provide restorations in primary and young permanent teeth which are aesthetically acceptable, durable and cost effective. A wide range of crowns are available for this purpose and the selection of the most appropriate crown will help achieve better final outcomes of treatment. The vary widely from being the directly bondable to the tooth surface to crowns which are luted onto the tooth surface. They may also vary in composition from metal crowns with or without facings to resin, polycarbonate, and ceramic crowns. This review attempts to assimilate and bring out the varied array of pediatric crowns available in the published data for utilization by the pedodontist as per the needs of the patient. The knowledge of the available resources and the various advantages, disadvantages and properties of the same will go a long way in enhancing the clinician’s ability to make the most appropriate choice for the patient.

Transmigration of mandibular cuspids: Review of literature M Nazargi Mahabob International Journal of Oral Care and Research 2020 8(4):88-90 Aim: The aim of this review was to summarize currently available data related to the prevalence and etiology of transmigrant mandibular canines and the different treatment options. Materials and Methods: A computer-based search of studies published from January 2016 to April 2020 was conducted. The studies were selected from various electronic databases such as Medline, Google Scholar, Epub, Embase, and Cochrane based on their title, study, design, keywords, Cochrane methodology, supplemented by a grey literature search and manually searched the references lists of the selected articles. Results: A total of 180 citations were searched initially and after proper screening, 19 relevant articles were included. According to the findings from our review, the incidence of canine impaction in the mandible ranges from 0.92% to 5.1%, whereas that of canine transmigration ranges from 0.1% to 0.31%. The literature search also shows that transmigration of canine almost exclusive in the mandible. Multiple factors have been attributed to the etiology of this condition. Cone beam computed tomography (CBCT) helps in giving clear details about their location, relation with adjacent structures, and pathology related to them. Conclusion: Early identification, proper treatment plan, and timely intervention needed to preserve the esthetic appearance and functional stability.

An update on the utilization of high-density polytetrafluoroethylene (d-PTFE) membranes for guided bone regeneration Reem Al-Kattan International Journal of Oral Care and Research 2020 8(4):91-96 Guided bone regeneration (GBR) procedure has produced acceptable results while utilizing various barrier membranes. Among the membranes used, expanded PTFE (e-PTFE) was the first material to demonstrate successful outcomes and it became the gold standard for GBR. However, early bacterial infection with membrane exposure affecting bone regeneration was the main drawback of e-PTFE. On the contrary, high density polytetrafluoroethylene (d-PFTE) ensures a good bone regeneration process in spite of membrane exposure in the oral cavity, and it also presents with a lower risk of early infection after surgical procedures. The purpose of this review is to provide an amendment to the existing knowledge about the GBR with special emphasis on the d-PTFE barrier membrane used for GBR. The relevant literature for this review was identified through a PubMed, MEDLINE, Scopus, and the Cochrane Library database search. Eleven articles that evaluated the use of d-PTFE as a barrier membrane for GBR were identified: two experimental studies and nine clinical studies. Considering the potential benefit they offer, d-PTFE is a favorable candidate for GBR. However, a careful surgical approach and thorough knowledge of the materials and management of complications significantly contribute to the success of GBR while utilizing d-PTFE.

Hemangiomas of the oral and maxillofacial region: A series of five cases with literature review Sooraj Soman, T Ajay Das, Leslie Sara Mathew Kalathil, Sachin Aslam, Tom Thomas, Vijayakumar Depesh International Journal of Oral Care and Research 2020 8(4):97-102 Most of the vascular tumors in the maxillofacial region are hemangiomas. Hemangiomas are basically benign lesions of a vascular origin. This article describes a series of five cases on hemangioma recorded on the lip, buccal mucosa, and zygoma. Here, we present four variants of hemangioma, namely cavernous hemangioma, capillary hemangioma, lobular capillary hemangioma, and intraosseous hemangioma, which were reported to our Maxillofacial Unit.

Transmigration of cuspids: Report of three rare cases Nazargi Mahabob Mahabob Basha International Journal of Oral Care and Research 2020 8(4):103-105 The pre-eruptive and intraosseous migration of teeth across the midline is called as transmigration. This rare phenomenon is common in the mandible compared to the maxilla. The occurrence of bilateral transmigration of mandibular canine is even rarer than unilateral transmigration. In these three cases, two of them were unilateral transmigration and the third was bilateral transmigration. In unilateral transmigration cases, one among them showed compound odontome-induced transmigration of canine and displaced premolar toward the third molar of the same side and another with unilateral transmigration of canine just crossing the midline. The case had bilaterally transmigrated canines. The occurrence of bilateral transmigration of the mandibular canine is very rare than the unilateral transmigration. Many factors had been suggested as causative agents for transmigration of mandibular canines, but there is no clear, established etiology for this phenomenon. Mupparapu proposed classifications for unilateral and bilateral transmigration of mandibular canines after reviewing literature.

Odontogenic myxoma of posterior maxilla: A case report with mini literature review Sooraj Soman, Ajay Das Thulasi Das, Abhilash Mathews Thomas, Tom Thomas International Journal of Oral Care and Research 2020 8(4):106-108 Odontogenic myxoma is an uncommon, benign, locally invasive neoplasm with a high chance of recurrence. It is exclusively present in tooth-bearing areas of the jaws. Odontogenic myxoma commonly occurs in age groups ranging from 20 to 40 years with a female predilection, and the common site of occurrence is the posterior mandible. The purpose of this case report was to describe the unusual rare presentation of odontogenic myxoma of the posterior maxilla in a 16-year-old male patient, which was managed by surgical excision, peripheral ostectomy, and chemical cauterization

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Cancer Research and Therapeutics

Effectiveness of mouthrinses in prevention and treatment of radiation induced mucositis: A systematic review Varsha Manoharan, Nusrath Fareed, Hemant Battur, Sanjeev Khanagar, Jaseela Praveena Journal of Cancer Research and Therapeutics 2020 16(8):1-10 Mucositis is a frequent, severe consequence of radiation therapy among patients undergoing radiotherapy for the head-and-neck cancer, often requiring hospitalization and even breaks or discontinuity in treatment. Mouth rinsing with various agents has demonstrated effectiveness in the prevention and treatment of radiation-induced mucositis (OM), but evidence for the same is lacking. This systematic review is therefore conducted with the aim of assessing the evidence for the effectiveness of mouthrinses in prevention and treatment of OM. Joanna Briggs Institute guidelines were followed to conduct this review. Six databases were searched and a total of 25 randomized clinical trials published over a period of the past 31 years were included for qualitative synthesis. Analysis of 25 studies revealed that 1299 participants, aged 46–69 years were assigned to the test groups and control groups. A total of 16 different formulations were studied among patients over a duration of 6 days to 1 year in varying dosages. The overall preventive fraction ranged from 1.9% to 77.8% for a reduction in clinical grades of mucositis, 7.6%–83.3% for a reduction in pain and 20%–50% for a reduction in bacterial counts. Adverse effects such as mouth burning, altered taste, sore throat, have been reported, especially with chlorhexidine and benzydamine hydrochloride. Evidence for the included studies is IC and ID. Studies using herbal based products and tissue regenerating agents revealed comparatively better effectiveness with lesser side effects. However, the number of studies to support such a claim is very limited.

Thyroid paraganglioma: A case-based systematic review of literature Pritinanda Mishra, Somanath Padhi, Gayatri Behera Journal of Cancer Research and Therapeutics 2020 16(8):11-21 Thyroid paragangliomas are distinctly rare primary thyroid neoplasms with nearly 75 cases reported worldwide. Due to their similar embryological origin and cytohistomorphology with other thyroid neoplasms, they may pose great diagnostic challenges for pathologists, radiologists, endocrinologists, as well as surgeons leading to unnecessary aggressive therapy. With recent advances in molecular genetics, the prognostic significance of such seemingly innocuous thyroid neoplasms has been better understood. In this manuscript, we describe such a case and present a systematic review of all reported cases till date giving an update on our current knowledge regarding their diagnostic pitfalls, pathology, and molecular genetics.

