Ophthalmology

The burden of uncorrected refractive error Santosh G Honavar Indian Journal of Ophthalmology 2019 67(5):577-578

Radiation therapy for exudative choroidal hemangioma Paul T Finger Indian Journal of Ophthalmology 2019 67(5):579-581

Bilateral pale posterior pole sans pain: A "hard" sell Ramya Appanraj, Vinay S Kumar, Pukhraj Rishi, Jyotirmay Biswas Indian Journal of Ophthalmology 2019 67(5):582-582

Prevalence of refractive errors, uncorrected refractive error, and presbyopia in adults in India: A systematic review Sethu Sheeladevi, Bharani Seelam, Phanindra B Nukella, Rishi R Borah, Rahul Ali, Lisa Keay Indian Journal of Ophthalmology 2019 67(5):583-592 Purpose: The objective of this review is to estimate the prevalence of refractive errors, uncorrected refractive error (URE), and uncorrected presbyopia in adults aged ≥30 years in India. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. A detailed literature search was performed to include all studies published from India from the year 1990 using the Cochrane Library, Medline, and Embase. Refractive error was defined by >0.50 D ametropia. URE was defined by presenting visual acuity (PVA) worse than 6/18 improving with pinhole or spectacle correction, and uncorrected presbyopia by near vision

Commentary: Uncorrected refractive errors in Indian adults: An unrecognized problem Ronnie George Indian Journal of Ophthalmology 2019 67(5):592-593

Comparison of the safety and efficacy of topical Tacrolimus (0.03%) versus dexamethasone (0.05%) for subepithelial infiltrates after adenoviral conjunctivitis Rahul Bhargava, Prachi Kumar Indian Journal of Ophthalmology 2019 67(5):594-598 Purpose: To compare the safety and efficacy of tacrolimus 0.03% ointment with dexamethasone 0.05% ointment for subepithelial infiltrates (SEIs) following adenoviral keratoconjunctivitis (AK). Methods: A randomized, double blind trial was done. Eligibility criteria was corrected distance visual acuity of 6/9 Snellen or worse for at least 4 weeks with corneal SEIs following AK. The grading of SEIs was done on a scale of 0 to 3; 0, no infiltrates, 1 mild infiltration, 2 moderate infiltration and 3, severe infiltration. Consecutive patients with SEIs following AK were randomized to receive either topical tacrolimus 0.03% or dexamethasone 0.05% ointment twice daily for 6 months. Treatment was successful if there was reduction of SEIs and improvement in vision. Results: A total of 45 patients each were assigned to the Tacro and Dexa groups, respectively. Baseline characteristics of patients did not differ significantly (P > 0.001). There was a significant change in symptoms, vision and SEIs in both the groups. However, the magnitude was greater in tacro group. Treatment was successful in 37 (92.5%) patients in Tacro and 34 (85%) patients in dexa group. In dexa group, after a period of 1.24 ± 0.24 months, 7 (15.6%) patients developed a significant rise in intraocular pressure (IOP). Three (7.5%) eyes in tacro and 6 (15%) eyes in dexa group had recurrence of SEIs after cessation of therapy. Conclusion: Tacrolimus 0.03% is an effective alternative to dexamethasone 0.05% with low recurrence rate, no significant rise in IOP but may cause burning and foreign body sensation in some patients.

Objective optical assessment of tear-film quality dynamics in patients with meibomian gland dysfunction and aqueous-deficient dry eye optical quality changes in different dry eye subtypes Fen Ye, Feng Jiang, Yan Lu, Chun Yan Xue, Xiao Min Zhu, Yan Wu, Zhen Ping Huang Indian Journal of Ophthalmology 2019 67(5):599-603 Purpose: To evaluate the optical quality and tear-film dynamics in patients with aqueous-deficient or evaporative subtype of dry eye disease (DED). Methods: Twenty-five aqueous-deficient dry eye (ADDE) patients, 25 DED patients with meibomian gland dysfunction (MGD), and 25 healthy subjects were included in this study. Vision-related health-targeted quality of life was evaluated using the Ocular Surface Disease Index (OSDI) questionnaire. Dynamic recording with a double-pass system (Optical Quality Analysis System [OQAS]) was performed in right eyes. Scattered light was measured as the objective scatter index (OSI) at 0.5-second intervals over 20 seconds without blinking. Then, we recorded OSI every 0.5 seconds within a 20-second period with the subjects asked to blink freely. Several parameters were established to evaluate the dynamic alterations of optical quality and the effects of blinks: OSI, OSI standard deviation (SD), ΔOSI, ΔOSI/time, blinking change (BC), and blinking frequency (BF). Additional clinical examination included tear film break-up time (BUT), Schirmer I test (SIT), fluorescein staining grade (FL), meibomian gland quality, meibomian gland expressibility, and meibomian gland drop-out. Results: The OSI, SD, ΔOSI, ΔOSI/time, BC, and BF were significantly higher in DED patients than controls (P < 0.01, respectively). The OSI, SD, ΔOSI, ΔOSI/time, BC, and BF were significantly higher in patients with MGD than patients with ADDE (P < 0.01). In the MGD group, BUT, FL staining score, lid abnormality, meibomian gland expressibility, and meibomian gland drop-out were correlated with Δ OSI and Δ OSI/time. Conclusion: Dry eye patients with MGD had significant alterations of optical quality compared with ADDE patients. The double-pass system has potential to be a useful quantitative method to evaluate the optical quality and tear-film dynamics in patients with dry eye.

Iridocorneal endothelial syndrome: Evaluation of patient demographics and endothelial morphology by in vivo confocal microscopy in an Indian cohort Chintan Malhotra, Natasha G Seth, Surinder S Pandav, Arun K Jain, Sushmita Kaushik, Amit Gupta, Srishti Raj, Deepika Dhingra Indian Journal of Ophthalmology 2019 67(5):604-610 Purpose: To evaluate the patient demographics and morphological characteristics of corneal endothelium by in vivo confocal microscopy (IVCM), in patients with Iridocorneal Endothelial (ICE) Syndrome. Methods: In this retrospective observational series, IVCM acquired endothelial images of patients with ICE syndrome were evaluated. 'ICE cells' morphology was classified as “−” or “+” if they were larger or smaller than contralateral normal endothelium. It was correlated with patient demographics and clinical manifestations. Results: IVCM was performed on 41 eyes of 21 patients, with 13 males (62%) and 8 females (38%). The disease was unilateral in 19 (90.5%) and bilateral but asymmetric in two (9.5%) patients. Total ICE was seen in 91% eyes. Eighty percent patients (12 out of 15) with ICE—cells were males while 83.3% (5 out of 6) patients with ICE + cells were females. Mean age of patients with ICE- cell type and ICE + cell type was 45.8 ± 17.8 years and 40.3 ± 9.2 years respectively (P = 0.02). Both ICE – and ICE + eyes had similar incidence (33.3%) of corneal edema. ICE + eyes had more severe (grades 2/3) glaucoma (n = 5/6 eyes, 83.3%) compared to ICE – eyes (n = 8/15 eyes, 53.3%). Conclusion: A male preponderance, predilection of ICE – and + cell variants for male and female gender respectively, lack of association of the endothelial cell morphology with corneal edema, and apparent association of ICE + phenotype with more severe glaucoma occurring at a relatively younger age, are some novel findings of the present study. In the clinical setting correlation of patient demographics with these IVCM findings may help in better long-term prognostication of eyes with ICE syndrome.

Commentary: In vivo confocal microscopy in iridocorneal endothelial syndrome Vineet Ratra Indian Journal of Ophthalmology 2019 67(5):610-611

Discharge teaching, readiness for discharge, and post-discharge outcomes in cataract patients treated with day surgery: A cross-sectional study Chujin Qiu, Xianqiong Feng, Jihong Zeng, Hongmei Luo, Zhifeng Lai Indian Journal of Ophthalmology 2019 67(5):612-617 Purpose: To investigate the quality of discharge teaching, readiness for hospital discharge (RHD), and post-discharge outcomes (PDO) of cataract patients in a day ward and to explore the relationships among these three variables. Methods: This cross-sectional study used an opportunistic sample from the ophthalmic day ward in a general hospital in Sichuan province, China. Data were collected using four questionnaires. Results: The total average score on the Quality of Discharge Teaching Scale was 192.95, and the dimension with the lowest score was “guidance obtained practically.” The total average score on the Readiness for Hospital Discharge Scale was 175.51, and the dimension with the lowest score was “knowledge of disease.” The total average score on the Post-Discharge Outcome Questionnaire was 77.08, and the four dimensions with the lowest scores were “compliance behaviors,” “avoiding excessive use of eye,” “avoiding strenuous exercise,” and “regular check-up.” Pearson correlation coefficients indicated low to moderate correlations between discharge teaching quality and PDO (0.245, P < 0.01), RHD and PDO (0.271, P < 0.01), and discharge teaching quality and PDO (0.559, P < 0.01). Conclusion: The quality of discharge teaching among cataract patients who underwent day surgery was relatively high, and patient preparation for discharge and PDO were good. However, medical staff should focus more attention on patients' individualized needs for discharge teaching while emphasizing the importance of compliance behavior.

