Dental appearance is considered as the main feature to determine the attractiveness of face thus it influences the human social interactions .A patient’s smile expresses a feeling of success, affection, sensuality and courtesy that reveals self-confidence. The smile is considered as a sign of communicating that relates to the socialization and attraction. Different factors that affects the smile which includes tooth shape, position, and quality of restoration, color and general arrangement of dentition, Smile has been classified as high, average and low. High smile shows complete display of cervico-incisal length of maxillary incisors along with contiguous band of gingiva whereas low smile has less than 75% of display. In an average smile there is 75 to 100% display of maxillary incisors with the incise curvature of the maxillary anterior teeth paralleling the inner curvature of lower lip.

Certain attractive smile is the most significant social holding motion and key to your expert improvement. With the coming of new materials and procedures in the field of esthetic dentistry, individuals have changed their concept of smile and how it's structured. In the present time we have computerized smile structure as a multipurpose advanced instrument with certain clinically important favorable circumstances.

Nowadays people are concerned more about smile, it is not just a facial expression, but has a lot of benefits. Smile makes people more attractive, an attractive smile plays a major role in voting and judge decisions, job recruitment and other social interactions. Attractive people are considered to be at high social standing, more interesting and more intelligent. Studies show that we are more trustful of others when they smile. In one study done by Schliemann JPW, et al. participants were more trusted by others if they were smiling. This study found that a smile increases the people’s willingness to trust. Attractive smiles not only influence other people’s perceptions but also affect the psychosocial well-being of individual as well as their behavior.

Esthetics are characterized by the smile, however, the smile comprises of dental arch. Dental smile design likings differ from one person to other based on different factors such as: social level, economic level, education level and ethnic origin. There is a lack of similar studies in the UAE.

The purpose of this study is to determine which features of smile are attractive that are rated by the people of dental professionals of UAE. The participants were not randomly selected and were not a representative sample of the UAE population but a convenience sample. The participants were all adults above the age of 17 years. The questionnaire had 7 separate aesthetic features with between 3 to 6 different standardized computer generated images for each feature. The different features include the how much amount of tooth is exposed? lip line height, buckle corridor and midline position.

Results: There were total 380 participants between age of 28.6 years (SD 7.9) of which 228 (60%) were female. Significantly more females compared to males preferred a convex smile irrespective of whether the upper teeth contacted the lower lip. Females tends to prefer low lip line compared to males but this was at the borderline of significance (p=0.067).

Interestingly, more married respondents preferred the low lip line, whereas unmarried respondents were evenly distributed among an average and low lip line (p<0.05). The coincidence of dental and facial midlines would be expected as the preferred choice for both dental professionals and as well as for lay people but significantly more lay people preferred the smile that deviated towards the right. Whereas, dentists preferred midlines to be coincident (p<0.001). Furthermore, residents of Abu Dhabi, Dubai and Sharjah preferred the coincidence of midlines. Whereas, the lay people from Fujairah preferred the right deviation of the dental midline. Over all half of the unmarried respondents had a significantly greater preference for midline coincidence but married respondents were more evenly split regarding this aspect of smile design (p<0.05). There were no preference differences for the smile design features as it is judged by dentists and lay people.

Conclusion and Recommendations

Beauty must be considered and assessed to improve the quality of treatment provided to dental patients. The opinions and perceptions on lay people and dental professionals regarding beauty and attractiveness of smile were similar, except two variables known as smile line and the relation were of inter incise line to the facial mid line.

The majority of lay people and dental professionals preferred that more than half tooth is shown at rest. An Incise curve which is convex to the lower lip, smile width with ten visible teeth, a wide labial corridor and a Colusa plane that is parallel to the commissural line. This can be considered as the preferred esthetic smile among the UAE community.The significant differences between lay people and dental professionals in this study is line height, where the lay people preferred a low smile line and dental professionals preferred an average smile line.Other significant differences between lay people and dental professionals in this study was regarding the inter incise slime related to the facial midline, which shows that dental professionals prefers the  inter incise line to coincide with the midline while lay people prefers the inter incise line that deviated to the right of the facial midline.

Melasma may be a common hyperpigmentation disorder which mainly affects women with a high prototype and sometimes remains active for several years, being related to a substantial psychological impact. The management of melasma is often challenging, because it is very resistant to treatments and requires long-term therapeutic protocols. Conventional treatment includes de-pigmenting products, like hydroquinone (HQ), retinoid, equinox, atelic acid, arbutin, kojic acid, etc., which exert their action at different stages of melanogenesis. In addition, avoidance of aggravating factors is strongly indicated. Combination therapy is typically prescribed, with a typical association of HQ and retinoic acid. However, HQ?s safety has been questioned in certain cases, and prolonged use may lead to adverse effects such as depigmentation and ochronosis, so it cannot be considered as a golden standard. In the look for safer alternatives, a replacement product supported RetinSphere technology has been designed. It incorporates two topical retinoids: Retinol glycospheres and hydroxypinacoloneretinoate, which directly interacts with the retinoic acid receptor but doesn't induce irritation. Additionally, the product includes other DE pigmenting active ingredients. The objective has been creating a product which may reduce or even substitute the use of HQ in the management of melasma patients. We will show the results of clinical assays on several skin types and thus the efficacy and safety of the new combination of retinoids within the improvement of melasma will be discussed.