The relevance of long noncoding RNAs in colorectal cancer biology and clinical settings Atefeh Talebi, Mazaher Azizpour, Shahram Agah, Mohsen Masoodi, Gholam Reza Mobini, Abolfazl Akbari Journal of Cancer Research and Therapeutics 2020 16(8):22-33 Colorectal cancer (CRC) is one of the most frequent causes of cancer-related death worldwide. The prognosis of the malignancy and patient survival is commonly poor. Therefore, the discovery of pertinent biomarkers is essential to provide an accurate diagnosis and effective therapy. Newly, a group of noncoding RNAs named long noncoding RNAs (lncRNAs) has been found to involve in CRC development and progression. In this review, we highlighted the biological function of lncRNAs and reviewed their potentials as clinical tools in the CRC. A literature search of PubMed, EMBASE, MEDLINE, Web of Science, Scopus, and Cochrane Library using the MeSH terms “CRC,” “long noncoding RNA,” “lncRNA,” and relevant was completed. The review included all articles that reported on the significance and role of lncRNAs in CRC development and clinical settings. All identified articles were cross-referenced for further articles, and any unavailable online were retrieved from hardcopy archive libraries. CRC-related lncRNAs could regulate a number of cellular processes, and their dysregulations have been suggested as potential biomarkers.

Predicting outcome of advanced head-and-neck cancer by measuring tumor blood perfusion in patients receiving neoadjuvant chemotherapy Kishore Singh, Rubu Sunku, Arun K Rathi, Gaurav S Pradhan Journal of Cancer Research and Therapeutics 2020 16(8):34-38 Purpose: The purpose of this study was to correlate treatment response with tumor blood perfusion in patient of advanced head-and-neck cancer undergoing neoadjuvant chemotherapy. Materials and Methods: A total of 40 patients of advanced head-and-neck cancer, who were planned for neoadjuvant chemotherapy, were included in the study. All patients underwent diagnostic computed tomography (CT) with perfusion study for staging and quantitative measurement of tumor volume as well as perfusion parameters (including tumor blood volume, blood flow, permeability, and time to peak enhancement), at baseline and after completion of neoadjuvant chemotherapy. Total 3 cycles of neoadjuvant chemotherapy with paclitaxel, cisplatin, and 5 fluorouracil were given. Tumor response was evaluated in terms of change in tumor volume and correlated with perfusion parameters. Results: Out of 40 patients, 22 patients had more than 50% reduction in tumor volume, who were grouped as responder and remaining 18 patients had <50% decrease in tumor volume, grouped as nonresponder. Both the groups were similar in terms of age, gender, performance status, stage, nodal status, or addiction. Baseline CT scan shows a significant difference in tumor blood flow (P = 0.048) and marginal difference in time to peak enhancement (P = 0.058) in two groups. However, there is no difference in tumor blood volume (P = 0.32) and permeability surface area (P = 0.07). Conclusions: Evaluation of tumor blood flow by perfusion CT is helpful in predicting chemotherapy outcome and deciding appropriate treatment modality, but further evaluation with more number of patients is required for validating the predictive role of each perfusion parameters.

Butyrylcholinesterase: An economical marker of disease activity in oral squamous cell carcinoma before and after therapy Shradha Gagan Jaiswal, Gagan Rajesh Jaiswal Journal of Cancer Research and Therapeutics 2020 16(8):39-42 Introduction: Biomarkers which can predict disease progression and serve as prognostic indicators are necessary for better management of oral cancer. Studies have shown that Cholinesterase plays an important role in cellular proliferation, differentiation and may have a possible involvement in tumor growth. Aim and Objective: The present study is aimed to determine the utility of serum Butyrylcholinesterase (BChe) levels as a marker for progression of oral squamous cell carcinoma (OSCC) in relation to the grade of the tumor and to determine if any variation occurred in the levels of BChe before and after therapy. Materials and Methods: A total of 120 patients were included in the study and divided into two groups as Group A-30 patients (healthy individuals) and Group B-90 cases of histopathologically diagnosed OSCC. The blood sample was collected before surgery, re-collected after the completion of radiotherapy (i.e., 3 and 6 months postsurgery) and analyzed biochemically for the concentration of BCh. Statistical Analysis: Paired t-test, ANOVA, and post hoc test (Bonferroni) were used for determining the statistical significance. Results: BChe levels were lower in OSCC (2940.32–1405.50 u/l when compared with controls (11149.60–11243.07 unit/l) and this difference was statistically significant. Postoperatively at 3 months, the serum BChe levels of OSCC patients increased almost two-fold compared to the preoperative values, and this difference was also statistically significant (P = 0.000) After 6 months, these levels further increased but did not reach those of controls. Conclusion: BChe can be used as an inexpensive, easy to use, noninvasive biomarker for the evaluation of disease-free survival in OSCC patients.

Good prognostic factor in patients with nonmetastatic nasopharyngeal carcinoma: Programmed death ligand-1 expression in tumor cells Hayriye Sahinli, Nalan Akyürek, Mukaddes Yılmaz, Olcay Kandemir, Ayşe Ocak Duran, Sezer Kulaçoǧlu, Gökhan Uçar, Elif Acar, Ahmet Özet, O Berna Ç. Öksüzoǧlu, Nuriye Y Özdemir Journal of Cancer Research and Therapeutics 2020 16(8):43-47 Purpose: Programmed death ligand-1 (PD-L1) is the main ligand for programmed death-1 (PD-1), and is one of the major targets for cancer immunotherapy. Only a few studies are available for the clinical significance of PD-1/PD-L1 in nasopharyngeal carcinoma (NPC). There is a controversial association between PD-L1 expression and survival in NPC. This study aimed at defining any potential association between PD-L1 expression in tumor cells (TCs) and prognosis in NPC. Patients and Methods: A total of seventy NPC patients treated between January 2008 and December 2016 were included in the study. PD-L1 expression was assessed by immunohistochemistry (IHC) in tumor specimens. The IHC assay was considered positive if ≥5% of TCs are stained. Clinicopathological variables were documented. Variables included in the analysis were PD-L1 expression, clinicopathological characteristics, and prognosis. Results: The estimated 5-year overall survival (OS) rate was 62%. Nearly 55.7% (n = 39) of the TCs tested positive for PD-L1 expression. No associations were found between the level of PD-L1 in TCs and clinicopathological characteristics. Comparisons between patients with PD-L1-positive tumors and PD-L1-negative tumors revealed that OS was statistically significantly longer in patients with PD-L1-positive tumors as assessed by the univariate Cox regression analysis (hazard ratio [HR], 0.378; 95% confidence interval, 0.158–0.905; P = 0.029) and Kaplan–Meier curves (P = 0.023). Conclusion: PD-L1 expression is an important prognostic factor in NPC. PD-L1 expression positively correlates with survival.

Eyelid carcinoma: An experience from a tertiary cancer center Shivakumar Thiagarajan, Ameya Bahani, Devendra Chaukar, Anil K Dcruz Journal of Cancer Research and Therapeutics 2020 16(8):48-52 Context: Eyelid carcinoma is rare tumors of the head and neck. They are rarely lethal but can be associated with significant morbidity if not treated early and appropriately. There are limited data available from world over and in particular the Indian subcontinent regarding eyelid carcinoma and its prognostic factors influencing treatment outcomes. Setting and Design:Retrospective study of patients treated in a tertiary cancer center between 2005 and 2016. Methodology: In this study, 51 patients with eyelid carcinoma treated at single tertiary cancer center were included. The demographic, clinical data, which includes the treatment received, histopathology report and follow–up, were recorded. All the relevant variables influencing disease-free survival (DFS) were analyzed. Results: Sebaceous carcinoma was the most common eyelid carcinoma followed by squamous cell carcinoma and basal cell carcinoma in descending order in this series. Lower eyelid was involved most often. The incidence of nodal metastasis was low (14%). Multivariate analysis revealed that margin status influenced the DFS (P= 0.001) (hazard ratios = 15.9 [95% confidence interval: 1.8–135.2]). The 5 years' DFS was 70%. Conclusion: Eyelid tumors are less common cancer with good prognosis if treated appropriately. The morbidity associated with treatment can be reduced if treated early.