Growth Factors and Stem Cells in Dentistry

Microtissues and tridimensional cell models: A new paradigm in tissue engineering Gutemberg Gomes Alves, Daniela Costa-Silva International Journal of Growth Factors and Stem Cells in Dentistry 2019 2(1):1-2

Evaluation of the receptor activator of nuclear factor-κb ligand/osteoprotegerin ratio in the gingival crevicular fluid of patients under periodontal maintenance Marilia Marta Guerra Da Costa Reis, Priscila Ladeira Casado, Ana Carolina Batista Brochado, Gutemberg Gomes Alves, José Mauro Granjeiro, Eliane Dos Santos Porto Barboza International Journal of Growth Factors and Stem Cells in Dentistry 2019 2(1):3-7 Context: Periodontitis is an infectious disease characterized by an inflammatory response and bone resorption, which can cause tooth loss. The bone destruction may be caused by deregulation of the receptor activator of nuclear factor κB/receptor activator of NF-κB ligand/osteoprotegerin (RANK/RANKL/OPG) system, stimulating osteoclastogenesis. After the treatment of the active disease, a formal program of periodontal maintenance is implemented according to each patient needs. Aims: This study aimed to evaluate the RANKL/OPG relation in patients under periodontal maintenance. Setting and Design: Thirty individuals were selected and divided into the test group, comprised of patients who received periodontal treatment and were under periodontal maintenance showing active sites (n = 15), and nonactive sites of the disease (n = 15), and the control group, comprised of healthy periodontium (n = 15). Materials and Methods: The GCF was collected by absorption into paper cones. The measurement of RANKL and OP was performed by xMAP technology and a Luminex 200 flow luminometer system. Statistical Analysis: Data were compared through Kruskal–Wallis test, at 5% significance. Results: There was no intrapatient difference on the RANKL/OPG ratio, but it was significantly lower in the active sites of patients treated of periodontitis, under a maintenance program, compared with the control (P < 0.05), even tough all ratios were under the range reported for healthy individuals. Conclusions: Patients in periodontal maintenance have a significantly lower RANKL/OPG ratio than healthy indivduals, demonstrating its importance for patients' periodontal health.

Immediate implant and customized abutments: Esthetic peri-implant preservation alternative without immediate loading esthetic customized abutment Aldir Machado, Rackel Goncalves, Aristides Da Rosa Pinheiro, Cleonicio Cordeiro Filho, Bruno Cunha Rangel, Raphael Monte Alto, Priscila Ladeira Casado International Journal of Growth Factors and Stem Cells in Dentistry 2019 2(1):8-12 The aim of this case report was to describe an alternative treatment for the healing and maintenance of peri-implant mucosa in esthetical region. Managing the peri-implant soft tissue is one of the most challenging tasks in anterior implant esthetics, especially when replacing a failing tooth. However, not all patients underwent extraction, and immediate implant placement can receive loading, conducting to uncertain predictability. This is a case report that describes an alternative treatment for the healing and maintenance of the peri-implant mucosa in an esthetically significant region, through the use of a customized abutment to obtain an emergency profile when there is insufficient torque for immediate implant loading. The present technique was able to ensure not only healthy peri-implant soft and hard tissues, but also esthetic maintenance of the anterior region for immediate implant placement. This clinical case demonstrates a different manipulation technique from the peri-implant soft tissues in immediate implants of the esthetic region favoring the peri-implant health and clinical results, promoting treatment success, and patient satisfaction.

Proposal for point-of-care testing of platelet-rich plasma quality Tomoyuki Kawase, Akira Takahashi, Taisuke Watanabe, Tetsuhiro Tsujino International Journal of Growth Factors and Stem Cells in Dentistry 2019 2(1):13-17 Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) regenerative therapy lacks evidence to make clinical decisions. This weakness cannot be addressed only by standardization of preparation protocols and devices. In this article, we have emphasized on the necessity for quality testing to obtain strong evidence supporting PRP/PRF therapy.

The "ring-shaped" autologous fibrin matrix: A technical note Fernando Luiz Duarte de Almeida, Leonel Alves de Oliveira International Journal of Growth Factors and Stem Cells in Dentistry 2019 2(1):18-21 The use of platelet-rich fibrin has gained importance as an autologous scaffold for tissue regeneration. One of its features is, when placing implants in fresh extraction sockets, to function as a selective scaffold and also as a barrier in order to correct marginal bone defects and/or to avoid collapse of surrounding soft tissue. However, its handling and placement require specific manipulation skills, to avoid unintentional slipping and dislodging during the suture procedure. In order to avoid these problems and to allow easier and faster use of the PRF matrix, a simple device for providing a self-stabilized fibrin plug has been developed. This plug surrounds, as an elastic ring, the transmucosal extension of the prosthetic components for conical internal connection implants, thus enhancing the effectiveness of the fibrin matrix expected performance.

Emergencies, Trauma, Shock

Whats New in Emergencies, Trauma and Shock? Is Intracranial Pressure Monitoring Essential in the Management of Traumatic Brain Injury? Dhaval P Shukla, Amit Agrawal Journal of Emergencies, Trauma, and Shock 2019 12(1):1-2

Compliance with 6 h-Sepsis Resuscitation Bundle of Surviving Sepsis Campaign before and after Resident Physicians' Training: A Quality Improvement Interventional Study among Indian Patients Swaroop K Raj, Prasan Kumar Panda, Naveet Wig, Praveen Agarwal, RM Pandey Journal of Emergencies, Trauma, and Shock 2019 12(1):3-9 Background: Surviving sepsis campaign (SSC) recommends 6 h-sepsis resuscitation bundle for severe sepsis (now termed “sepsis” after the Sepsis-3 definition) or septic shock. The study was done to assess the guideline compliance in Indian patients before and after the resident physicians' training and their impact on the survival. Subjects and Methods: Prospective interventional study (time series design) was conducted. Resident physicians, who were regularly managing the patients of severe sepsis/septic shock, were trained by providing the education and feedback on the guideline compliance at 6-month intervals for three quality improvement (QI) phases. Case details of preintervention and QI phases' patients were reviewed as per the quality indicators, defined by SSC guideline, and compared. Results: The baseline compliance of composite six components of 6 h-sepsis resuscitation bundle was low and significantly increased on postintervention (baseline 0% to 18% at QI 3 (P for trend = 0.01). The compliance of individual components was improved too: serum lactate measurement (26%, P = 0.002), obtaining blood culture (28%, P = 0.003), antibiotic administration (2%, P = 0.56), provision of fluid bolus (60%, P = 0.02), attainment of target central venous pressure (50%, P = 0.03), and optimization of central venous oxygen saturation (20%, P = 0.21). The hospital mortality showed a decreasing trend (18%, P = 0.06). Patients compliant to composite bundle got the mortality benefit (odds ratios = 0.25, 95% [confidence interval, 0.07–0.9]). The study, however, did not show any benefits of mean hospital/Intensive Care Unit (ICU) length of stay. Conclusions: The study establishes lack of acceptance to the prevailing guideline; however, it has shown a significant improvement in adaptation and mortality benefit without reducing mean hospital/ICU length of stay after physicians' repeated educational programs. The barriers to implementation of the prevalent guideline should be searched out in further trials.

Utility of point-of-care ultrasound in differentiating causes of shock in resource-limited setup H Humbal Rahulkumar, Parikh Rina Bhavin, K Patel Shreyas, H Pancholi Krunalkumar, Saxena Atulkumar, Chawada Bansari Journal of Emergencies, Trauma, and Shock 2019 12(1):10-17 Background: Delivering early diagnosis of shock in resource-limited setting is challenging, especially with limited availability of point-of-care laboratory and radiological diagnostic facilities. There is growing urgency to provide point-of-care diagnosis and treatment for time-sensitive condition like shock. Aims: We tried to evaluate the application of point-of-care ultrasound (Rapid Ultrasound for Shock and Hypertension [RUSH] protocol) considering different disease cohort and practice realities in our setup. Settings and Design: This study was a single-center prospective diagnostic study to check the diagnostic accuracy of point-of-care ultrasound (RUSH protocol). This study was approved by the ethics committee. Materials and Methods: The study was conducted at the emergency medicine department of a tertiary care government hospital in Central Gujarat from November 16 to October 17. All adult patients with clinical features of shock with systolic blood pressure <90 mmHg and shock index >1 presenting to emergency department were included as participants. The results of point-of-care ultrasound (RUSH protocol) were compared with the diagnosis given by consultants of respective department as per standard departmental practices. Statistical Analysis and Results: A total of 130 patients were enrolled in this study. Mean time taken to examine by the point-of-care Ultrasound (RUSH protocol) was 12 min (range 11–14 min). Kappa index was 0.860. This protocol was able to correctly diagnose 100% of obstructive shock, 96.3% of cardiogenic shock, 94.4% of hypovolemic shock, 80.9% of mixed type of shock, and 75% of distributive type of shock. Conclusion: This study highlights the role of point-of-care ultrasound (RUSH protocol) for early diagnosis of the shock etiology in emergency medicine department. Diagnosis using point-of-care ultrasound (RUSH protocol) significantly agreed with medical diagnosis. It showed good efficacy of point-of-care ultrasound (RUSH protocol) to differentiate causes of shock with good accuracy except distributive shock.