Patients/Methods

Prospective, double-blind, vehicle-controlled, and randomized study in 30 patients with melasma. The product was applied on one side of the face and the vehicle on the other, twice daily during 3 months. Standardized photographs were taken using RBX technology on the three visits (basal, at one and a half months and at 3 months). The main variable to work out the efficacy was the development of the hemi facial Melasma Area Severity Index (MASI). Other variables were determined like improvement perceived by the investigator, improvement perceived by the patient, impact on quality of life or side effects. Results The MASI improvement at 3 months of treatment was significant on the treated side vs. the vehicle side, reaching an improvement of 70%, which is like the share of improvement described with hydroquinone. No notable side effects were detected, in spite of an enormous percentage of patients included within the study citing a history that might be compatible with sensitive skin.

Conclusions:

This new combination of retinoids and DE pigmenting agents proved to be effective and safe within the treatment of melasma.

Introduction

Melasma could also be a hyperpigmentation condition distributed generally symmetrically within the facial area, which can have a very negative impact on patients’ quality of life. It mainly affects women with a high prototype. It often persists indefinitely, remaining active for several years. The exact ethology is unknown, but certain trigger factors are suggested like genetics, ultraviolet, light, hormone alterations (pregnancy, oral contraceptives), and increase of the melanocyte-stimulating hormone (MSH).2 Melasma is usually immune to treatments, and therefore, it's a frustrating dermatosis for both patients and dermatologists. The results are variable, often imperceptible. Conventional treatment includes avoiding possible trigger factors, daily application of suitable photo protection also as DE pigmenting products. The efficacy of sun protection is backed by the study of Ennes et al. 7 where 8.3% of the patients showed total disappearance of the melasma and 58% partial improvement when treated exclusively with photo protection cream.

Lakhdar observed an incidence of melasma of two .7% in pregnant women who used photo protection 8 compared to 53% in pregnant women of that exact same population who didn't use it as demonstrated by Khadir.9 DE pigmenting agents exert their action through different mechanisms: elimination of excess melanin, regulation of the activity of melanocytes, control of the dispersion of melanin granules, or inhibition of the transfer of melanin to keratinocytes. Most commonly used DE pigmenting agents include hydroquinone, retinoids, mequinol, azelaic acid, arbutin, kojic acid, oleosin, liquorice extract, ascorbic acid, n-acetyl-glucosamine, niacin amide, etc.10–16 A new product has been designed recently, supported RetinSphere Technology, which encompasses the association of two topical retinoids: retinol glycospheres and hydroxypinacolone retinoate. Retinol encapsulated in glycospheres has been used previously in patients with acne. The retinoic acid ester, hydroxypinacolone retinoate, has similar action to tretinoin, but doesn't cause the irritation observed with this retinoid. Recently, Veraldi demonstrated that use at 0.1% during 2 weeks in patients with acne can improve skin roughness by 50% and scaling by 40%. 14 Unlike retinol and other derivatives that has got to be converted into the biologically active sort of retinoic acid, hydroxypinacolone retinoate binds on to retinoic acid receptors (RAR).17 RetinSphere technology has combined with other DE pigmenting active ingredients like N-acetyl glucosamine (inhibits glycosylation of tyrosinase), kojic acid, Cromabright and Antiques (they uptake the copper and iron ions needed by tyrosinase for its activation), albatin & alistin (they act synergistically inhibiting melanin synthesis), and niacin amide (vitamin B3 that forestalls the transfer of melanosomes to keratinocytes). Furthermore, the formulation contains 10% of hydrating active ingredients and 3% anti-irritant, anti-inflammatory active ingredients. This study aimed to determine the efficacy of the protocol with the study products vs. a vehicle within the treatment of patients with melasma. A secondary objective was to determine the safety of the product vs. the vehicle.

Materials and methods

A prospective, randomized, double-blind, vehicle-controlled study was carried out. 30 patients were selected. Inclusion criteria were as follows:

● Aged over 18 years.

● Absence of treatment for melasma in the last 3 months.

● No desire to get pregnant in the forthcoming months and use of contraceptives.

● No concomitant diseases.

● No administration of another topical or systemic product that may interfere or affect the process.