Cytopathology-histopathology correlation and the effect of nodule diameter on diagnostic performance in patients undergoing thyroid fine-needle aspiration biopsy Nusret Yilmaz, Guven Baris Cansu, Serap Toru, Ramazan Sari, Guzide Gokhan Ocak, Cumhur Arici, Hasan Ali Altunbas, Mustafa Kemal Balci Journal of Cancer Research and Therapeutics 2020 16(8):53-58 Introduction: Although thyroid fine-needle aspiration biopsy (FNAB) is established to have a good overall sensitivity and specificity, various outcomes have been reported on its performance in large nodules. The aim of the study was to evaluate the diagnostic performance of FNAB and the effect of the nodule diameter on its diagnostic performance. Materials and Methods: The outcomes of a total of 7319 patients who underwent FNAB over the course of 5 years were analyzed retrospectively and 648 patients who had undergone post-FNAB thyroidectomy or lobectomy were included in the study. FNAB results were classified according to the Bethesda system. After evaluating the compatibility between cytology and pathology results, all-nodules and diameter-based (<4 cm and ≥4 cm) sensitivity, specificity, false positivity, false negativity, and accuracy rates of FNAB were calculated. Results: Sensitivity of FNAB was 85.4% for all nodules, 88.3% for nodules <4 cm, and 75.8% for nodules >4 cm (P < 0.001). Specificity was 58.4% for all nodules, 49.3% for nodules <4 cm, and 75.1% for nodules >4cm (P < 0.001). While false positivity was 41.6% for all nodules, it was 50.7% for nodules smaller than 4 cm and was 24.9% for nodules larger than 4 cm (P < 0.001). False negativity was 14.6% for all nodules and was 11.7% for nodules smaller than 4 cm and 24.2% for nodules larger than 4 cm (P < 0.001). Finally, among the entire set of nodules, the accuracy was 64.4%, which was 59.2% in nodules smaller than 4 cm, and 75.2% in nodules larger than 4 cm (P < 0.001). Conclusion: Despite a higher rate of false negativity, FNAB has higher specificity and accuracy in large nodules than those in the small nodules. Nodule diameter should not be used alone as a criterion to recommend thyroidectomy to the patient.

The radioprotective effect of melatonin against radiation-induced DNA double-strand breaks in radiology Farid Esmaely, Aziz Mahmoudzadeh, Mohsen Cheki, Alireza Shirazi Journal of Cancer Research and Therapeutics 2020 16(8):59-63 Objective: The objective of this study is to observe the effect of 100-mg melatonin in reducing the levels of double-strand breaks (DSB) induced by 10 mGy and 100 mGy X-ray in peripheral lymphocyte applying H2AX immunofluorescence microscopy and comparing the different efficacies of melatonin ingestion 1 and 2 h before irradiation. Materials and Methods: Informed consent was obtained from five healthy males, nonathlete, and nonsmoking human volunteers aged between 25 and 35 years. Each volunteer was given a single oral dose of 100 mg melatonin at 9 a.m. Blood samples were collected in vacutainer tubes (without any preservative to separate the serum, and with heparin as an anticoagulant for separating leukocytes for in vitro exposure to gamma radiation) 5–10 min before then 1 and 2 h after melatonin ingestion. Afterward, each sample was subdivided into nonirradiated and irradiated groups (10 mGy and 100 mGy). After irradiation, lymphocytes of samples were separated. The isolated lymphocytes in each group were permeabilized for DSB assessment and stained against the phosphorylated histone variant γH2AX. Results: Melatonin ingestion 1 and 2 h before irradiation caused a significant reduction in γH2AX foci. Results further indicate that the change in ingestion of melatonin from 1 to 2 h before exposure had no significant effect. In addition, melatonin administration showed no side effects. Conclusion: The present study showed that melatonin will prove effective in radioprotection against ionizing radiation (IR)-induced DNA damage in human lymphocytes. Our results suggest ingestion of 100-mg melatonin by patients before exposure to IR in radiology.

Estimation of cancer risk due to radiation exposure for some daily consumption of foods Akbar Abbasi, Vali Bashiry Journal of Cancer Research and Therapeutics 2020 16(8):64-67 Aims: Considering the increasing concern about the cancer risk caused by environmental radiological effects related to the food consumption, the study was carried out evaluate the activity concentrations and cancer risk assessments of 226 Ra,232 Th, and 40 K in 72 food samples collected from different suppliers in Tehran Province of Iran. Subjects and Methods: The specific activity concentration was determined by means of a high-resolution high-purity germanium gamma-spectroscopy system. The collected various sample groups were wheat, rice, meat, milk, and mushroom. Results: The maximum concentration of 226 Ra and 232 Th was found in the wheat sample, equal to 0.7862 Bq/kg and 0.968 Bq/kg, respectively, whereas for 40 K, it was 598.35 Bq/kg in the milk sample. The annual effective dose rate ranged from 2.47 μSv/y in mushroom to 64.66 μSv/y in rice. The average excess lifetime cancer risk (ELCR) was varied from 1.60 × 10–5 for mushroom to 4.20 × 10–4 for milk, with the total ELCR value from main daily diets 1.37 × 10–3, which was a little more than the acceptable ELCR limit of 10–3. Conclusions: The ELCR due to five main daily diets was a little more than the acceptable ELCR limit of 10–3 for radiological risk in general.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Neurological Sciences and Neurophysiology

Neuroinflammation in Alzheimer's disease continuum Aslihan Taskiran-Sag, Müge Yemişçi Neurological Sciences and Neurophysiology 2020 37(4):155-163 Aging population brings an ever-increasing global burden of dementia, and Alzheimer's disease (AD) is the most frequent type worldwide. Many years of research have introduced characteristic cerebral histopathological and molecular changes in this disease. However, all attempts to establish an effective treatment have failed. In this review, we aim to address the basic evidence regarding the role of inflammatory mediators in AD and their link to the other pathogenetic pathways. Novel findings based on advanced biotechnology and bioinformatics are covered briefly, as well.

Long latency reflexes in patients with postural instability and ataxia Ersin Deneri, Nesibe Tilek, Aysel Çoban, Cengiz Tataroğlu Neurological Sciences and Neurophysiology 2020 37(4):164-169 Objectives: Distal electrical stimulation of an upper extremity mixed nerve can generate a reflex response from the trapezius muscle. This reflex response may have a central neural pathway and can be affected by postural changes. Materials and Methods: In this study, long latency reflexes (LLRs) from both distal and trapezius muscle were evaluated in patients with Parkinson's disease (PD) with and without postural dysfunction and in patients with cerebellar ataxias. Thirty-three patients with PD, 10 patients with degenerative cerebellar ataxia and 22 healthy volunteers were included in the study. LLRs were recorded from ipsilateral thenar and trapezius muscles. Latencies and amplitudes of LLRs obtained from thenar (thenar LLR) and trapezius (trapezius LLR) muscles were analyzed. Results: In patients with PD, thenar LLRs showed significant shortening in the onset latencies and significant increase in the amplitudes in comparison with healthy controls. Trapezius LLRs did not show any significant difference in latencies or amplitudes; however, these responses showed a significant absence in one or two components in patients with Parkinson's disease with postural dysfunction. Additionally, this reflex was not recorded in patients with cerebellar ataxia. Conclusion: Trapezius LLRs can give some information regarding the physiology of neural circuits responsible for postural arrangement. Cerebellar connections may have a major role in the generation of trapezius LLRs.

The role of vestibular evoked myogenic potential and the video head impulse test in patients with multiple sclerosis without radiologic findings Reyhan Surmeli, Mehmet Sürmeli, Gözde Günay, Ayşe Destina Yalçın, Ayşe Aslı Şahin Yılmaz, Fatma Kulalı Neurological Sciences and Neurophysiology 2020 37(4):170-175 Objective: The aim is to evaluate the vestibular system using the video head impulse test (vHIT) and vestibular evoked myogenic potentials (VEMP) in patients with multiple sclerosis (MS) without central vestibular involvement in magnetic resonance imaging (MRI), and to determine whether there was subclinical vestibular system impairment. Materials and Methods: The study comprised 27 patients with MS and 26 healthy participants. The participants had no lesions in the central vestibular system in an MRI taken in the past 3 months. Detailed neuro-otologic and neuro-ophthalmologic examinations were performed on all participants. Then, the Dizziness Handicap Inventory (DHI) was completed for subjective vestibular system evaluation. In addition, vHIT and cervical VEMP (cVEMP) were performed for objective vestibular system evaluation. The results were analyzed statistically. Results: The mean age of the patients in the MS group was 39.3 ± 11.4 years and 42.7 ± 9.7 years in the control group. The median DHI score was 4 (range, 0–8) in the MS group and 2 (range, 0–6) in the control group. There were no statistically significant differences between the DHI score averages of the groups. The mean vestibulo ocular reflex (VOR) gain in vHIT was 0.76 ± 0.21 in the MS group and 0.99 ± 0.13 in the control group. VOR gain was statistically significantly lower in patients with MS. The VOR gain cut-off level was considered as 0.8. Gain level was below the cut-off level in 53.7% of patients with MS. There was no cVEMP response in 31.5% of patients with MS. In addition, patients with MS had prolonged P1 and N1 latencies and decreased P1-N1 peak-to-peak amplitudes. Conclusion: We found subclinical involvement in electrophysiologic tests (vHIT and cVEMP) in patients with MS without MRI lesions and without subjective vestibular system symptoms. We believe that vHIT and cVEMP can be used for subclinical evaluation in patients with MS without central vestibular system involvement in MRI.