The Association of Intracranial Pressure Monitoring and Mortality: A Propensity Score-Matched Cohort of Isolated Severe Blunt Traumatic Brain Injury Rebecka Ahl, Babak Sarani, Gabriel Sjolin, Shahin Mohseni Journal of Emergencies, Trauma, and Shock 2019 12(1):18-22 Background: Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) is common. Yet, its efficacy varies between studies, and the actual effect on the outcome is debated. This study investigates the association of ICP monitoring and clinical outcome in patients with an isolated severe blunt TBI. Patients and Methods: Patients were recruited from the American College of Surgeons-Trauma Quality Improvement Program database during 2014. Inclusion criteria were limited to adult patients (≥18 years) who had a sustained isolated severe intracranial injury (Abbreviated Injury Scale [AIS] head of ≥3 and Glasgow Coma Scale [GCS] of ≤8) following blunt trauma to the head. Patients with AIS score >0 for any extracranial body area were excluded. Patients' demographics, injury characteristics, interventions, and outcomes were collected for analysis. Patients receiving ICP monitoring were matched in a 1:1 ratio with controls who were not ICP monitored using propensity score matching. Results: A total of 3289 patients met inclusion criteria. Of these, 601 (18.3%) were ICP monitored. After propensity score matching, 557 pairs were available for analysis with a mean age of 44 (standard deviation 18) years and 80.2% of them were male. Median GCS on admission was 4[3,7], and a third of patients required neurosurgical intervention. There were no statistical differences in any variables included in the analysis between the ICP-monitored group and their matched counterparts. ICP-monitored patients required significantly longer intensive care unit and hospital length of stay and had an increased mortality risk with odds ratio of 1.6 (95% confidence interval: 1.1–2.5, P = 0.038). Conclusion: ICP monitoring is associated with increased in-hospital mortality in patients with an isolated severe TBI. Further investigation into which patients may benefit from this intervention is required.

An Analysis of the Economic Burden of the Trauma Services at a Level 1 Public Sector Trauma Center in South Asia Namrata Makkar, Amit Gupta, Shrey Modi, Dinesh Bagaria, Subodh Kumar, Sunil Chumber Journal of Emergencies, Trauma, and Shock 2019 12(1):23-29 Background: Incidence of road traffic injuries (RTIs) is increasing and accounting for country's 3% gross domestic product. It is crucial to perform a cost analysis of trauma systems to allocate resources judiciously. Aim and Objectives: To study the economic burden of trauma care on the patient attending a level I trauma center including stratification of costs according to injury. Materials and Methods: This is a prospective study, with patients of polytrauma (Injury Severity Score >16) admitted in the center. Cost analysis (cost descriptive study) was done by calculating direct costs to hospital by bottom-up microcosting considering fixed and recurrent costs including reference unit prices (RUPs). According to the anatomical site of injuries, major injury groups (MIGs) costs were also analyzed. Results: The demographics including mode of injury were similar to other studies. The RUP's and MIG's were defined which represented majority of the sample size. Due to highly subsidized nature of services in this Government institute, the cost to patient is less compared to other countries. Still, the total expenditure incurred by the low-income group was higher than the minimum wages at that time. The creation of plausible RUP's and the grouping of MIG's can help in reducing the costs by targeting and implementing strategic cost reduction measures. Conclusion: The study has shown that microcosting is feasible. Considering the low-income population demanding trauma services, further efforts are required to reduce costs substantially.

Delirium incidence and risk factors in adult critically ill patients in Saudi Arabia Akram Mohammad Rasheed, Mohammad Amirah, Mohammad Abdallah, Adel M Awajeh, PJ Parameaswari, Abdulrhman Al Harthy Journal of Emergencies, Trauma, and Shock 2019 12(1):30-34 Background: Delirium in intensive care units (ICUs) is associated with long ICU stay, long hospital stay and increased costs of treatment. Unfortunately, delirium in ICU is significantly underestimated and overlooked by healthcare providers. Aims: The aim of this tudy is to determine the incidence and associated risk factors of delirium among critically ill patients in Saudi Arabia. Methods: This is a prospective study. Patients were assessed for delirium using the confusion assessment method for the ICU. Delirium was the independent variable in this study. Results: Fifty-nine patients (17.3%) showed positive delirium at least once compared to 283 patients (82.7%) who did not show positive delirium. Certain factors for delirium found to be significantly correlated with delirium (P < 0.005); including receiving sedation, mode of sedation, receiving mechanical ventilation, resistance to mechanical ventilator, and baseline Glasgow Coma Scale. Conclusion: Delirium occurred in >17% of our ICU patients. More efforts should be directed to consider ICU delirium and to minimize its triggering factors.

Changing aspects in the management of splenic injury patients: Experience of 129 isolated splenic injury patients at level 1 trauma center from India Dinesh Bagaria, Atish Kumar, Amulya Ratan, Amit Gupta, Abhinav Kumar, Subodh Kumar, Biplab Mishra, Sushma Sagar Journal of Emergencies, Trauma, and Shock 2019 12(1):35-39 Background: The spleen is most the commonly injured solid organ in abdominal trauma. Operative management (OM) has been challenged by several studies favoring successful non-OM (NOM) aided by modern era interventional radiology. The results of these studies are confounded by associated injuries impacting outcome. The aim of this study is to compare NOM and OM for isolated splenic injury in an Indian Level 1 Trauma Center. Materials and Methods: This is a retrospective analysis of prospective database. Results: A total of 1496 patients were admitted with abdominal injuries. One hundred and twenty-nine patients admitted with diagnosis of isolated splenic injury from January 2009 to December 2016 were included in the study. RTIs, followed by falls from height, were the most common mechanisms of injury. Ninety-two (71.3%) patients with isolated splenic trauma were successfully managed nonoperatively. Thirty-seven (28.7%) required surgery, of which three were due to the failure of NOM. Three patients in the nonoperative group underwent splenectomy later, giving an overall success rate of 96.8% for NOM. Patients with isolated splenic trauma requiring OM had higher grade splenic injury (Grade 4/5), higher blood transfusion requirements (P < 0.001), and prolonged Intensive Care Unit and hospital stay in comparison to patients in the nonoperative group. No patient died in the NOM group; two patients died in the splenectomy group due to hemorrhagic shock and acute respiratory distress syndrome, respectively. Conclusion: Although NOM is successful in most patients with blunt isolated splenic injuries, careful selection is the most important factor dictating the success of NOM.

Clinical presentation and management of pelvic Morel–Lavallee injury in obese patients Mohammed Muneer, Ayman El-Menyar, Husham Abdelrahman, Musab Ahmed Murad, Sara M Al Harami, Ahmed Mokhtar, Mahwish Khawar, Ahmed Awad, Mohammad Asim, Rifat Latifi, Hassan Al-Thani Journal of Emergencies, Trauma, and Shock 2019 12(1):40-47 Introduction: Morel–Lavallee lesion (MLL) is an infrequent or underreported serious consequence of closed degloving injuries. We aimed to describe the clinical presentation and management of pelvic MLL in obese patients. Materials and Methods: A retrospective analysis was conducted for pelvic trauma patients with a diagnosis of MLL between 2010 and 2012. Patients' demographics, presentations, management, and outcomes were analyzed and compared based on the body mass index (BMI) and injury severity. Results: Of 580 patients with pelvic region injuries, 183 (31.5%) had MLL with a mean age of 30.1 ± 12.2 years. The majority (75.4%) of MLL patients had a BMI ≥30 and 44% patients had pelvic fracture. Based on the initial clinical examination, MLL was diagnosed in 84% of patients and clinically missed in 16% of patients. Nonoperative management (NOM) was performed in 93.4% of patients, while primary surgical intervention was indicated in 6.6% of patients. Failed NOM was observed in seven cases, of them five were obese. The overall mortality in MLL patients was 12.6% and the frequency of deaths was nonsignificantly higher in Grade I obese patients. Multivariate analysis showed that injury severity score (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.05–1.50) and Glasgow coma scale (OR: 0.72, 95% CI: 0.56–0.92) were the predictors of mortality in patients with MLL irrespective of BMI. Conclusions: One-third of pelvic region injuries have MLL and three-quarter of them are obese. This significant association of obesity and MLL needs further prospective evaluation.

A comparison of nonobese versus obese emergency department patient satisfaction scores utilizing Standard U.S. hospital survey query methodology Christopher Mock, Justin Hensley, K Tom Xu, Peter B Richman Journal of Emergencies, Trauma, and Shock 2019 12(1):48-53 Background: Prior research reveals that overweight patients have higher emergency department (ED) utilization rates, longer length of stay, and face increased misdiagnosis risk. Objective: The objective of this study was to evaluate the association between obesity and ED patient satisfaction. Methods: This study was a cross-sectional study. A convenience sample of inner-city ED patients completed a written survey, then rated overall satisfaction with ED care (10-point scale), and rated components of satisfaction (4-point scale; never to always). Body mass index (BMI) was calculated using triage records (obesity = BMI >30). Results: Five hundred and sixty-four patients were included in the study group (50.5%: obese, 55.4%: female, mean age: 43.2 ± 25.4 years). With respect to overall visit satisfaction (rating 8 or greater on 10-point scale), bivariate analysis revealed no differences between nonobese versus obese patients (74.6% vs. 73.9%; P = 0.85). There were no significant differences for score of 4 (always) for components of ED satisfaction: physician courtesy (87.9% vs. 90.4%; P = 0.34), nurse courtesy/respect (89.2% vs. 88.7%; P = 0.87), doctor listened (85.4% vs. 87.1%; P = 0.5), doctor explained (80.2% vs. 85.0%; P = 0.14), and recommend to friend (72.5% vs. 81.1%; P = 0.02). Within our multivariate model, obesity was not associated with overall satisfaction (scores of 8 or greater) (P = 0.97; odds ratio = 0.99 [95% confidence interval = 0.65–1.5]). Conclusions: Despite research that suggests that overweight patients have characteristics of their ED visit that might increase dissatisfaction risk, we found no difference in satisfaction scores between nonobese and obese patients.