● No allergy to the product ingredients

Treatment

The treatment protocol included the application of the active cream with sun protection factor SPF 50 (Neoretin discrom control gelcream—IFC Pharmaceuticals) during the day and active serum (Neoretin discrom control serum booster fluid—IFC Pharmaceuticals) at night on one side of the face vs. vehicle gelcream with SPF 50 during the day and vehicle serum during the night on the opposite side of the face; thus, the patient was also the control group. The vehicle had the same photo protector as the study product.

Clinical assessment

The observation period was 3 months, organized into visits at baseline (T0), at one and a half months (T1) and at 3 months (T2). Classical clinical photography was administered and with polarized light via Reveal System with RBX technology (Red/Brown/X identified). To determine the efficacy, the share of improvement within the Melasma Area Severity Index (MASI) after treatment was deemed as principle variable.

The MASI is calculated supported the share of relative surface of involvement (A), the intensity of darkness (D) of melasma, and therefore the homogeneity (H) of the hyperpigmentation. The area of involvement is given a numerical value of 0–6 (0 indicates no involvement; 1, 0–9%; 2, 10–29%; 3, 30–49%; 4, 50–69%; 5, 70–89%; and 6, 90–100%). The intensity of darkness (D) and therefore the homogeneity of melasma (H) were rated on a scale from 1–4 (0 indicates absent; 1, slight; 2, mild; 3, marked; and 4, maximum).

The global MASI (0–48) and the MASI on each side of the face (0–24) were calculated. A coefficient of correlation was applied consistent with location: Each cheek corresponds to 30% of the entire face, the forehead corresponds to 30%, and therefore the chin corresponds to 10%. On the unilateral MASI, the forehead corresponds to 15% and the chin to 5%, and only one cheek is taken into account (30%).The higher the score, the more intense the melisma.

Over the past half century there have been few therapeutic breakthroughs for the treatment of spinal cord injuries. It has been previously shown that following a Spinal Cord Injury (SCI), scar tissue develops at the site of injury through which axons are unable to penetrate to make appropriate neurological connections into the distal spinal cord. Over the past few years it has been reported that placing the momentum directly on a traumatized spinal cord can result in a favourable clinical result. The momentum has been shown to limit the development of scar tissue following SCI, which strongly suggests that omental transposition to an SCI now appears warranted to justify a carefully controlled evaluation of the benefits of omental application to an SCI. Spinal cord injuries are devastating events. Unfortunately, in spite of improved medical and surgical treatment of the condition, there has not been a significant improvement in the neurological results of these injuries during the past half century. The purpose of this paper is to suggest a surgical technique that might increase functional improvement in the future treatment of spinal cord injuries (SCI). A new approach to the problem seems warranted. Over a hundred years ago, Ramon y Cajal, the famous neuro-histologist, stated that axons are unable to connect to neural structures distal to an SCI based on his observations that axons cannot penetrate through connective tissue which routinely develops at the location of an SCI. A half century later, Dr. L.H. Freeman, confirmed Cajal’s observations by showing that axons had the inherent capacity to grow distally within an injured spinal cord (SC), but their progress routinely encountered a scar barrier in which axons “simply form neuromata at the injury site”. Based on these observations, if neuro-protection within an SCI is to be addressed, laboratory and clinical efforts should be increasingly aimed at preventing the development of scar tissue in an acute SCI and decreasing the scar barrier present during a chronic SCI.

Background:

In the late 1800's, Ramon y Cajal, Father of Neuropathology stated that the rationale patients who suffered a medulla spinalis injury (SCI) don't improve is that a scar develops at the location of the SCI which prevents axons from penetrating through the scar barrier. The aim of the study was to find out if a scar following an SCI might be surgically removed, followed by reconstruction of the medulla spinalis which could lead on to functional improvement following the injury.

Method:

Studies were administered within the laboratory to find out a way to ascertain if a bit of a medulla spinalis might be removed followed by subsequent functional improvement. It was found that when a neighbourhood of the medulla spinalis in animals might be surgically excised with reconstruction of the medulla spinalis being successfully performed followed by functional success.

Results:

It was learned in cats when a bit of medulla spinalis was removed, the medulla spinalis might be reconstructed by filling the medulla spinalis defect with collagen followed by the placement of an intact vascularized omentum directly on the underlying collagen connection. Not only was this possible, but a patient underwent excision of 1.6" of her medulla spinalis with subsequent ability to steer which was confirmed by video.

Conclusion:

It appears that chronic medulla spinalis injured patients may have within the future the power to possess the scar which is present during a chronic injury removed with expectations following a medulla spinalis reconstruction that functional return can occur.