The association between causes and electrophysiology in myoclonus: When and why electrophysiology? Meral E Kiziltan, Aysegül Gündüz, M Hazal Ser, S Naz Yeni, Çigdem Özkara, Veysi Demirbilek, Cengiz Yalçınkaya, Günes Kızıltan Neurological Sciences and Neurophysiology 2020 37(4):176-182 Objective: We aimed to identify the possible causes of myoclonus and related electrophysiological features in a cohort of young patients. Patients and Methods: We performed a retrospective analysis of all clinical and electrophysiological recordings of patients who had myoclonus and were under 60 years between 2005 and 2018. The clinical data included age at examination, gender, age at onset, and main neurological or systemic findings, underlying cause and electrophysiological features constituted surface electromyogram, long-loop reflexes, electroencephalography, and somatosensory-evoked potentials. Results: In the study period, we identified 155 patients with myoclonus. Myoclonus was most commonly related with epilepsy and movement disorders. Myoclonus with epilepsy was the leading cause between 10 and 30 years, whereas myoclonus with movement disorders was more common after 30 years. In our country, SSPE was an important cause of myoclonus under the 20 years of age. We identified cortico-subcortical subtype followed by cortical, cortical reflex, subcortical-basal ganglia, subcortical-brainstem and propriospinal subtypes, and correlated these subtypes with relevant disorders. Conclusion: The electrophysiological classification provides anatomical subtyping, which is favorable in diagnosing certain cases such as brainstem and propriospinal myoclonus. Certain characteristics such as reflex nature of myoclonus and accompanying features narrow the list of differentials and help in making the diagnosis.

Sleep disorders in a shift worker population sample in Turkey Duygu Kurt Gok, İlker Ünal, Kezban Aslan Neurological Sciences and Neurophysiology 2020 37(4):183-189 Aims: This study aims to determine the sleep quality of night-shift workers, determine the prevalence and characteristics of sleep disorders related to shift work, and compare sleep characteristics between shift workers and day workers. Subjects and Methods: The study included 1473 individuals employed in three different areas (health, security, and labor) as shift (78.5%) or day (21.5%) workers in the city of Adana, Turkey. Data were collected using a structured questionnaire consisting of 132 questions. The questionnaire included demographic data, education level, socioeconomic status, shift schedule, accompanying health problems, sleep disorders and sleeping habits, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, the Berlin Questionnaire, and the Restless Legs Syndrome (RLS) scale. Statistical Analysis Used: The SPSS for Windows 20.00 software package was used for statistical analyses. Results: Day workers and shift workers exhibited excessive daytime sleepiness in 17.1% and 24.9% (P = 0.004), poor sleep quality in 41.5% and 44.3% (P = 0.374), chronic insomnia in 8% and 16.2% (P < 0.001), RLS in 4.7% and 5.3% (P = 0.818), and sleep-disordered breathing in 7.3% and 7% (P = 0.864), respectively. Conclusions: Shift work significantly compromises sleep quality. In particular, fixed night shifts or rotating shift workers experience relatively higher rates of decline in subjective sleep quality, excessive daytime sleepiness, and chronic insomnia compared with day workers.

The ratios of estradiol and progesterone to testosterone influence the severity of facioscapulohumeral muscular dystrophy Ceren Hangul, Selen Bozkurt, Ugur Bilge, Sebahat Ozdem, Hasan Altunbas, Hilmi Uysal, Filiz Koc, Sibel Berker Karauzum Neurological Sciences and Neurophysiology 2020 37(4):190-196 Background: Facioscapulohumeral muscular dystrophy (FSHD) occurs as a consequence of genetic deletion of D4Z4 repeats on chromosome 4q35. Onset of FSHD is earlier in males, suggesting that testosterone may trigger the disease. In accordance, the rapid progression of disease in women after menopause suggests a protective role for estrogen and progesterone. No studies have examined levels of all these hormones in relation with the severity of FSHD. Aims: To evaluate the possible correlation between the severity of FSHD with sex hormones, age, and genetic deletion on chromosome 4q35. Subjects and Methods: D4Z4 repeat units were investigated in 33 patients (19 males/14 females) with FSHD. In the blood samples, luteinizing hormone, follicle-stimulating hormone, free estriol, estradiol, free testosterone and total testosterone, progesterone, 17-OH progesterone, prolactin, albumin, and fibrinogen were measured. The severity of FSHD was identified using a Clinical Severity Score (CSS) scaling system. Spearman's correlation and regression analyses were performed as statistical analyses. Results: Age (P = 0.001, r = 0.541) and total testosterone (P = 0.045, r = 0.351) were positively correlated, and the progesterone/total testosterone (P = 0.025, r = −0.390) and estradiol/total testosterone ratios (P = 0.025, r = −0.389) were negatively correlated with the severity of FSHD. Conclusions: Our results indicate that age, total testosterone, ratios of estradiol and progesterone to total testosterone, but not deletion on chromosome 4q35, have a significant relation with the severity of FSHD. Given that both estrogen and testosterone treatment are considered in therapy, our results suggest that estrogen and progesterone but not testosterone are likely to be more effective on the severity of FSHD.

Botulinum toxin injections for neurological disorders: Experience between 1994 and 2019 Cem Boluk, Yesim Gökçe, Aysegül Gündüz, Nurten Uzun Adatepe, Feray Karaali Savrun, Asim Kaytaz, Meral E Kızıltan Neurological Sciences and Neurophysiology 2020 37(4):197-202 Aim: Reported results of botulinum toxin (BoNT) injections vary widely in different studies and in different neurological disorders. The aim of this study was to investigate the efficacy and safety of BoNT injections for each neurological disorder and to report our experience in this area since 1994. Materials and Methods: All patients who were injected with BoNT since 1994 were included in this retrospective study. Age, gender, etiology, specific diagnosis, time from first symptom to first injection, type of BoNT (onabotulinum toxin-abobotulinum toxin), doses, treatment response, and complications were extracted from patient files. Etiologies were classified into five main groups: hyperkinetic movement disorders, focal spasticity, painful conditions, sialorrhea, and hyperhidrosis. Positive treatment response was defined as any objective clinical improvement determined by the attending physician and declared by the patient. Results: We determined that 1792 patients were considered for BoNT injections. Among them, 341 were not found to be suitable for injections or did not accept to have the procedure done. In total, 1451 different patients were included in the study. The most common indications for BoNT injection were hyperkinetic movement disorders (72.3%) and focal spasticity (15.2%). Other disorders included painful conditions, hyperhidrosis, and sialorrhea. In 74.3% of the patients, the only injected toxin was onabotulinum toxin, whereas 10.2% of the patients were injected only with abobotulinum toxin. In 14.7% of the patients, the injection type was changed from one to the other, due to ineffectiveness or unavailability. Response rates were 95.4% for focal spasticity, 92.6% for hyperkinetic movement disorders, 81.1% for painful conditions, 66.7% for hyperhidrosis, and 63.1% for sialorrhea. Severe complications were seen in 0.6% of the patients. Conclusion: BoNT injections seem to be effective in all of the neurological disorders which we investigated. Except for mild cosmetic complications, BoNT is generally safe in experienced hands.