Costs and Characteristics of Undocumented Immigrants Brought to a Trauma Center by Border Patrol Agents in Southern Texas Evan Kane, Peter B Richman, K Tom Xu, Scott Krall, Osbert Blow Journal of Emergencies, Trauma, and Shock 2019 12(1):54-57 Background: The objective of this study was to evaluate the costs, characteristics, and outcomes of patients brought to a Texas trauma center emergenct department after apprehension by Border Patrol (BP)/Immigration and Customs Enforcement (BP/ICE). Materials and Methods: This is a secondary analysis of a trauma registry/financial records (1/1/11-12/31/14). Data were extracted utilizing a structured form. A multivariate ordinary least square was estimated to identify variables associated with hospital charges. Results: A total of 128 patients were enrolled as the study group; mean age was 28.6 ± 6 years, 20.3% were female, 100% were Hispanic, the most common mechanism of injury (MOI) was motor vehicle crash (75%), and mean charge was $162,152 ± $295,441. Mean length of stay (LOS) was 13.2 ± 29.8 days; 92.2% survived to discharge. Bivariate analysis revealed that MOI differed by gender (P = 0.021). In the multivariate analysis, the only variable that associated with increased charge was LOS. Total charges for the 128 patients were $20.6M, total costs were $4.5M, and total payments were $0.99M. Conclusions: Undocumented immigrants apprehended by BP/ICE and brought to our trauma center utilized significant health-care resources.

Transfusion Medicine

Massive transfusion needs during war or other casualties Sangeeta Pathak Global Journal of Transfusion Medicine 2019 4(1):1-5

Review of existing legislative instruments for blood systems of Countries in the WHO Eastern Mediterranean Region Cees Theodoor Smit Sibinga, Yetmgeta Eyayou Abdella, Frank Konings Global Journal of Transfusion Medicine 2019 4(1):6-15 Blood transfusion is an essential part of health-care systems; contributes to saving millions of lives; improves patient expectancy and quality of life; and supports medical and surgical procedures. Blood and blood products-whole blood, red blood cells, platelets, and plasma were added to the WHO Model List of Essential Medicines (EMs) in 2013. Effective blood regulation is crucial for establishing blood products as EMs which requires countries to implement an appropriate regulatory framework and functioning regulatory authority (RA). There are numerous situations, for example, in the less developed world, where these prerequisites have barely been implemented. Existing legislative tools of the Eastern Mediterranean Region countries were collected, analyzed for relevance and appropriateness for the regulation of blood products, associated substances and relevant medical devices. Literature search on matching combinations of regulatory system/framework, legislation, regulation, with production and use of blood products resulted in few references on national and international legislation. The WHO recommendations and EU Directives were used as reference. Formal legislative and regulatory documents issued by nine countries from 1960 to 2017 were reviewed. Most are descriptions of RA, operational establishments, and specific requirements. None comply with the WHO/EU recommended format and contents; will not support effective regulatory oversight to promote and enhance the quality, safety, and availability of blood and blood products. National authorities should provide effective leadership and governance in developing a national blood system (NBS), fully integrated into the national health system. Essential functions of NBS include an appropriate regulatory framework; legislation, regulations, and nonlegislative instruments administered by an RA. These should spell out ethics, principles and boundaries, standard setting, and organization of NBS to ensure and sustain an adequate supply of quality-assured blood products and safe clinical use.

Application of flow cytometry in transfusion medicine Rajesh B Sawant Global Journal of Transfusion Medicine 2019 4(1):16-20 Flow cytometry-based testing approaches have no longer remained restricted to the research laboratories. With widening of its horizons in the field of diagnostics in oncology and transplantation medicine, the flow cytometer-based testing approach is now relevant to many aspects of the field of transfusion medicine. Two of the most important applications of flow cytometry in transfusion medicine are the enumeration of CD34-positive cells in the peripheral blood and stem cell product and the enumeration of residual white blood cell counts in blood product as a quality control measure. The flow cytometer-based crossmatch for detection of donor-specific anti-human leukocyte antigen antibodies is also gaining popularity in the field of histocompatibility and immunogenetics. The utility of this platform in the field of immunohematology is also increasing and looks promising for clinical decision-making in the near future.

Comparative analysis of platelet storage lesion in whole-blood-derived platelets stored in autologous plasma versus platelets stored in platelet additive solution using flow cytometric assay of CD62 and Annexin V Subhashish Das, M L Harendra Kumar Global Journal of Transfusion Medicine 2019 4(1):21-27 Background: Platelets storage lesions remain a challenge in regular blood transfusion services. Flow cytometric study based on the expression of platelets activation markers in the stored platelets is a good method to study such lesions. Materials and Methods: Buffy-coat-derived platelet concentrates were stored under standard conditions for 7 days. The expression of activation antigens CD62p and Annexin V on total platelets and populations of small, medium-sized and large platelets was analyzed by flow cytometry during storage on days 0, 5 and 7. Results: There was significant difference in Annexin V expression between PAS and non- PAS group on Day 0, Day 5 and Day 7. The same observation was noted with regard to CD62 estimations. Conclusion: Our study confirm the beneficial effects of platelet additive solution as highlighted by the flow cytometric assay of CD62 and Annexin V. Evaluation of the level of expression of various activation markers on different platelet populations could be an additional valid tool in quality control of platelet concentrates, and could be a novel approach towards better platelet inventory management.

On-site and off-site adverse donor reactions in voluntary whole blood donors: A study from a tertiary care oncology center Priti D Desai, Anisha A Navkudkar, Sunil B Rajadhyaksha Global Journal of Transfusion Medicine 2019 4(1):28-32 Aim: The aim of this study was to analyze the frequency of on-site and off-site adverse donor reactions and its correlation with contributory factors if any. Materials and Methods: A prospective observational study was conducted from October 2016 to November 2016. A total of 1000 voluntary whole blood (WB) donors who consented to participate in the study were contacted telephonically the next day of donation. Donors were asked a structured questionnaire and information was documented. Results: Of the 1000 voluntary WB donors, 948 responded to the phone calls. Of these 948, 79 (8.33%) donors experienced adverse reactions. Of the 79 donors, 33% (26/79) reactions occurred on-site, whereas 67% (53/79) reactions occurred off-site (P < 0.05). Of the total on-site reactions, 92% (24/26) were vasovagal reactions (VVRs) and 8% (2/26) were hematomas (P < 0.001). Of the total off-site reactions, 47% (23/53) were vasovagal and 53% (30/53) were hematomas. Of the 79 donors, 60% (47/79) experienced VVR and 40% (32/79) experienced hematomas. Of the 32 hematoma reactions, 94% (30/32) were noticed off-site, whereas 6% (2/30) occurred on-site (P < 0.001). Majority of hematomas took more than 7 days to resolve. Conclusion: Maximum reactions occurred off-site, and hence donor follow-up after the donor has left the donation site is important. Postdonation follow-up proves to be an efficient tool to acquire information about adverse donor reactions. The next day telephonic follow-up was helpful as donor recall of the off-site reactions was better, which otherwise would have gone unreported.

Surrogate markers and their correlation to bacterial contamination and other quality parameters in random-donor platelets by platelet-rich plasma method Priyatesh Dwivedi, Abhishekh Basavarajegowda, Apurba Sankar Sastry Global Journal of Transfusion Medicine 2019 4(1):33-38 Introduction: Bacterial contamination in platelet concentrates (PCs) occurs more frequently than other blood components because of several factors such as storage in oxygen permeable blood bags at 20°C–24°C with continuous agitation which facilitates bacterial growth compared to other blood components which are kept frozen or refrigerated which inhibits bacterial proliferation in them. The purpose of the study was to assess the incidence of bacterial contamination of random-donor PCs and factors associated with its contamination and see how well the surrogate markers such as pH and swirling correlate with the same. Methodology: This was a cross-sectional study which included randomly chosen 500 random-donor platelets (RDPs) in blood bank prepared by platelet-rich plasma method. The samples chosen for the study were from the RDPs on the 5th day of storage after their preparation. pH, platelet count, and swirling in platelets, which act as surrogate markers for bacterial contamination, were checked on the RDP units. About 1–3 ml of PCs was inoculated from the RDP units into labeled culture bottles (BD Bactec Peds Plus/F). Results: Among a total of 499 random-donor PCs that were cultured in the automated BACTEC system for the study, none of them were culture positive. Thirty RDP units in the study were visibly lipaemic whereas 93 RDP units were visibly reddish in appearance. PCs having volumes <40 ml or >70 ml did not affect the swirling, pH, and platelet counts. There was a statistically significant difference between mean pH with RDP units having swirling Grade 2 and 3 and platelet counts with RDP units having swirling Grade 1 and 2. Conclusion: Bacterial contamination though poses a significant risk is a very rare event in a meticulously prepared and stored PCs. Surrogate markers though useful in resource-constrained settings does not correlate optimally with the quality indicators.