Pathophysiology of an SC Injury it's important to know the pathophysiological events that happen following an SCI during which there's deposition of edema and blood that routinely occurs rapidly after injury within the SC. This is the results of leakage of edema and blood through the porous endothelial lining of damaged capillaries located mainly within the central gray matter of the SC. The edema fluid is rich in protein which features a high pressure that draws an increasing amount of edema fluid. As edema and blood accumulates within the injured area, it causes an in depth physical swelling of the medulla spinalis which is contained within its no yielding Dura covering and the surrounding bony spinal column , a condition that causes an increased interstitial pressure at the location of the SCI. As the edema expansion intensifies, the interstitial pressure within the medulla spinalis continues to extend, causing compression of veins within the area. This action leads to an elevated blood pressure which further enhances the capillary extrusion of edema fluid and blood elements from the porous blood vessels at the injury site. Under normal conditions, extracellular edema fluid within the medulla spinalis drains into perivascular spaces with eventual drainage into spinal fluid. This flow pattern is essential for edema fluid elimination since there are no lymphatic’s in the spinal cord. As the volume of edema accumulates in an injured SC, there is eventual blockage of the central canal, subarachnoid and subdural spaces so that the normal edema drainage system within the spinal cord is compromised. Compensatory hydraulics develops within the medulla spinalis following injury within the plan to decrease expanding edema accumulation by displacing edema fluid up and down the medulla spinals. This longitudinal fluid movement, however, cannot catch up on the increasing edema volume that develops within the injury area. As edema accumulation increases, it causes the interstitial pressure at the SC injury site to become excessive, causing capillary compression which eventually can diminish capillary perfusion to the purpose of total vascular occlusion. When this happens, there's irreversible damage to neural tissue unless circulation are often restored within hours of injury. The blood-spinal cord barrier normally prevents leakage of blood into uninjured medulla spinals. Following a medulla spinals injury, however, the blood-spinal cord barrier is broken and blood enters the medulla spinals. It becomes critical at this point to use a way to eliminate, or a minimum of lessen, the deleterious effect of the free blood within the SC since blood is known to be injurious to neural tissue. Blood which leaks from porous SC blood vessels after injury incorporates fibrinogen which may be a normal component of the blood mixture. Fibrinogen is a soluble plasma protein synthesized in the liver that is converted into fibrin in the presence of blood coagulation. The key to eliminating medulla spinals scarring could rest with the absorption of fibrinogen. The evidence for this is that fibrinogen is deposited in the spinal cord following injury, which in turn inhibits neuritis outgrowth by triggering an inhibitory signal transduction pathway to neurons. This inhibition of neuritis outgrowth by the presence of fibrinogen in the SC occurs as early as one day after injury, peaks at seven days, and decreases in the following weeks. These activities indicate the importance of absorbing fibrinogen as early after injury as possible since the neuritis inhibition by fibrinogen may begin the process of spinal cord scarring. Absorbing fibrinogen within the blood of an SC may eventually convince be crucial to limiting scar formation within the injured SC through which axons cannot penetrate. The question is how blood with its fibrinogen component is often absorbed within the SC following injury.

This presentation will comprehensively review evaluation and management of laryngeal leukoplakia. Though white vocal fold lesions are common, management remains challenging; doing insufficient may allow precancerous lesions to progress, while doing an excessive amount of may create unnecessary dysphonia through scar. I will present a framework for management of leukoplakia which balances oncologic with functional outcomes with the goal of achieving disease control without creating scar. State-of-the-art advances in care of leukoplakia will be emphasized and surgical techniques discussed will include role of infusion, use of the KTP laser and micro flap resection of diseased epithelium. Advanced use of the KTP laser for office treatment of laryngeal dysplasia, a crucial a part of my very own practice and something which is merely available during a limited number of centres worldwide is going to be discussed also, to incorporate appropriate Anesthesia techniques for office based procedures. Epidemiology of leukoplakia, rates of progression to malignancy and role of office-based biopsy will be reviewed. Though focus are going to be on KTP laser strategies as these represent leading edge approached to management of this disease, i will be able to also discuss cold instrument and CO2 laser techniques so that the audience, regardless of the tools available to them in their own practices, will be able to transition techniques learned in this presentation to care of their own patients. Approaches to anterior commissure involvement, bilateral disease and multiply recurrent dysplasia are going to be discussed through case presentations which should increase audience interest.

Tracheo Bronchopathia Osteo Ch"art-12">The overall incidence of this disease varies as reported within the literature—on average 1:125 to 1:6000 cases during bronchoscopy . The presentation is often asymptomatic or may instead include nonspecific respiratory complaints, with cough and dyspnoea the most common. The etiology of TBOC is unclear, but it's considered secondary to chronic airway inflammation. The diagnosis is formed on bronchoscopic findings and sometimes, CT imaging of the chest, with little role in histopathology to verify findings aside from to exclude other pathologies. Treatment is symptomatic, ranging from cough suppression to excision and dilation depending on severity of the airway compromise.

In this report, we present a case of tracheobronchopathia osteochondroplastica found incidentally during a patient being managed for recurrent vocal fold leukoplakia and dysplasia. We review the clinical manifestations, diagnosis, pathophysiology and treatment for our patient with this rare disease.