Agomelatine is superior to melatonin in pain suppression: An experimental study Ali Okan Yucel, Devrim Demir-Dora, Mehmet Ferit İsbir, Babür Dora Neurological Sciences and Neurophysiology 2020 37(4):203-207 Objective: Agomelatine is a synthetic analog of melatonin with selective agonist action on melatonin MT1 and MT2 receptors and antagonistic effect on serotonin 5HT2c receptors. Similar to melatonin, it also has antinociceptive properties. There are only a few studies comparing the antinociceptive effects of agomelatine to melatonin. Methods: Male Wistar albino rats were grouped into seven treatment groups and a control group (8 animals each). Treatment groups received intraperitoneal injections of agomelatine 25 mg/kg, 35 mg/kg and 50 mg/kg; agomelatine 35 mg/kg + luzindole 10 mg/kg; melatonin 60 mg/kg and 90 mg/kg and melatonin 60 mg/kg + sertraline 10 mg/kg. Animals were placed on a hot plate and time to pain avoidance behavior was measured. Results: Agomelatine 25 mg/kg, 35 mg/kg and 50 mg/kg were significantly superior to placebo (all p < 0. 0001); agomelatine 35 mg/kg and 50 mg/kg were significantly superior to melatonin 60 mg/kg (p < 0.05 and p < 0.01, respectively) and melatonin 90 mg/kg (p < 0.001 and p < 0.001, respectively) in prolonging reaction times. Agomelatine 50 mg/kg was superior to melatonin 60 mg/kg + sertraline 10 mg/kg (p < 0,05); on the contrary; agomelatine 25 mg/kg was significantly inferior to this combination in prolonging reaction times (p = 0,041). Melatonin 90 mg/kg but not 60 mg/kg was significantly superior to placebo in prolonging reaction times (p < 0.0001). Both agomelatine 50 mg/kg and 35 mg/kg were superior to agomelatine 25 mg/kg (p < 0.0001 and p = 0.002, respectively), but the difference between agomelatine 50 mg/kg and 35 mg/kg was not significant. Conclusions: We demonstrated that agomelatine is superior to melatonin on pain behavior in a dose -dependent manner using an experimental pain model. The a ddition of a serotonergic agent increased the antinociceptive effect of melatonin in regard to agomelatine, but high doses of agomelatine were still more effective, suggesting a dose -dependent effect of agomelatine on 5-HT2c receptors.

Management of hardware infections in deep-brain stimulation: A 4-year, single-center experience Vural Hamzaoglu, Hakan Özalp, Okan Doğu, Nevra Öksüz, Sabri Aydın, Tolga Akbıyık, Ahmet Dağtekin, Emel Avcı, Celal Bağdatoğlu Neurological Sciences and Neurophysiology 2020 37(4):208-214 Objectives: The introduction of deep-brain stimulation (DBS) was a milestone in the treatment of movement disorders, intractable epilepsy, and severe psychiatric disorders. We aimed to identify risk factors for hardware infection in patients with these conditions who underwent DBS at our center over a 4-year period. Materials and Methods: Bilateral DBS was performed in seventy patients by the Department of Neurosurgery at the Mersin University School of Medicine between April 2016 and January 2020. The surgical indication was Parkinson's disease in 48 patients, dystonia in 11 patients (10 primary generalized and 1 secondary), and tremor in 11 patients (10 essential tremor and 1 other). Results: Infection was detected in eight patients (11.4%). There were no hardware complications other than infection or postoperative intracerebral hematomas. The entire device was explanted in four (50%) patients with infection; device explantation occurred at 3, 13, 19, and 42 months after surgery. The other 4 (50%) patients who developed infection were successfully treated with antibiotics without complication. A patient with primary dystonia who underwent bilateral globus pallidus interna DBS sustained a severe acute subdural hematoma due to trauma 45 days after electrode implantation but prior to stimulation. We elected not to explant the device after hematoma evacuation; delayed stimulation programming was successful. Conclusion: DBS surgeries are susceptible to complications related to the anatomic target, hardware, and the procedure itself. Infection is the most common complication; however, there is no established protocol for its treatment. Antibiotics and partial removal of the device may be a rational approach.

Craniopharyngiomas: Analysis of 68 surgical cases Emrah Akcay, Hakan Yılmaz, Hüseyin Berk Benek, Alper Tabanlı, Alaettin Yurt Neurological Sciences and Neurophysiology 2020 37(4):215-220 Objective: Although craniopharyngiomas are benign pathologies, they have surgical challenges due to their locations, infiltrations, and potential for neuroendocrine problems. We evaluated the surgical outcomes, complications, the neuroendocrine problems in patients who underwent total or subtotal resection, and to reveal the ideal treatment regimen. Materials and Methods: We retrospectively reviewed 68 patients who received pathologic results of craniopharyngioma between 1999 and 2019 in our neurosurgery clinic. The demographic characteristics, hormone levels, resection ratio (total/subtotal), residue and recurrence rate, and the complications after surgery were used in the analysis. Results: Twenty-six (38.2%) patients underwent total tumor removal, and 42 (61.8%) had subtotal removal. Fifteen (22%) patients had recurrence. Of the total tumor removal group, only one patient was determined as having recurrence. We detected hypothalamic–pituitary system deficiency in 15 patients with total removal and nine patients with subtotal removal. Of the 37 patients who had lesions smaller than 4 cm, only one died and 30 were in good health after surgery. Of the 31 patients who had lesions larger than 4 cm, five died and 15 were in poor or moderate health. Conclusion: Tumor size is one of the most important factors affecting surgical results. Subtotal tumor removal is associated with tumor recurrence and total removal with serious hypothalamic deficiency symptoms.

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Preventive and Clinical Dental Research

Effect of titanium oxide and zirconium oxide nanoparticle incorporation on the flexural strength of heat-activated polymethyl methacrylate denture base resins – An in vitro experimental study Prasanth Viswambharan, AR Adhershitha International Journal of Preventive and Clinical Dental Research 2020 7(4):91-95 Introduction: Flexural strength is one of the most important properties which determine the clinical success of dentures. Even though titanium oxide nanoparticles (nano-TiO2) and zirconium oxide nanoparticles (nano-ZrO2) are extensively used to modify the properties of polymethyl methacrylate (PMMA) resin, there is negligible documentation in the literature comparing these two. Aim: The aim of the study is to find out and compare the effect of incorporation of 1 weight % nano-TiO2 and nano-ZrO2 on the flexural strength of heat-activated PMMA resin. Materials and Methods: 1 weight % of TiO2 and ZrO2 nanoparticles were weighed using a digital weighing balance and mixed with PMMA resin powder using the geometric dilution method. Sixty “35 mm × 10 mm × 3 mm” rectangular-shaped specimens fabricated were divided into three different groups, each containing twenty samples each. The specimens were loaded to failure at a crosshead speed of 1 mm/min and with 500 N load cell in a Universal Instron Testing Machine, Model 3345. Flexural strength was registered by the machine with 0.001 MPa precision. Results: PMMA with nano-TiO2 group had the maximum flexural strength, load at maximum flexure, and load at break followed by unreinforced PMMA and PMMA with nano-ZrO2. Statistically significant difference was noted between the three groups (P < 0.001). Post hoc analysis using Tukey's post hoc test showed a statistically significant difference for all three pair-wise comparison. Conclusions: Within the limitations of this study, it can be concluded that nano-TiO2 greatly enhanced the flexural strength, load at maximum flexure load, and load at break of PMMA resin, whereas nano-ZrO2 significantly reduced these properties of PMMA.

Prevalence of periodontal diseases in orthodontic patients Ujjwal Priyadarsi, Mohammad Shahbaz Alam, Abid Hussain, Farrukh Azam, Priyanka Kumari, Md Abu Nafe International Journal of Preventive and Clinical Dental Research 2020 7(4):96-98 Objective: The objective was to investigate the association between orthodontic treatment and periodontitis in a representative sample of Jharkhand. Methodology: The clinical examinations at six sites per tooth were assessed using visible plaque index (VPI), gingival bleeding index (GBI), bleeding on probing (BOP), periodontal probing depth (PPD), and clinical attachment loss (CAL). A manual Williams probe (Neumar, São Paulo, Brazil) was used, except for the VPI. Data analysis was done. Results: The median percentage values of sites positive for VPI, GBI, and BOP were calculated for each group and compared using a Mann–Whitney test and the mean values for PPD and CAL with a Student's t-test. Intragroup comparisons between teeth were performed with Tukey's analysis of variance. The level of significance was set at 5%. Conclusion: The use of orthodontic appliances is not necessarily related to worsening periodontal conditions. The results of the present study reinforce the importance of susceptibility to periodontal disease independent of the presence of a well-known retentive plaque factor, i.e., orthodontic appliances and/or bands.