Spectrum of alloimmunization among multitransfused beta-thalassemia major patients Usman Waheed, Muhammad Arshad, Muhammad Saeed, Akhlaaq Wazeer, Ahmed Farooq, Abida Arshad, Hasan Abbas Zaheer Global Journal of Transfusion Medicine 2019 4(1):39-44 Introduction: The development of alloantibodies is a major problem among thalassemia major individuals due to periodic blood transfusions. The current study assessed the frequency and specificity of erythrocytes alloimmunization and also the variables affecting the extent of alloimmunization in repeatedly transfused thalassemia patients. Materials and Methods: This prospective, cross-sectional study was conducted at the Department of Blood Transfusion Services and Thalassemia Centre of Pakistan Institute of Medical Sciences from August 2017 to February 2018. Of the 475 thalassemia major patients, alloantibodies were screened and identified by 3-red cell antigen panel and afterward by an extended 11-cell antigen panel. The data analysis was done through SPSS version 20.0. Chi-square test was employed. Results: Alloantibodies were detected in 77 (16.2%) patients, 5 (6.5%) patients were found with double alloantibodies. Anti-D (31.1%) and Anti-E (29.9%) antibodies had the highest incidence and were found in 24 and 23 patients, independently. Anti-K antibody was observed in 11 (14.3%) and Anti-C in 3 (3.9%) patients. Anti-C (2.6%), Anti-E (2.6%), and Anti-Kpa (2.6%) all were found in two patients, individually. Similarly, Cw (1.3%), k (1.3%), Jka (1.3%), Anti-Fyb (1.3%), and Anti-s (1.3%) antibodies were detected in one patient each. Alloantibodies were common in males, splenectomized patients, in those who initiated their transfusions before 2 years of age, in patients receiving nonleukoreduced blood and in B and O blood group patients. Conclusion: The proper management and prudence are needed for thalassemia patients due to hemolytic nature of these alloantibodies. New techniques should be introduced to reduce the incidence of red blood cell alloimmunization.

Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan? Maqsood Ahmad, Muhammad Saeed, Aamir Hanif, Usman Waheed, Muhammad Arshad, Noor Ul Ain, Farhan Rasheed, Shahida Hussain Global Journal of Transfusion Medicine 2019 4(1):45-51 Aims: This study was planned to evaluate the trends of transfusion-transmissible infectious diseases (TTID). Setting and Design: This cross-sectional retrospective study was conducted on donor community attending Transfusion Medicine Department, Punjab Institute of Cardiology, Lahore, Pakistan from January 1, 2012, to December 31, 2016. Subject and Methods: A total of 79,774 blood donors were processed for HbsAg anti-HCV, anti-human immunodeficiency virus (HIV), syphilis, and malaria detection by rapid immune chromatographic technique. Statistical Analysis: The data analysis was done through SPSS 20.0. Chi-square test was employed. Results: Males and females were 91% and 9%, respectively. The mean age was 44 ± 10 years, the prevalence of TTID was 4.0%, and year-wise decreasing trends were observed as 4.4%, 4.2%, 3.7%, 3.9%, and 3.9%, respectively, in 2012–2016. Overall Co-infection was 0.36%, HBV+HCV co-infection was most common. The seroprevalence of HBV, HCV, syphilis, malaria, and HIV was 0.9%, 1.7%, 1.1%, 0.1%, and 0%, respectively. Year-wise seroprevalence of HCV was 2.1%, 1.8%, 1.7%, 1.7%, and 1.3%; HBV was 1.2%, 0.8%, 0.8%, 1.0%, and 1.0%, syphilis was 0.8%, 0.8%, 0.9%, 1.4%, and 1.5%, and malaria was 0.1%, 0.03%, 0.1%, 0.1%, and 0.05% in 2012–2016, respectively, and no single case of HIV was detected. Conclusion: Raising trends for syphilis among blood donors underscore the concern about growing infection of this disease in the community as these blood donors represent the highly selective community. The zero prevalence of HIV in Pakistani population supports the growing awareness of this life-threatening disease. HBV and HCV infections still continue to be a menace to the society because, in spite of decreasing trend, burden of the disease is still high in general community.

Revisit of efficiency of blood usage – Need for continuous audit Soumee Banerjee, Parimala Puttaiah, Sitalakshmi Subramanian Global Journal of Transfusion Medicine 2019 4(1):52-57 Background: The most common indices assessing blood usage are crossmatch-to-transfusion (C/T) ratio, transfusion probability (%T), Transfusion Index (TI), nonusage probability (NUP), and wastage as percentage of issue (WAPI). This study, in a South Indian tertiary care hospital, audits blood utilization efficiency and revisits it after implementing corrective measures for deficiencies identified by the first audit highlighting the importance of continuous surveillance and proper measures in efficient blood utilization. Materials and Methods: Blood utilization over 6 months, assessed by C/T ratio, TI, %T, and NUP indicated inefficient blood usage (high C/T ratio). After initiating appropriate measures, reaudit over 1 month assessed effect on blood usage. The total duration was from December 2017 to November 2018. Request forms packed red blood cells provided patient demographics, number of units requested, and indication. Blood bank records provided number of units crossmatched and issued against each request. Results: Initial audit: total requests- 4450, C:T ratio-3.6, TI-0.5, %T- 32% and NUP- 72%. Reaudit: Total requests-948 (medical 52%, surgical 48%), Overall monthly WAPI- 0.1%, C:T ratio-2.4 (medical 1.3, surgical 3.5), %T-63.5%(medical 84%, surgical 43%), TI-1 (medical 1.4, surgical 0.6), NUP- 24% (medical- 11%, surgical 37%) C/T ratio – no subspecialty crossed the highest acceptable value (2.5) except gynecology and obstetrics (4.1) and pediatric surgery (2.75). All departments met the lowest acceptable %T (30%) except G&O (25.2%). All departments met minimum TI (0.5) except G&O (0.3), pediatric surgery (0.47), and surgical super specialties (0.3). Conclusion: Initial audit showed inefficient blood utilization. Appropriate steps taken to improve this included the establishment of standard protocols. Reaudit showed efficient blood utilization in medical departments and the need for further revision in practices for surgical departments. Hence, continuous monitoring is vital in ensuring effective blood usage.

To evaluate hemoglobin thresholds of elective surgical patients and blood typing policy for reducing the erythrocyte transfusion in a hospital setting Sankalp Sharma, Dhananjay Prasad, Saurabh Lehre Global Journal of Transfusion Medicine 2019 4(1):58-64 Introduction: The existing methods to quantify blood requirement in elective surgical procedure are the baseline hemoglobin (Hb) and hematocrit of patients. The risk-based scoring systems available are maximum allowable surgical blood loss and maximum surgical blood ordering schedule employ retrospective data evaluation or patient-specific variables, respectively. The aim of the present study was to evaluate a single institutional data for analyzing red blood cell (RBC) requirement among various surgical diagnoses. The study also evaluated RBC threshold for blood transfusions and efficacy of blood typing policy toward reducing unnecessary transfusions in an institution. Study Design and Methods: This study is a retrospective data evaluation from a single institution of blood transfusion patterns among elective surgical patients. Results: The blood transfusions in surgical diagnoses (n = 259) got integrated under 16 categories. The overall crossmatch-to-transfusion ratio was 1.4, average Hb before transfusion was 9.0 g/dl across the surgical categories, and average erythrocyte transfusion per patient for the various clinical diagnoses was 0.4 blood units. The effective Blood usage was 73.2% of requisitions received and blood typing was performed in 46.3% of total requisitions. Blood typing policy showed a statistically significant improvement in the blood transfusion of crossmatched units in the hospital. A per-unit reduction of blood cost in patients was also observed. Conclusions: The blood transfusion across the surgical categories showed similar Hb thresholds before transfusion. Blood typing policy improved EBU and reduced unnecessary crossmatches and transfusion costs among the patients.

Medical Research

Unfinished business - Leprosy still not defeated David M Scollard Indian Journal of Medical Research 2019 149(1):1-4

Celiac disease & type 1 diabetes: A double burden Eesh Bhatia Indian Journal of Medical Research 2019 149(1):5-7

Non-alcoholic fatty liver disease associated with hepatocellular carcinoma: An increasing concern Ekta Dhamija, Shashi Bala Paul, Saurabh Kedia Indian Journal of Medical Research 2019 149(1):9-17 Hepatocellular carcinoma (HCC) is the sixth most common cancer in world and third largest cause of cancer-related deaths. The last few decades have witnessed the emergence of non-viral causes of HCC, the most important being non-alcoholic fatty liver disease (NAFLD). NAFLD ranges from simple steatosis in the absence of excessive alcohol intake to non-alcoholic steatohepatitis (NASH) with or without cirrhosis. About 3-15 per cent of the obese patients with NASH progress to cirrhosis and about 4-27 per cent of NASH with cirrhosis patients transform to HCC. It is also known that HCC can develop de novo in patients with NASH without the presence of cirrhosis. Yearly cumulative incidence of NASH-related HCC is low (2.6%) compared to four per cent of viral-HCC. NAFLD has been associated with risk factors such as metabolic syndrome, insulin resistance, altered gut flora and persistent inflammation. Due to alarming rise in metabolic diseases, both in the developing as well as the developed world, it is expected that the incidence of NAFLD/NASH-HCC would rise manifold in future. No definite guidelines have been drawn for surveillance and management of NAFLD/NASH-associated HCC. It is thus important to discuss the entity of HCC in NAFLD at length with special focus on its epidemiology, risk factors, pathophysiology, diagnosis, clinical presentation and prevention.