A 77 year-old male presented with dysphonia and history of prior outside surgery for leukoplakia, with outside pathologic diagnosis of dysplasia. At time of presentation to our clinic, Tran’s oral stroboscope revealed scar of the right vocal fold consistent with his prior surgery and persistent/recurrent leukoplakia. The patient had no complaints of dyspnea, cough or inspiratory stridor. With persistent disease and desire to re-establish pathologic diagnosis, the patient was taken to the OR for suspension micro laryngoscopy and micro flap excision of diseased vocal cord epithelium. During micro laryngoscopy, views of the anterior subglottic demonstrated little nodular sub mucosal lesion along the anterior tracheal wall just beneath the cricoid cartilage. This anterior tracheal lesion was biopsied during the procedure. While the vocal cord leukoplakia was found on histopathology to be dysplasia without evidence of invasion, the ultimate pathology of the proximal tracheal lesion was chronic inflammation.

Serial follow-up for the patient’s vocal cord dysplasia was recommended, and approximately three years after surgery, recurrence of the vocal cord leukoplakia was noted. The patient elected in-office KTP laser treatment of his lesion, and with advantage of laryngeal Anesthesia, tracheobronchoscopy was through with a versatile scope at the time of the procedure; of note, all prior exams in the office had been done with a rigid scope for magnified, brilliantly illuminated visualization of his vocal folds, and this was the first time a flexible scope had been used for this patient during this practice. Findings of tracheobronchoscopy were characteristic for TBOC. The patient never endorsed any airway symptoms, cough, haemoptysis, pneumonia etc., and thus no further treatment was indicated. To this day, the patient continues to be monitored for his vocal fold leukoplakia with no evidence of disease and no evidence of any airway complaints.

The existing knowledge about the rare entity of TBOC is essentially from case reports and case series, with the primary report of TBOC supported autopsy findings. The condition was described by Wilks in 1857 as ossific deposits within the anterior portion of the trachea. In 1896, Von Schroeder became the primary to use a laryngeal mirror to document these lesions on a living patient. Shortly thereafter, Killian described these lesions using bronchoscopy in 1899. In 1910, Ascoff was credited for coining the name tracheobronchopathia osteoch"art-18">the largest case study described is by Leske et al with 41 patients. Most other case series are smaller, between one and three patients, all with variable presentations.

Overall the disease entity is rare, but its relevance is vital within the laryngology field with reference to presentation and evaluation on bronchoscopy.

The best approximation of incidence of TBOC is cited as 11 per 10,000 cases. There is no difference in distribution between males and females, and family history does not appear to play role. The average age of diagnosis is between the fourth and seventh decade. It is a benign disease, with most cases incidentally found on bronchoscopy or autopsy. Patients are normally asymptomatic on diagnosis, and it's thought that those that become symptomatic may have acquired a superimposed infection or progressive airway stenosis secondary to the lesions. In turn, they present with nonspecific complaints, the most common ones cited being cough and dyspnea with exertion.

The etiology of TBOC is unknown. Theories have been formulated regarding the pathophysiology of the disease. These have included chondrosis and exostosis of the tracheal cartilaginous rings or metaplasia of the sub mucosal stroma. Associations with other diseases like atrophic rhinitis and neoplastic processes are reported, but there's no science to consistently demonstrate this relationship.

Introduction: Obesity is one of the most prevalent chronic diseases in childhood, being an important public health issue. Excess weight has been associated with autonomic dysfunction but the evidence in children is scarce. Therefore, this study aimed to assess the effect of overweight and obesity on the autonomic nervous system activity in children. Because dysfunction of the autonomic nervous system (ANS) may lead to development or stabilization of obesity and is related with cardiovascular mortality, the study of ANS function in obesity is of significant clinical interest. Studies of ANS function in obese children have been limited to investigations of cardiac autonomic function through analysis of heart rate variability. These studies have generally revealed a reduced parasympathetic activity. It remains unclear, whether abnormalities of ANS can be found in the sympathetic nervous system, and outside of the cardiac autonomic nerve function in overweight and obese adolescents and children.

Methods to measure autonomic nervous system function outside the cardiac system include sympathetic skin response (SSR) and quantitative pupillography. SSR is a simple, reproducible method to assess the polysynaptic reflex loop which comprises diverse afferents, a common efferent pathway through the spinal cord, pre- and postganglionic sympathetic fibres, and perspiratory glands as effectors. SSR may be affected by pathology of both the central sudomotor and peripheral nervous systems. In obese adults, SSR is not distorted. However, SSR has, to the best of our knowledge, not been assessed previously in overweight or obese children. Autonomic innervation of the pupil is controlled by both the sympathetic and the parasympathetic nervous systems. Pupillary response may be quantified by means of direct pupillography by measuring the pupil diameter in the dark (PDD) and subsequent exposure to a light stimulus. Pupil size and re-dilation velocities (early and late) are thought to reflect sympathetic pupillary modulation while latency light reflex, amplitude and constriction velocity are controlled by parasympathetic activity. PDD and amplitude, velocity of pupillary constriction and latency of pupillary response and of re-dilation following light stimulation are impaired in diabetic patients and may represent the earliest manifestations of peripheral autonomic neuropathy. In diabetic adolescents the PDD and pupillary dilation are significantly decreased compared to healthy peers and the degree of the impairment correlates with the duration of the disease. It has not previously been studied that how pupillary function is influenced by obesity.