Awareness and attitude toward COVID-19 among the students of a rural tertiary care center and dental college: A cross-sectional study AR Adhershitha, Prasanth Viswambharan, Sheela Virginia Rodrigues International Journal of Preventive and Clinical Dental Research 2020 7(4):99-103 Introduction: Awareness, attitude, and practice play a major role in containing any infectious disease. Coronavirus disease 2019 (COVID-19) has no definitive treatment or vaccines; hence, it is momentous to spread awareness regarding the prevention strategies. It is crucial for the government and concerned authorities to understand the students' perception and attitude in the time of the current pandemic. Aim: The aim of this study is to assess the level of awareness among the students of Government Dental College Alappuzha, a rural tertiary care center and Dental College in Kerala, India, regarding COVID-19 and their attitude toward the pandemic. Methodology: Questionnaire which included 21 items was used for the research. Observed data were coded, tabulated, and analyzed using IBM SPSS Statistics for Windows (Version 20.0. Armonk, NY, USA: IBM Corp.). The total awareness score calculated was 20. Comparison between gender (males/females) and study groups (preclinical students/clinical students) was made using the Chi-square test. Comparison of total awareness scores between study groups was made using independent t-test. Results: Most of the study participants across study groups regularly kept track of the latest news on COVID-19 and perceived it to be of moderate or very dangerous risk though they were quite optimistic of its control. About 96% of males and 82% of females felt it is necessary to get mental health help if one panics in lieu of the pandemic situation. The mean total awareness score (out of 20) was 15.16 ± 1.81. There was no significant difference in total awareness score based on gender (15.23 ± 2.24 for males and 15.15 ± 1.71 for females) and also among the category of students (14.88 ± 1.94 for preclinical students and 15.35 ± 1.69 among clinical students). Conclusions: Attempts should be made for increasing the awareness regarding the preferred method of hand hygiene, protocol for performing aerosol-generating procedures, and airborne infection isolation room.

Knowledge attitude and practice of school personnel on COTPA Dhwani Desai, Dhvani Desai International Journal of Preventive and Clinical Dental Research 2020 7(4):104-106 Background: The “Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act (COTPA)” has been formulated to control the Tobacco epidemic in India. School personnel serve as role models for students and have daily interaction with students, while college students may be under the influence of adolescent behavior and cigarettes is easier to procure. Materials and Methods: A cross-sectional questionnaire-based study carried out on a convenience sample of 100 school personnel aged 18–60 years, participated in the study. Five schools were undertaken in this study on the basis of convenience sampling. All the school personnel preseent on the day of conduction of survey were included in the study. Results: The awareness of school personnel in relation to COTPA ranges between 21% and 79% whereas least awareness (80%) was seen in relation to loose cigarettes not to be sold. Conclusion: The present study indicates that participants have lesser and inappropriate knowledge and attitude toward COTPA and majority of not taken any step to implement COTPA in their work place

Trends in the patterns of maxillofacial fractures in Kolkata Gourab Das, Dhritiman Pathak, Bharat Shukla, Ruchira Shukla, Dazy Patel, Krishna Mondal International Journal of Preventive and Clinical Dental Research 2020 7(4):107-110 Background:- The maxillofacial skeleton is commonly fractured due to its prominent position. Maxillofacial fractures lead to cosmetic disfigurement as well as problems in oral functioning. Aim: The aim of this study was to determine the incidence, etiology, mode, and the pattern of fractures in the maxillofacial region. Methods: A retrospective study of maxillofacial injuries at ESIC Medical College and Hospital, Joka (Kolkata) between Feb 2018 to April 2019 was conducted and data extracted from patients who were either treated in emergency room or in outpatient department. Results and Conclusion: The study concluded that better road safety laws need to be enforced along with the improvement of the education and socio-economic setup.

Temporomandibular disorders: An updated review M Nazargi Mahabob International Journal of Preventive and Clinical Dental Research 2020 7(4):111-114 A group of conditions related to temporomandibular joint (TMJ) is called as “temporomandibular disorder” (TMD). Several attempts were made to classify TMD based on the frequency of occurrence, etiology, and anatomy, but they have had some shortfalls, and one mostly accepted is diagnostic criteria/TMD classification. TMD is a group of clinical problems; it involves either TMJ or its associated structures separately or combination. Any factor that affects one part of the system is likely to have an impact on the other parts also, so it is essential to approach carefully when considering likely signs and symptoms of TMD. About 20%–30% of the adult populations are affected to some degree of TMD, and it is predominately affected young and middle-aged adults. The prevalence rate of TMD problems twice common in females than the males. The etiology of TMD is inconclusive, and now, it has been accepted that multiple factors play a role in TMD. Since it is multifactorial, treatment should be planned according to that and varies patient to patient. Majority of the patients having mild-to-moderate TMD and conservative treatment approach over surgery results in satisfactory outcomes. The aim of this review is to evaluate the recent updates and propose solutions for patients with TMD.

Prosthodontic rehabilitation of an edentulous hemimandibulectomy patient Saumil Chetan Sampat, Mistry Saloni, Banga Parmeet, Dole Vinay, Dubey Amol International Journal of Preventive and Clinical Dental Research 2020 7(4):115-118 Edentulous patients with lateral discontinuity defects of the mandible pose a challenge for the prosthodontist. With variable degrees of bony and soft-tissue resection, the prosthodontic prognosis is dependent on a number of complex factors. Complete dentures in such patients are primarily given for improvement of esthetics. In a selected few patients, however, such prosthesis may improve speech and masticatory function. This case report describes the use of two rows of nonanatomic teeth (in the maxillary denture) on the unresected side to broaden the occlusal table, thus fulfilling the patient's needs and requirements.

Apexification in primary central incisor Nandita Mohan, Shriyam Sharan, Supreeya Patel, Divya Nigam, Aarti Kumari, Silpi Chatterjee International Journal of Preventive and Clinical Dental Research 2020 7(4):119-121 The upper deciduous incisors are frequently the teeth most commonly affected either by dental caries or due to the impact of trauma. In such cases, there may be complete coronary destruction of teeth. As they erupt around 7½–9 months of age and the roots only complete at approximately 18–24 months, pulp involvement may occur even before the end of this process. Hereby, we highlight the case of a 15-month-old male patient who reported with a history of trauma. Treatment plan of apexification was made after confirming with multiple radiographs. Root-end closure was obtained after a period of 7 months.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Medical Journal

Reliability of international hip dysplasia institute classification for the developmental dysplasia of the hip among different medical personnel in Iraq Jagar Omar Doski Mustansiriya Medical Journal 2020 19(2):41-44 Background: The international hip dysplasia institute (IHDI) classification is a new method for quantifying the severity of the developmental dysplasia of the hip (DDH). Objectives: This study aimed to compare the reliability of this classification between different medical personnel such as pediatricians, general practitioners, and family doctors in addition to orthopedic surgeons and radiologists. Methods: Hundred pelvic radiographic films (with 200 hips) were randomly selected from the files of children already diagnosed and treated as DDH cases. These films were analyzed by 12 independent observers of four different specialties: three orthopedic surgeons (Ortho Group), three radiologists (Radio Group), three pediatricians (Pediat Group), and three general practitioners (GP Group). Results: The average measures (Cronbach's alpha) for the intraclass correlation coefficient (ICC) for absolute agreement between all observers was 0.874 (with 95% confidence intervals between 0.780 and 0.925). This was considered as having a good level of reliability and agreement between all observers. The ICC for agreement between the observers of radio group showed the highest score (0.904) while that between those of GP Group had the lowest one (0.826). However, during the comparison between the mean score of each group with that of the other groups by the one-way ANOVA method, there was no statistically significant difference between all groups (P values were 0.563, 0.415, 0.399, and 0.291 respectively). Conclusion: The IHDI classification method for cases of DDH has a good level of reliability among different medical personnel regardless of their specialties.

Management of florid diabetic retinopathy Faiz I Shakarchi, Ahmed F Shakarchi, Shadha A Al-Bayati Mustansiriya Medical Journal 2020 19(2):45-48 Background: Florid diabetic retinopathy (FDR) is a severe form of proliferative diabetic retinopathy associated with high risk of blindness. Aim: The aim of this study is to evaluate the efficacy and safety of prompt intravitreal injection of bevacizumab followed by complete pan-retinal photocoagulation (PRP) for treating eyes with FDR. Setting and Design: Prospective, interventional case series. Patients and Methods: Patients with FDR were treated initially with intravitreal injections of bevacizumab 1.25 mg. One week after the injection, patients were sent for wide field fluorescein angiography (WFA), and PRP was performed in two sessions, 2 weeks apart. Patients were examined every 2–4 weeks to determine the status of new vessels (NVs). Additional laser burns were applied in cases with recurrence of NVs. Statistical Analysis: Numbers and percentages were calculated and reported. Results: Eleven patients (18 eyes) with FDR were included. All included patients had poorly controlled diabetes mellitus with mean glycated hemoglobin of 10.6%. One week after the injection, all eyes showed clinical regression of NVs. WFA showed extensive areas of peripheral retinal capillary nonperfusion. Eight weeks after the injection, three eyes (16.7%) showed recurrent increase in NVs, and additional laser therapy was performed for these eyes with special attention to ablating the areas of peripheral capillary non-perfusion. After 16 weeks from the primary treatment, 15 eyes (83.3%) had complete neovascular regression on clinical and angiographic assessment. Pars planavitrectomy was required for three eyes (16.7%) with tractional retinal detachment (2 eyes) or macular epi-retinal membranes (one eye). Conclusions: According to this study, most cases with FDR stabilized after prompt bevacizumab injection followed by complete PRP with special attention for ablating the peripheral capillary nonperfusion areas, guided by WFA images.