Role of anti-tissue transglutaminase IgA+IgG antibodies in detection of potential celiac disease in patients with type 1 diabetes Navchetan Kaur, Ranjana W Minz, Sanjay K Bhadada, Biman Saikia, Devi Dayal, Shashi Anand, Neha Joshi, Jagdeep Singh, Babu R Thapa, Rakesh K Kochhar, Kim Vaiphei Indian Journal of Medical Research 2019 149(1):18-25 Background & objectives: Celiac disease (CD) can exist in various forms in type 1 diabetes (T1D) patients and can remain undetected, leading to severe complications. This study was aimed to evaluate five commercially available anti-tissue transglutaminase (tTG) ELISA kits with distinct formats for the detection of CD and potential CD in T1D patients. Clinical and demographic profiles of the patients with different disease subsets were also studied. Methods: Fifty T1D patients with classical and non-classical symptoms of CD and 100 T1D patients without any symptoms of CD were included in this study. Anti-tTG autoantibody levels were estimated by five ELISA kits followed by histological examination of duodenal biopsy. HLA DQ2-DQ8 and DRB1-DQB1 typing was done, and serum levels for transforming growth factor (TGF)-β1 were also estimated. Results: Assay format detecting anti-tTG IgA antibodies against recombinant antigens along with neopeptides of gliadin was most efficient in the detection of CD in symptomatic patients, and assay format detecting IgA+IgG helped in the detection of potential CD in asymptomatic T1D patients. These findings were supported by histological examination and human leucocyte antigen analysis. Patients with potential CD were found to have markedly deranged glycaemic control parameters and also had significantly raised serum levels of TGF-β1, (P <0.05) compared to T1D patients. Interpretation & conclusions: Potential CD can be frequently seen in T1D patients. This can be attributed to the dietary patterns prevalent in the subcontinent and the genetic basis of the disease. Anti-tTG IgA+IgG antibodies can be useful in the detection of these potential CD cases in T1D patients. Early intervention with gluten-free diet can be considered in these patients for better disease management.

Effect of socio-economic status & proximity of patient residence to hospital on survival in childhood acute lymphoblastic leukaemia Sidharth Totadri, Amita Trehan, Appinderjit Kaur, Deepak Bansal Indian Journal of Medical Research 2019 149(1):26-33 Background & objectives: Survival in paediatric acute lymphoblastic leukaemia (ALL) in lower/middle income countries continues to lag behind outcomes seen in high-income countries. Socio-economic factors and distance of their residence from the hospital may contribute to this disparity. This study was aimed at identifying the impact of these factors on outcome in childhood ALL. Methods: In this retrospective study, file review of children with ALL was performed. Patients were treated with the modified United Kingdom (UK) ALL-2003 protocol. Details of socio-economic/demographic factors were noted from a web-based patients' database. Modified Kuppuswamy scale was used to classify socio-economic status. Results: A total of 308 patients with a median age of five years (range: 1-13 yr) were studied. Patients belonging to upper, middle and lower SE strata numbered 85 (28%), 68 (22%) and 155 (50%). Nearly one-third of the patients were underweight. There was no treatment abandonment among children whose mothers were graduates. Neutropenic deaths during maintenance therapy were lower in mothers who had passed high school. In patients who survived induction therapy, the five year event-free survival (EFS) of upper SE stratum was significantly better 78.7±4.9 vs. 59±7.2 and 58.1±4.6 per cent in middle and lower strata (P =0.026). Five year overall survival was higher in the higher SE group; being 91.2±3.5, 78.3±5.6 and 78.8±3.9 per cent (P =0.055) in the three strata. Survival was unaffected by a distance of residence from treating centre or rural/urban residence. High-risk and undernourished children had a greater hazard of mortality [1.80 (P =0.015); 1.98 (P =0.027)]. Interpretation & conclusions: Our findings showed that higher socio-economic status contributed to superior EFS in children with ALL who achieved remission. Undernutrition increased the risk of mortality.

Comparative study of alloimmunization against red cell antigens in sickle cell disease & thalassaemia major patients on regular red cell transfusion Keyuri Jariwala, Kanchan Mishra, Kanjaksha Ghosh Indian Journal of Medical Research 2019 149(1):34-40 Background & objectives: Sickle cell disease (SCD) patients require red cell transfusion during different clinical complications of the disease. Such patients are at a high risk for developing alloantibody against red cell antigens. From India, there are limited data available on alloantibody formation in multiply transfused SCD patients. The present study was thus undertaken to fill up this lacunae by looking at the development of red cell alloantibodies in SCD and β-thalassaemia patients on regular transfusion. Methods: All sickle cell disease patients undergoing red cell transfusion between 2008 and 2016, were included. During this period, a large number of β-thalassaemia major patients also underwent regular red cell transfusion. These thalassaemia patients were also included to compare the tendency of antibody formation between SCD and β-thalassaemia major patients. All patients before regular transfusion were regularly assessed for the development of red cell antibody. Red cell antigen, antibody screen crossmatch and antibody identification were done using the standard technique. Results: A total of 138 patients with SCD aged between 4 and 53 yr (mean 17.6 yr) consisting of 83 males and 55 females (male:female, 1.5:1) along with 333 transfusion-dependent β-thalassaemia patients were studied. Over the last eight years, 15 patients with SCD and four patients with thalassaemia developed alloantibody (P <0.001). Antibody specificity of their alloantibodies was against Rhc, RhE, Kell, Fya and Fyb only. Sickle cell disease patients with and without alloantibody required on the average 11.8 and 8.6 units of red cell concentrate, respectively (P <0.05). Interpretation & conclusions: About 11 per cent of the transfused sickle cells patients developed alloantibodies. The antibody specificity was restricted to Rh, Kell and Duffy blood group systems. Extended antigen matching involving Rh, Kell and Duffy antigens may prevent alloantibody in such patients.

Antidiabetic effect of free amino acids supplementation in human visceral adipocytes through adiponectin-dependent mechanism Vidhya Srinivasan, Selvi Radhakrishnan, Narayanasamy Angayarkanni, KN Sulochana Indian Journal of Medical Research 2019 149(1):41-46 Background & objectives: Amino acids are general nutrients having anti-diabetic property. The present study was undertaken to investigate the mechanism of anti-diabetic effects of amino acids in human visceral adipocyte cells in high glucose environment. Methods: Experiments were carried out in human visceral adipocytes. Adiponectin (APN) siRNAs were designed using Ambion tools. APN mRNA expression was quantified using real-time polymerase chain reaction, and protein level was studied using ELISA. AMP-activated kinase (AMPK) activity was measured and glucose uptake by 2-deoxyglucose uptake method. Results: Amino acids (proline and phenylalanine) exposure to adipocytes significantly (P <0.01) increased APN mRNA by 1.5-folds when compared to control whereas proline increased APN secretion by 10.6-folds (P <0.01), phenylalanine by 12.7-folds (P <0.001) and alanine by 6.3-folds (P <0.01). Free amino acid-induced AMPK activity and glucose uptake were decreased with the transient knockdown of APN. Interpretation & conclusions: Antidiabetic effect of the tested amino acids was exhibited by increased glucose uptake through the AMPK pathway by an APN-dependent mechanism in human visceral adipocytes. This should be tested and confirmed in in vivo system. Newer treatment modalities with amino acids which can enhance glucose uptake and APN secretion can be developed as drug for treating both diabetes and obesity.

A descriptive pilot study of mitochondrial mutations & clinical phenotype in fibromyalgia syndrome Sumita Danda, Blessy Mariam Thomas, G Paramasivam, Raji Thomas, John Mathew, Debashish Danda Indian Journal of Medical Research 2019 149(1):47-50 Background & objectives: Fibromyalgia syndrome (FMS) is one of the most common chronic pain conditions of unknown aetiology. Mitochondrial dysfunction has been reported in FMS with some studies reporting the presence of mitochondrial mutation namely A3243G, which also causes mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes. This pilot study was conducted to assess this mutation and also detect large deletions in mitochondrial DNA (mtDNA) in patients with FMS. Methods: Thirty female patients with FMS participated and 30 matched controls were included. Genomic DNA was subjected to polymerase chain reaction (PCR) amplification using specific primers followed by restriction digestion with Apa I enzyme to detect the specific A3243G mtDNA mutation. Long-range PCR was done in two sets to detect the large deletions in the mtDNA. Biochemical parameters including thyroid-stimulating hormone and vitamin D levels were also looked at. Results: None of the patients were found to carry the common mutation or large deletions. Low vitamin D level was a common finding. Hypothyroidism was found in a few patients. Interpretation & conclusions: Although the common mutation or large mtDNA deletions were not detected in blood mtDNA in the FMS patients, mutations in the muscle and sequence variation in mtDNA remained a possibility. Future studies in both blood and muscle tissue including mtDNA sequencing are warranted in such patients to determine if a subset of FMS patients have mitochondrial myopathy.