Methods: Data were collected from a cross sectional study including 916 children (7 to 12 years), from 20 primary schools in Porto, Portugal. Anthropometric measurements and bioelectrical impedance analysis were performed to assess body mass index (BMI) and characterize body composition - body fat percentage, body fat mass and total body water. BMI was classified according to age- and sex-specific percentiles defined by the World Health Organization, the US Centers for Disease Control and Prevention and the International Obesity Task Force. Pupillometry was performed to evaluate autonomic activity. Mann-Whitney, the chi-square, and Kruskall-Wallis tests were used as appropriate.

1. Clinical and anthropometric data

A thorough medical history was obtained, and a physical assessment was performed in all participants to exclude any concomitant disease. For anthropometric measurements, all children were assessed barefoot and only wearing light underwear. Body height of those children was measured by the digital stadiometer Dr. Keller III. Body weight was determined by a digital scale. Body mass index (BMI) was calculated by the formula: weight in kilograms divided by the square of height in meters. The BMI-SDS provides a normalized measurement for the degree of overweight or obesity. By applying the LMS method, it is assumed that BMI data of each age group are normally distributed. A cut off ≥1.28 SDS (90^th centile) classifies overweight and a cut off ≥1.88 SDS (97^th centile) classifies obesity in children. Pubertal stage was assessed according to Tanner stages 20.

In obese children, fasting plasma glucose, fasting insulin, transaminases (ALAT, ASAT, GGT), uric acid, triglycerides, cholesterol, HDL-cholesterol and LDL-cholesterol levels were measured by a certified laboratory. An oral glucose tolerance test (OGTT) was performed to exclude impaired glucose metabolism. Blood samples for the OGTT were collected at 0, 30, 60, 90 and 120 minutes after a glucose load of 1.75 g/kg body weight (maximum of 75g glucose). Impaired glucose tolerance was defined as a glucose level >7.8 mmol/l 120 minutes after the glucose load 18. Insulin sensitivity was determined by applying insulin resistance (HOMA-IR) for the homeostasis model assessment. HOMA-IR was calculated using the equation HOMA-IR = fasting insulin (µU/mL) x fasting glucose (mmol/l)/22.5. (21). Blood pressure was obtained by the arithmetic mean of three single measurements by a certified device in the supine position after a rest period.

2. Autonomic nervous function

For the classification of autonomic nervous function (sympathetic/parasympathetic activity), 3 different methods were applied. Measurements were performed during afternoon between 1 and 3 pm, following a rest period of 15 minutes.

2.1. Heart rate variability (HRV): To screen for cardiac autonomic function, HRV was measured in the resting position and following deep breathing via the computer-based system ProScicard. Measurements were performed over a five minute period, and the time-domain and frequency-domain indices of HRV were analysed: root mean square of successive differences (RMSSD), power spectral analysis in the low frequency spectrum ln(LF); (0.05–0.15 Hz) and in the high frequency spectrum ln(HF); (0.15–0.5 Hz) and the low frequency/high frequency ratio (ln(LF/HF) ratio) were calculated. Measurements under deep breathing were performed over a period of 110 heart beats and a stable respiratory frequency of 6 cycles per minute. The ratio of the longest RR interval during expiration to the shortest interval during inspiration (E/I ratio) was calculated.

2.2. Sympathetic skin response (SSR): For the evaluation of sympathetic skin reaction, all children were investigated in a dark and silent room, in a supine position, with their eyes closed. A short rectangular electric stimulus (10 mA, 0.1 ms duration) over the glabella, sympathetic skin reaction was recorded with surface electrodes (palmar and plantar) with a dedicated device (Keypoint, Natus Europe GmbH, München, Germany). The mean latency of 2 responses, one from each side of the body, was calculated in order to screen for sympathic ANS dysfunction.

2.3. Quantitative pupillography: Using a pupillograph (AMTech Pupilknowlogy GmbH, Weinheim, Germany), pupil diameter in darkness (PDD) was detemined. Pupillary light reflex was measured over a period of 2 seconds (intensity of light stimulus: 10⁴ cd/m², duration of stimulus 200 ms) and several parameters were obtained: relative light reflex amplitude, latency, constriction velocity, early re-dilation velocity (RDV). The mean value of 2 stable measurements of the left eye were used for further analyses 8.