Male circumcision using bone cutter with thermal cautery Salih Abdul Kafi Hammoodi Al-Ani Mustansiriya Medical Journal 2020 19(2):49-53 Background: Bone cutter is a widely used procedure to cut the prepuce during circumcision. Aim of the study: The aim of the study was to assess the safety of circumcision of male using bone cutter with thermal cautery, including the operative time and healing time and the effect of dressing on rate of infection and bleeding. Materials and Methods: Over 20 years period from 1996 till 2015, six thousands of males were circumcised under local anesthesia (in form local infiltration of 1% plain lidocaine 5 min before circumcision and xylocaine spray after the procedure) using a bone cutter with thermal cautery, the first assistant is to fix the upper limbs, while the main assistant is to fix the knees in a fully extended position by the left hand, while the right hand used to elevate the two mosquitoes, then by using thermal cautery to cut the foreskin above the jaw of bone cutter and by using S-ring in certain situation to fix the bone cutter tightly. Results: Six thousands males were included in this study. The mean operative time was 1-2 minutes, healing time was 5-7 days, 387 cases (6.45%) developed early & late complications, 180 (3%) bleeding, 195 (3.25%) developed infection, 3 (0.05%) with mild glans injury need dressing only for 24-48 hours only 9 (0.15%) need re-circumcision later on in the same procedure. Conclusions: Bone cutter with thermal cautery circumcision is feasible with a relatively lower complications rate, shorter operative time, and short healing time.

Evaluation of maternal serum sestrin2 levels in preeclampsia and their relationship with the Disease severity Raghad Ahmed Fadhil, Lilyan W Sersam Mustansiriya Medical Journal 2020 19(2):54-58 Background: Preeclampsia (PE) is considered one of the major causes of both maternal and fetal mortality and morbidity. Advances have been made on understanding the pathophysiology of this pregnancy-specific disorder. Sestrin2 (SESN2) is a metabolic regulator protein, whose expression is induced in response to exposure to different adverse effects such as hypoxia, DNA damage, or oxidative stress, thus acting as cytoprotective. Objective: The objective of the study was to investigate the levels of maternal serum SESN2 in preeclamptic and uncomplicated pregnancies and their association with the disease severity. Patients and Methods: This was a case–control study conducted at the Department of Obstetrics and Gynecology at Al-Yarmouk Teaching Hospital in Iraq – Baghdad city from the first of March till the end of November 2019. The study included a total of 92 pregnant women, 27 with a healthy pregnancy, 33 with nonsevere PE, and another 32 having severe PE. From all participants, blood samples were collected for the evaluation of serum SESN2 levels using enzyme-linked immunosorbent assay. Results: The mean readings of SESN2 for normal pregnancies were 5.22 ± 1.71 ng/ml which was significantly lower than that for the nonsevere PE group (8.41 ± 1.42 ng/ml), while SESN2 levels were the highest among those with severe PE (16.92 ± 5.15 ng/ml). A negative correlation was found between each of GA at delivery, birth interval, and birth weight and the SESN2 level (P = 0.001); while mean arterial pressure positively correlated with SESN2 levels (P = 0.001), the cutoff value for the diagnosis of severe PE was 9.95 ng/ml (sensitivity of 93.8% and specificity of 98.8%). Conclusion: Maternal serum SESN2 levels are significantly higher in pregnancies complicated by severe PE than nonsevere PE and control groups. It could be a useful biomarker that can help in diagnosing severe PE.

Assessment of left ventricular longitudinal function in hypertensive patients without left ventricular hypertrophy by mitral annular plane systolic excursion Samara Mohammad Khider, Ghalib Al-Shareefi Mustansiriya Medical Journal 2020 19(2):59-65 Background: Hypertension is an important risk factor for many cardiovascular diseases worldwide. Assessment of left ventricular (LV) systolic function has a major diagnostic and prognostic importance in patients with hypertension. The use of mitral annular plane systolic excursion in the assessment of LV systolic dysfunction is helpful especially in cases of poor imaging quality, “since good imaging quality is needed for the modern echocardiographic techniques. Objectives: Detection of early subclinical LV longitudinal systolic dysfunction in hypertensive patients without LV hypertrophy (LVH) with preserved ejection fraction by mitral annular plane systolic excursion. Patients and Methods: A comparative case-control study which took place at Al-Yarmouk Teaching Hospital in Baghdad/Iraq from October 2018 to October 2019. The study population consisted of 60 patients without LVH and 60 healthy subjects considered as controls. Echocardiographic parameters for left ventricular systolic assessments were done for all subjects. Results: Mean peak annular systolic velocity was significantly lower in hypertensive patients without LVH compared to controls (P = 0.034). There was no significant difference between hypertensive patients without LVH and controls regarding mitral annular plane systolic excursion (P = 0.4). There was positive linear correlation between mitral annular plane systolic excursion and peak annular systolic velocity for hypertensive patients without LVH (r = 0.535, P = 0.015). Conclusion: Although there was a significant linear correlation between mitral annular plane systolic excursion and peak systolic velocity and both are considered as a surrogate for LV longitudinal systolic function, mitral annular plane systolic excursion cannot be used for assessment of LV longitudinal systolic function in patients with hypertension without LVH.

The portrayal of microbes in respiratory medicine M V Raghavendra Rao, Vijay K Chennamchetty, Dilip Mathai, Mahendra Kumar Verma, Tiara Calvo Leon, Pamphil Igman, Surekha Bhat, Mohammad Ismail Nizami, Sanjay Kumar Agarwal, Lakshmi Hitesh Billa, Abrar A Khan Mustansiriya Medical Journal 2020 19(2):66-72 Respiratory diseases caused by a number of infectious agents including Streptococcal pneumonia, streptococcal pyogenes, Klebsiella pneumonia H. influenzae, Legionella pneumophilia, Mycoplasma pneumonia, Coxiella Bunetii, chlamydia pisittaci. These microbes enter into the lungs and cause primary cases of pneumonia. The whole respiratory epithelium down to the internal bronchioles is ciliated. The cilia and the thin film of mucus covering them have the critical function of trapping foreign particles, including bacteria, and propelling them toward the pharynx. They contribute to the prevention of respiratory infection as they do the macrophages utilizing their secretory, phagocytic, and bactericidal activity. Despite the wonderful defense, the bacterium escapes and settles in the lungs to produce diseases. Pneumonia is the term used to describe inflammation of the lung. Pneumococcal pneumonia is characterized by homologous consolidation of one or more lobes or segments. Pneumococcal pneumonia occurs at all ages but most frequently in early and middle adult life. Pneumonia is characterized with the rise in body temperature 39-40oC, remain associated with painful cough initially dry, but later patient develops production of tenacious sputum, which is often rusty and occasionally bloodstained. Staphylococcal pneumonia is caused due to Streptococcus aureus, which may occur either as a primary respiratory infection or as a blood-borne infection from a staphylococcal lesion elsewhere in the body. Klebsiella pneumonia is caused due to K. pneumoniae, a rare disease with high mortality. There is usually massive consolidation and excavation of one or more lobes, with the upper lobes being most often involved and with large amounts of purulent sputum, sometimes characteristic red currant jelly sputum. Legionella pneumonia is caused by Gram-negative bacillus L. pneumophila, which is usually transmitted in water droplets from infected cisterns used to provide water for showers, particularly in warm climates. It is often a serious and occasionally a fatal illness. C. psittaci causes psittacosis (ornithosis), a systemic illness contracted from infected birds. Pneumonia associated with it may be extensive, with severe toxemia. M. pneumoniae is a pleomorphic bacterium; symptoms of mycoplasma pneumonia are mild compared to other cases of pneumonia (walking pneumonia). On the other hand, liver function test derangements and dyselectrolytemia are more common. It is susceptible to tetracyclines though a few strains are sensitive only to erythromycin.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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Otolaryngology & Head and Neck Surgery