Prospective analysis of factors predicting feasibility & success of longitudinal intussusception vasoepididymostomy in men with idiopathic obstructive azoospermia Devi Prasad Tiwari, Abdul Razik, Chandan J Das, Rajeev Kumar Indian Journal of Medical Research 2019 149(1):51-56 Background & objectives: Microsurgical reconstruction for idiopathic obstructive azoospermia is a challenging procedure, and selection of appropriate patients is important for successful outcomes. This prospective study was done to evaluate the ability of scrotal ultrasound measurements to predict the surgical feasibility and determine factors that could predict a patent anastomosis following vaso-epididymal anastomosis (VE) in men with idiopathic obstructive azoospermia. Methods: In this prospective study, men diagnosed with idiopathic obstructive azoospermia, scheduled for a longitudinal intussusception VE, underwent a scrotal ultrasound measurement of testicular and epididymal dimensions. During surgery, site and type of anastomosis, presence of sperms in the epididymal fluid and technical satisfaction with the anastomosis were recorded. All men where VE could be performed were followed up for appearance of sperms in the ejaculate. Ultrasound parameters were compared between men who had a VE versus those with negative exploration. Predictive factors were compared between men with or without a patent anastomosis. Results: Thirty four patients were included in the study conducted between September 2014 and August 2016 and a VE was possible in only 19 (55%) patients. Of these 19 patients, six had a patent anastomosis with one pregnancy. Preoperative ultrasound measurements could not identify patients where a VE could not be performed. Motile sperm in the epididymal fluid was the only significant predictor of a successful anastomosis. Interpretation & conclusion: Forty five per cent of men planned for a VE for idiopathic obstructive azoospermia could not undergo a reconstruction. Ultrasound assessment of testicular and epididymal dimensions could not predict the feasibility of performing a VE. The presence of motile sperms in the epididymal fluid was the only significant predictor of a patent VE in our study.

Comparative analysis of virulence factors & biotypes of Gardnerella vaginalis isolated from the genital tract of women with & without bacterial vaginosis Kumari Nisha, Beena Antony, Jeppu Udayalaxmi Indian Journal of Medical Research 2019 149(1):57-61 Background & objectives: Bacterial vaginosis (BV) involves the presence of a thick vaginal multispecies biofilm, where Gardnerella vaginalis is the predominant species. The reason for an increase in the number of G. vaginalis which are usually present as normal flora of the female genital tract in cases of BV, is not known. Hence, the objective of the present study was to compare the biotypes and virulence factors of G. vaginalis isolated from the genital tract of women with and without BV. Methods: High vaginal swabs collected from 811 women of reproductive age were cultured. G. vaginalis isolates were biotyped and tested for adherence to vaginal epithelial cells, biofilm formation, agglutination of human red blood cells (RBCs), protease production, phospholipase production and surface hydrophobicity. Results: Of the isolates from women with BV, 83.3 per cent (60/72) showed good adherence, 78.4 per cent (58/74) produced biofilm, 82.9 per cent (63/76) produced phospholipase, 67.1 per cent (51/76) produced protease, 77.3 per cent (58/75) were positive for surface hydrophobicity and 61.6 per cent (45/73) were positive for haemagglutination of human RBC. In case of G. vaginalis from non-BV women, 25 per cent (15/60) isolates showed good adherence, 18.4 per cent (9/49) biofilm production, 35 per cent (21/60) phospholipase, 36.6 per cent (22/60) protease, 41.7 per cent (25/60) surface hydrophobicity and 10.1 per cent (6/59) agglutination of human RBCs. Maximum number of isolates belonged to biotypes 6, 2 and 3. Biotype 3 was more associated with non-BV rather than BV; biotype 6, 2 and 1 were more associated with cases of BV. Maximum virulence factors were expressed by biotypes 6, 2 and 1. Interpretation & conclusions: Virulence factors were more expressed by G. vaginalis isolates obtained from women with BV rather than from non-BV. Biotypes 6, 2 and 1 were more associated with cases of BV and expressed maximum virulence factors.

Nursing and Midwifery

The maternal near miss incidence ratio with WHO Approach in Iran: A systematic review and meta-analysis Sedigheh Abdollahpour, Hamid Heidarian Miri, Talat Khadivzadeh Iranian Journal of Nursing and Midwifery Research 2019 24(3):159-166 Background: Maternal near miss (MNM) is one of the important criteria for checking the quality of care in maternal health. This systematic review and meta-analysis study was conducted in 2017 to evaluate the incidence ratio of MNM using the World Health Organization approach in Iran. Materials and Methods: This study was designed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for systematic reviews, and Web of Science and PubMed databases were searched systematically, which, respectively, yielded 171 and 137 papers published before June 9, 2017. To include papers written in Persian by Iranian scholars, Google Scholar database was searched and 542 papers were retrieved. Finally, 12 papers which had covered the topic more appropriately were included in the study. Random-effects meta-analysis was used to pool the incidence ratio. Heterogeneity was explored using formal tests and subgroup analyses, then the study quality was also explored. Results: The pooling of overall potentially life-threatening conditions ratio was I2 (97.60%, p < 0.001, ratio = 2.50/1000 live births [LBs] [95% CI: 2.00-3.00]), which is divided into two indicators: severe complication ratio (2.40/1000 LBs) and critical intervention ratio (2.54/1000 LBs). The pooling of overall life-threatening conditions ratio was I2 (95.10%, p < 0.001, ratio = 0.86/1000 LBs [95% CI: 0.64-1.07]). Conclusions: The incidence ratio of MNM needs more attention in Iran. Therefore, it is necessary to identify the factors related to MNM and then implement suitable strategies to reduce the risk factors of the maternal morbidity and improve the quality of maternal care in facilities.

Inner voice of pregnant women: A qualitative study Arpi Manookian, Mansooreh Tajvidi, Nahid Dehghan-Nayeri Iranian Journal of Nursing and Midwifery Research 2019 24(3):167-171 Background: Spirituality becomes more significant and evident during crises like pregnancy; therefore, it is crucial for healthcare providers to be supportive during pregnancy through exploring and understanding the meaning of spirituality for pregnant women. This study aimed to discover the experiences of Iranian pregnant women regarding spirituality. Materials and Methods: This qualitative, inductive, content analysis study was performed in 11 pregnant women (28–36 weeks' gestation) who attended the healthcare centers of Karaj, Iran. The subjects were selected by purposive sampling and invited to participate in the study. The data were collected through semi-structured, face-to-face, and in-depth interviews and were analyzed using the inductive content analysis approach. Results: Three major themes emerged during data analysis: “permeable transcendence,” including “spiritual awareness of mother,” “spiritual light of baby,” and “personal transformation and improvement.” “Doubled responsibility” comprised two subthemes of “spiritual nourishment for mother” and “spiritual nourishment for child,” and “spiritual circumstance” consisted of two subthemes of “religious background” and “spirituality of healthcare provider.” Conclusions: Considering the importance of spirituality and religion in gestational health promotion, the results of this study can assist healthcare providers in recognizing the women's spiritual needs and valuing the protective role of religious/spiritual well-being during pregnancy.

The Iranian Psychiatric Nurses' perception of transition in psychiatric wards: A qualitative study Narges Rahmani, Eesa Mohammadi, Masoud Fallahi-Khoshknab Iranian Journal of Nursing and Midwifery Research 2019 24(3):172-178 Background: Transition means moving from one period to another and it is usually associated with significant changes in objectives, roles, and responsibilities. Considering the challenges of the psychiatric ward, psychiatric nurses experience numerous problems, especially at the early stages of their job engagement. This study aimed to examine the perception of the Iranian psychiatric nurses in psychiatric wards and their transition period. Materials and Methods: The study was designed as a qualitative content analysis study in three referral hospitals in Mazandaran and Tehran, Iran 2016. Participants included 18 nurses who had experienced transition at the psychiatric ward and had at least 3 months job experience in three referral hospitals of Iran and were selected purposefully. Data were collected using unstructured interviews and analyzed using the inductive approach and conventional content analysis. To ensure the trustworthiness of the data, Guba and Lincoln's criteria were used. Results: The major themes of transition among the nurses of psychiatric wards included “inadequate preparation,” “mental stress,” “self-awareness and capabilities,” and “the effective role of nurses' full support in adjustment.” Conclusions: The findings revealed that nurses did not have a decent transition. In this regard, educational systems must provide training courses to prepare nurses to support them in their arrival stage and to facilitate their transition. The findings of this study can help mentally prepare nurses for their preparation to perform their role and improve the quality of care.

Exploring the barriers to sexual and reproductive health education for men in Iran: A qualitative study Khadigeh MirzaiiNajmabadi, Leila Karimi, Abbas Ebadi Iranian Journal of Nursing and Midwifery Research 2019 24(3):179-186 Background: Considering the obvious reasons for the necessity of men's sexual and reproductive health education, the present qualitative study aims to identify and contextualize the barriers to sexual and reproductive health education to men in Iran. Materials and Methods: This qualitative research was conducted using conventional procedures of content analysis. A total of 34 participants consisting of authorities in health organizations, healthcare providers, clergies, and adult men in a general population were interviewed in two large cities of Iran including Tehran and Mashhad in 2016. Purposive sampling continued until data saturation was ensured. Data were collected through individual in-depth semi-structured interviews. All interviews were tape-recorded and transcribed in verbatim. Finally, the data were analyzed using conventional qualitative content analysis. Results: Participants' experiences were categorized into three main themes including (1) individual barriers, (2) sociocultural barriers, and (3) structural barriers along with seven subthemes including low perceived threat, unwillingness to learn, sociocultural taboos, family's lack of knowledge and malperformance, policy-making barriers, executive barriers, and health system deficiency barriers. Conclusions: Considering the results obtained, many barriers to men's sexual and reproductive health education could be eliminated through overcoming the individual and structural barriers and sociocultural taboos, as major obstacles. The findings suggest overcoming these barriers and promoting men's health require raising awareness overcoming sociocultural taboos. In this regard, policy-makers should provide sexual and reproductive health education programs and create opportunities and facilities along with appropriate learning environments for men.