Results: Final analysis included 858 children, 50.6% boys, with a prevalence of obesity ranging between 7.5% and 16.2% according to the International Obesity Task Force and percentage of body fat criteria, respectively. The average dilation velocity was significantly higher among children with obesity, regardless of BMI criteria.

Conclusions: Our results suggest that obesity in children is associated with a dysautonomia in autonomic nervous system, namely with changes in sympathetic activity. Moreover, this findings provide support for the role of the autonomic nervous system in the interaction between lifestyle, diet and the BMI in children.

Background: Febrile seizures (FS) are the most common type of childhood seizures, affecting 2–5% of children older than 1 month and most commonly from 6 months–5 years old. It is a major cause of paediatric admissions worldwide. In India, AAP 2010 guidelines are followed for performing Lumbar Puncture (LP) in first episode of febrile seizure despite India having wide difference in the epidemiology of meningitis and immunisation coverage as compared to USA. This study has been done to find out whether AAP guidelines are applicable in India also or there is a need for our own guidelines. Although FS induce by age related hyper-excitability of the brain to fever, determining the cause of the fever is critical in the evaluation of these children. The relationship between seizure and bacterial meningitis has been identified well in previous studies. Seizures may be the sole presentation of bacterial meningitis in febrile infants. Seizures are the first manifestation of meningitis in 16.7% of children and in one-third of these patients, whereas meningeal signs and symptoms may not be evident. Therefore, it is mandatory to exclude underlying meningitis in children presenting with fever and seizure prior to making the diagnosis of FS. The initial concern in these children is always to make a proper decision regarding to do an LP to exclude meningitis. Awareness of the prevalence of meningitis and its related factors in children presenting with FS to help physicians to make proper decisions in these situations is necessary. There are several clinical studies worldwide reporting the prevalence of meningitis among children with FS. Some of these studies suggest that in the absence of typical meningeal signs, then an LP should be considered in children with complex seizures, prior antibiotic therapy, age less than 12 months, or incomplete vaccination history.The present study determines the prevalence of meningitis and its associated risk factors in children with FS.

Aims & objectives: Primary Objective-To find out the prevalence of meningitis in first episode of febrile seizure in children aged 6 to 18 months. Secondary Objective-To find out predictors of meningitis in in children with first episode of febrile seizure.

Materials & Methods: A cross-sectional study over a period of 18 months was carried out in paediatric wards of Safdarjung Hospital. LP was performed and results analysed for meningitis as per guidelines. Exclusion criteria included history of previous non-febrile seizures or a previously diagnosed underlying illness associated with seizures, an immune compromised state, or the presence of a ventriculoperitoneal shunt or known trauma. The data collected were age, gender, type of seizure, history of previous FS, signs of meningeal irritation (neck stiffness, Kernig’s or Brudzinski’s Sign(s)), impaired consciousness lasting longer than one hour after seizure, pretreatment with antibiotics (from any rout for days before occurring seizure), and results of LP, cerebrospinal fluid (CSF) culture, and blood culture. CSF pleocytosis was defined as a white blood cell (WBC) count of 6μL or more in the CSF. The WBC count for traumatized LP was determined by using the following corrections: corrected CSF WBC count= (CSF WBC count – [CSF red blood cell count/500]). Bacterial meningitis (BM) was defined as growth of a pathogen from CSF culture or CSF pleocytosis with growth of a pathogen from the blood culture. CSF pleocytosis with mononuclear cell dominancy and no growth of a pathogen from CSF or blood culture was considered as aseptic meningitis if the patient was not pretreated with antibiotics during the previous week. In cases with CSF pleocytosis and history of pretreatment with antibiotics if a diagnosis of BM was given on the side of caution and the patient was treated as having BM, we identified her or him as a case of BM.

Results: 200 cases were analysed. The prevalence of meningitis in children aged 6 to 18 months presenting with first episode of Febrile Seizure was 16%.Bacterial Meningitis was seen in 3%.The independent predictors of meningitis were high TLC(>16500/mm³),positive CRP and prematurity. High grade fever (>102˚F), high seizure duration (>12 minutes), low MCV (<75fl), malnutrition (lesser weight for age) and longer post ictal state duration(>14 minutes) were seen as predictors of meningitis but after logistic regression they were not found to be independent predictors. Streptococcus pneumoniae was the most common organism isolated in the blood (42.8%) as well as the CSF (50%) of the cases taken. Most common type of cell seen was monocytes which were alone seen in 56.2% of the meningitis cases.

Conclusion: India needs its own guidelines for performing LP in cases of first episode of FS. Meningitis can be predicted in those with high TLC (16500/mm³), CRP positive and who are prematurely born.