Imaging-based navigation technologies in head and neck surgery Purpose of review Image guided navigation has had significant impact in head and neck surgery, and has been most prolific in endonasal surgeries. Although conventional image guidance involves static computed tomography (CT) images attained in the preoperative setting, the continual evolution of surgical navigation technologies is fast expanding to incorporate both real-time data and bioinformation that allows for improved precision in surgical guidance. With the rapid advances in technologies, this article allows for a timely review of the current and developing techniques in surgical navigation for head and neck surgery. Recent findings Current advances for cross-sectional-based image-guided surgery include fusion of CT with other imaging modalities (e.g., magnetic resonance imaging and positron emission tomography) as well as the uptake in intraoperative real-time 'on the table' imaging (e.g., cone-beam CT). These advances, together with the integration of virtual/augmented reality, enable potential enhancements in surgical navigation. In addition to the advances in radiological imaging, the development of optical modalities such as fluorescence and spectroscopy techniques further allows the assimilation of biological data to improve navigation particularly for head and neck surgery. Summary The steady development of radiological and optical imaging techniques shows great promise in changing the paradigm of head and neck surgery. Correspondence to Jonathan C. Irish, MD, Princess Margaret Cancer Centre and University Health Network, TECHNA Institute, Guided Therapeutic (GTx) Program, Toronto, 200 Elizabeth St 8NU-882, Toronto, ON, Canada, M5G 2C4. Tel: +1 (416) 340 3113; e-mail: Jonathan.Irish@uhn.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Oral potentially malignant disorders: new insights for future treatment Purpose of review The purpose of this review is to define the issues regarding oral potentially malignant disorders (OPMDs) and provide an overview of currently available treatments and ongoing clinical trials for future opportunities. Recent findings Nowadays, the treatment of choice of OPMD is surgery, whose role in preventing malignant transformation is however limited because of the high rate of recurrence and field cancerization. There have been several attempts of combining systemic therapies with surgery to reduce risk of malignant transformation. The identification of biomarkers that could predict malignant transformation is crucial in better tailoring the risk profile and possible therapeutic approaches. Summary Loss of heterozygosity remains the most predictive marker of malignant transformation; however, role of specific microRNA and OPMD immune infiltration are emerging as potential biomarkers. Given the failure of previous trials with various chemopreventive strategies, new strategies should be defined to address the issue of systemic prevention of malignant transformation. Recent updates about immune infiltration and the immune-equilibrium concept for OPMD could shed light into new preventive approaches. Correspondence to Paolo Bossi, Department of Medical and Surgical Specialties, Medical Oncology, Radiological Sciences and Public Health University of Brescia, ASST-Spedali Civili, Piazzale Spedali Civili 1, 25123 Brescia, Italy. Tel: +39 0303998969; e-mail: paolo.bossi@unibs.it Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Therapeutic challenges in radiation-induced salivary gland cancers Purpose of review To give an overview of recent advances in therapeutic approaches of radiation-induced salivary gland cancers (ri-SGCs). Recent findings Reirradiation with protons and carbon ions demonstrated to be feasible, safe and to offer good local control rates, with the possibility of overcoming radioresistance and dosimetric issues in previously irradiated cancer patients. Chromosomal rearrangements, gene fusions and expression profiles are important to identify specific cancer subtypes and can guide tailored systemic therapy. Summary Ri-SGCs are rare and heterogeneous. Patients are often heavily pretreated and at risk of toxicities, and their management remain challenging. A multidisciplinary approach in referral centers is mandatory. Knowledge about SGCs cellular and molecular mechanisms is constantly evolving. In the last years, novel advances in therapeutic approaches, such as carbon ion radiotherapy, are emerging as safe and effective options in active treatment, but further efforts are needed to offer tailored personalized treatments and to improve survival. Correspondence to Sara Ronchi, MD, Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Strada Campeggi 53, 27100 Pavia, Italy. Tel: +39 0382078501; e-mail: sara.ronchi@cnao.it Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

A roadmap of six different pathways to improve survival in laryngeal cancer patients Purpose of review Laryngeal cancer continues to require improvement in earlier stage diagnosis and better imaging delineation of disease, and hence 'more evidence-based' selection of treatment, as recent evidence suggests that related mortality, in the last decades, has not significantly decreased worldwide. Even though the reasons are not fully understood, there persists an urgency for a review and development of future strategies to embrace such clinical and diagnostic challenges from a political, societal, as well as scientific and clinical points of view. Recent findings This review of the published literature suggests that survival improvement in laryngeal cancer may be achieved by fuelling and combining at least some or all of six targeted agendas: documentation of disease global incidence and national burden monitoring; development and implementation of high-quality cancer registries; education on risk factors and hazardous habits associated with laryngeal cancer for the general population; active modification of proven at-risk population lifestyles; centralization of treatment; and use of machine learning of gathered 'big data' and their integration into approaches for the optimization of prevention and treatments strategies. Summary Laryngeal cancer should be tackled on several fronts, commencing with disease monitoring and prevention, up to treatment optimisation. Available modern resources offer the possibility to generate significant advances in laryngeal cancer management. However, each nation needs to develop a comprehensive approach, which is an essential prerequisite to obtain meaningful improvement on results. Correspondence to Patrick J. Bradley, 10 Chartwell Grove, Mapperley Plains, Nottingham NG3 5RD, UK. E-mail: pjbradley@zoo.co.uk Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Immediate dental implant placement and restoration in the edentulous mandible in head and neck cancer patients: a systematic review and meta-analysis Purpose of review Oral rehabilitation with dental implants in head and neck cancer (HNC) patients is challenging. After tooth removal prior to radiotherapy, immediate placement of dental implants during panendoscopy or surgery is thought to reduce the oral rehabilitation time improving patients' quality of life. Recent findings There is lack of consensus on the timing of dental implant placement and loading protocols. The aim of this study was to perform a systematic review of the literature regarding the performance and survival rate of immediately inserted dental implants placed prior to radiotherapy. Of 1003 articles, 10 were finally included comparing immediate vs. delayed placement of implants and comparing the effect of radiotherapy on immediately placed implants. Meta-analysis demonstrated a slightly higher survival of immediately placed implants compared with postponed placed implants [risk ratio: 0.92, 95% confidence interval (95% CI): 0.48–1.78, P = 0.81, I2 = 0%]. The other meta-analysis comparing radiotherapy vs. nonradiotherapy showed a clearly better survival of immediately placed implants not having received radiotherapy (risk ratio: 5.02, 95% CI: 0.92–27.38, P = 0.10, I2  = 56%). Summary Guidelines are recommended for immediate dental implant placement in the edentulous mandible in HNC patients prior to radiotherapy to allow homogeneity regarding the treatment protocols and thus comparison of treatment outcomes. Correspondence to Frank K.J. Leusink, MD, PhD, Amsterdam UMC, location VUmc, Department of Oral and Maxillofacial Surgery, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands. Tel: +31 20 444 1023; fax: +31 20 444 1005; e-mail: f.leusink@amsterdamumc.nl Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.co-otolaryngology.com). This is an-open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Treatment of persistent/recurrent nodal disease in nasopharyngeal cancer Purpose of review Persistent or recurrent disease in the neck lymphatics is an unusual pattern of failure in nasopharyngeal carcinoma (NPC) after definitive radiotherapy or chemoradiotherapy. The purpose of this review is to critically synthesize the current knowledge regarding salvage treatment of this unique form of failure in NPC. Recent findings Surgery in the form of radical neck dissection has been established as the standard salvage treatment with 5-year regional control of 60--86%. Recent shift in paradigm has resulted in the use of modified or selective neck dissection as salvage surgery in some centers. Risk factors for poor survival outcome include recurrent nodal disease, number of involved lymph nodes, extracapsular extension, high lymph node ratio, and positive resection margin. There are no well controlled studies on the role of additional radiotherapy or chemotherapy to improve local control or survival after salvage neck dissection in this group of patients with regional failure. Summary There is limited literature regarding the extent of surgical dissection in treating nodal persistent or recurrent disease. Prospective studies are also needed to determine whether adjuvant therapy improves treatment outcomes. Correspondence to Wai-Tong Ng, Department of Clinical Oncology, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, China. Tel: +852 2255 4352; fax: +852 2872 6426; e-mail: ngwt1@hku.hk Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

Telephone consultation 11855 int 1193,