Comparing the effects of two methods of group education and peer education on sexual dysfunction of menopausal women: A randomized controlled trial Zahra Vakili, Mahnaz Noroozi, Soheila Ehsanpoor Iranian Journal of Nursing and Midwifery Research 2019 24(3):187-192 Background: Sexual problems could cause severe personal discomfort and affect interpersonal relationships. Considering that selection of appropriate methods has an important role in success of the education, this study was conducted to compare the effects of two methods of group education and peer education on sexual dysfunction of menopausal women. Materials and Methods: In this randomized controlled trial, 108 menopausal women were allocated into three groups in the health centers of Isfahan, Iran. After educating four menopausal women, educational sessions were conducted by them for the participants (36 women) in the peer groups. Two educational sessions were conducted by the researcher in the group education. The control group received no intervention. Before and 1 month after the intervention, female sexual function index was completed by the participants. Data were analyzed using descriptive and inferential statistics (one-way analysis of variance, paired t-test, Chi-square, Kruskal–Wallis, and Post hoc LSD test). Results: The total mean score of sexual function and its domains in the peer education and group education groups was significantly higher than the control group after the intervention (F2, 93= 23.52, p < 0.001); but the difference between the peer education group and the group education group was not statistically significant. Conclusions: Both methods of peer education and group education have been effective in improving the sexual function of menopausal women. So, considering the advantages of peer education such as its low cost, affordability, and no need to train specialized individuals, its implication in educational programs for menopausal women is recommended.

Effect of a supportive training program on anxiety in children with chronic kidney problems and their mothers' caregiver Burden Niloofar Bahrami, Saeid Pahlavanzadeh, Maryam Marofi Iranian Journal of Nursing and Midwifery Research 2019 24(3):193-199 Background: Chronic problems have a long course of treatment and are one of the important causes of the childhood hospitalization. The aim of this study was to determine the effect of a supportive training program on the children's anxiety and their mothers' caregiver burden. Materials and Methods: This study was a randomized controlled clinical trial, performed on two groups in three stages in the autumn of 2017 on 112 individuals. The study population consisted of all children with chronic kidney problems who hospitalized in Emam Hossein Hospital (Isfahan, Iran) and their mothers. Sampling selection method was convenient. Participants were randomly assigned to experimental (n = 56) and control (n = 56) groups and the supportive training program, that was a self-regulating program, was done for the experimental group. The Face Anxiety Scale and the Zarit Caregiver Burden Scale were completed by both groups before, after and 1 month after the intervention. Statistical significance was set at 5%. Results: There was a significant difference in the mean scores of anxiety and caregiver burden in the experimental group preintervention [anxiety: (t54= 0.31, p = 0.75); caregiver burden: (t54= 1.34, p = 0.18)], postintervention [anxiety: (t54= 5.30, p < 0.001); caregiver burden: (t54= 2.72, p = 0.009)], and follow-up [anxiety: (t54= 2.39, p = 0.01); caregiver burden: (t54= 3.06, p = 0.003)], whereas there was no significant difference in the mean scores of anxiety and caregiver burden in the control group. In order to controlling for pretest scores, the repeated measure analysis of covariance was adopted. Conclusions: The results showed that the supportive training program can reduce children's anxiety and their mothers' caregiver burden and suggesting to nurses, an effective program to reduce the negative effects of hospitalization on children and their mothers.

The Effect of the cool dialysate on the restless leg syndrome in hemodialysis patients: Randomized triple-blind clinical trial Ehsan Kashani, Zahra Mirhosseini, Sedigheh Rastaghi, Mostafa Rad Iranian Journal of Nursing and Midwifery Research 2019 24(3):200-205 Background: Restless leg syndrome (RLS) is a common symptom of some diseases specially observed during hemodialysis. Cooling the dialysate is a safe and nonpharmacological method. The aim of this study was to assess the effect of cool dialysate on RLS in hemodialysis patients. Materials and Methods: A total of 79 patients were selected for screening based on the four main criteria set by the RLS International Association. Finally, in line with the inclusion and exclusion criteria, 63 hemodialysis patients were recruited and participated in this clinical trial. The patients were randomly assigned to the intervention group (n = 32) and the control group (n = 31). The intervention group received 35.5°C dialysate and the control group received 37°C dialysate three times a week for a period of 1 month. The severity of RLS was measured in both groups using a standardized RLS questionnaire. Using R software version 3.3.1, the data were analyzed using the Student's t-test, and Wilcoxon test, at 95% confidence interval. Results: In terms of RLS severity, there was no significant difference between intervention and control groups before the intervention (t = -2.11, p > 0.05). After the intervention, the mean (SD) of RLS severity in the control group was 28.77 (5.45) and in the intervention group was 11.66 (4.69), in which t test showed a significant difference between two groups (t = 14.03, p= 0.001). Conclusions: Using cool dialysate as a nonpharmacological treatment may reduce the severity of RLS in patients on hemodialysis. Therefore, using this method to improve RLS in hemodialysis patients is recommended.

Self-Actualization: Self-Care outcomes among elderly patients with hypertension Hanieh Gholamnejad, Ali Darvishpoor-Kakhki, Fazlollah Ahmadi, Camelia Rohani Iranian Journal of Nursing and Midwifery Research 2019 24(3):206-212 Background: This study aims to analyze the experiences of older patients with hypertension to realize the outcomes of their self-care behaviors for controlling hypertension. Materials and Methods: This is a qualitative research with a conventional content analysis approach. The participants consisting of 23 people were selected through purposive sampling. Data were collected through semi-structured interviews until data were saturated. Granheim and Lundman's conventional content analysis was applied to analyze the data. Results: After data analysis, four main categories including self-efficacy, active lifestyle, spirituality, and stress management were obtained. These categories show the experience and outcomes of self-care behaviors among elderly patients with hypertension. Conclusions: Awareness of the elderly of their potentials and role in disease control in addition to relying on the power of spirituality provides positive results in hypertension management. Self-actualization of the elderly resulted in resisting against the destructive effects of internal and external stress and moving in the direction of growth. Health professionals should be vigilant to encourage and promote education about the importance and advantages of self-care for elderlies.

Compassionate care challenges and barriers in clinical nurses: A qualitative study Sima Babaei, Fariba Taleghani Iranian Journal of Nursing and Midwifery Research 2019 24(3):213-219 Background: Compassion is the heart of nursing care. Barriers to compassion in nursing may be influenced by the prevailing culture and religion of a society. Determining the barriers to providing compassion-based care would help nurses to plan better and more appropriate interventions. This study aimed to explore the challenges and barriers to compassionate care in nurses. Materials and Methods: This ethnographic study was performed in 2014–2016. The study participants consisted of 40 nurses, 16 patients, and 8 family members in medical and surgical wards. Data collection was performed through observations and interviews. Data analysis was performed based on Strauss and Corbin's constant comparative method. Results: Data analysis defined three themes as the challenges and barriers to compassionate care; challenges and barriers related to the contextual environment of hospitals, sociocultural challenges and barriers, and challenges; and barriers related to staff. Conclusions: This study described the challenges and barriers to compassionate care. Therefore, to eliminate these barriers and challenges, corrective action should be taken by managers. Attention to teaching the concept of compassion and patient-centered care and increasing the number of nurses and positive attitude toward the nursing profession in clinical environment can be effective in providing compassionate care.

Effect of nursing intervention integrating an Islamic praying program on labor pain and pain behaviors in primiparous Muslim women Desmawati , Waraporn Kongsuwan, Warangkana Chatchawet Iranian Journal of Nursing and Midwifery Research 2019 24(3):220-226 Background: Labor pain has always been a priority issue for primiparous women. Pain behaviors appear as a response to labor pain. This study aimed at examining the effect of nursing interventions integrating an Islamic praying (NIIIP) program on labor pain and pain behavior. Materials and Methods: In this experimental design, 42 women in the control group received the usual care; 41 in the experimental group received the usual care and an NIIIP program from the 32nd week of pregnancy. This was done by providing childbirth education which they then practiced at home every day until they entered the labor room in the Bhinneka Bhakti Husada Hospital and Community Health Center Pamulang, Indonesia. They conducted 30 min of reciting from the Quran, stroking, positioning during their inter contractions, just breathing during contractions at the 1st, 2nd, 3rd h after cervical dilation of 3–4 cm. The visual analogue scale (VAS) and pain behaviors observation scale (PBOS) were used to measure pain and pain behaviors. Repeated measures of the ANOVA and t test were used to analyze the data. Results: There were significant differences in experience of labor pain ([F = 113.07, df (1, 81), p < 0.001] and pain behavior ([F = 147,49 df (1, 81), p < 0.001] between the control and experimental groups. There were significant statistical differences of over four times at the points of pain [F = 82.84, df (2, 182), p < 0.001] and pain behaviors [F = 165.55, df = (2, 189), p < 0.001]. Conclusions: The program effectively resulted in lower pain and increased pain behaviors.