Study relevance :

The chronic hepatitis, especially with viral etiology are considered to be valuable problem of the public healthcare due to the wide spread, long lasting course and adverse complications. The main aim of this study was determining the multi parameter ultrasound approach at the validation of stage activity of the disease in patients who has a verifies diagnosis of chronic hepatitis.

Materials and methods. There were three groups formed from 172 people for the investigation. The first group consisted of 80 patients with verifies diagnosis of chronic hepatitis, who have no any clinical laboratory data for the signs of liver cirrhosis. The second group consisted of 72 patients with different somatic pathologies without chronic hepatitis. The third group consisted of 20 professional sportsmen. The complex investigation, liver ultrasound and elastography of the patients of all groups was conducted. By the standard methodic the doppler ultrasound conducted to investigate the blood circulation of the portal vein.

Results and discussions.

According to our study, ultrasound signs were present in 35% of patients with chronic hepatitis in a seroscale ultrasound examination. The echo graphical signs, mentioned in the literature as typical for chronic hepatitis, were even observed in young healthy people in 2 cases (11%). In the group of patients without liver disease, the described symptoms occurred in 8 (10.5%) cases. The most common symptom was the liver parenchyma echogenicity. In all patients of the chronic hepatitis group with weak liver fibrosis, the portal vein diameter did not significantly change. The doppler graphical data more clearly showed the difference between the groups.

In all patients with mild hepatic fibrosis, the portal vein diameter increased, but the changes were not significant. As the severity of the liver parenchyma fibrosis increased, a varied change in blood flow velocity in the portal vein was noted. In patients with severe fibrosis, a decrease in the average blood flow velocity in the portal vein was noted. The presence and stage of fibrosis do not significantly affect the frequency of manifestation of each of the studied symptoms, however, the frequency of absence of echographic changes in the liver is significantly lower in healthy people than in hepatitis with severe fibrosis.

Conclusions

The ultrasound liver examination is not considered to be sufficient to diagnose the chronic hepatitis, and assess its stages and activity.

The doppler graphic study is informative for the differential diagnosis of stages of liver fibrosis.

The project was carried out at 500 bedded Hospital on improvement of the biomedical waste compliance for a period of 3 months. Hospital was with G+6 floors with departments like: Emergency, Laboratory, Radiology, Pharmacy, OPD, ICU, HDU, CCU, NICU, PICU, Oat basement. The audit was carried out on the parameters like; Knowledge on segregation, Handling at point of care, Segregation at point of care/ ward, Transportation & handling and Disposal.

The adherence to the protocol was found to be 66% (baseline) and the nonfresher’s and don’t have any previous knowledge or experience on BMW segregation, Training was provided only during induction, No guideline displayed on instant rsufficient PPE’s at the POC. Mixing of waste of red and yellow bins, Bins were overflowing; Ampoules and needles are not discarded in the puncher proof container instead lying onampoules in the designated container and throws from a distance. Wastes are transported in buckets which in smaller capacity and overflows while transporting. The bins are usually draggedbags are transported unsealed. Puncher proof containers are opened and wastes are shifted to bigger buckets before handed over to agency. Reason being supply of puncher proof containers is limited due to unThe waste segregations area found to be smaller as compare to the amount of waste generated. The frequency of the collection by agency is irregular. The puncher proof containers are lying outside the designated area as no speciffor demarcated. The quality management tools like Dash-board, Histogram, Pareto, Fish Bone, CAPA, Gantt Chart was used in the project. The adherence has increased to 75% over 3 monthsintervals and daily briefing, display of guidelines at waste segregation area, regularization of PPE supply with budget allocation, supply of proper sized waste bins and transport buckets; after reviewing the waste quantity. Waist height platforms were created to keep PPC for easy reachimplement the system of “NOT TO OPEN SEALED PPCs” and demarked area for holding it, regularizing the agency visit from every alternate day to daily.

Background: Extensive vascular lesions can endanger the life of a child by their virtue of consumptive coagulopathy or cardiac failure. A conservative surgical approach is difficult and can be life-threatening due to uncontrolled bleeding. We report successful limb salvage in an infant despite an extensive and infected arterio-venous malformation of upper limb, complicated by severe consumptive coagulopathy.

Case Report: A term male, 3.2 kgs, presented with a swelling over left arm detected antenatally. Antenatal scan- soft tissue swelling 10.8x6.8x5.4 cm from left shoulder to elbow with heterogeneous cystic spaces and minimal vascularity; O/E- non compressible, no bruit heard. 

As the swelling was increasing in size, prednisolone was started at 1 mg/kg/day and slowly escalated to 3 mg/kg/day. However, he presented at 2 months of age with severe anemia and consumptive coagulopathy refractory to medical treatment. Investigations revealed features of consumptive coagulopathy (hemoglobin: 7.3 g/dL; total leukocyte count: 2160/mm 3; platelet count: 76,000/mm 3; prothrombin time: 35.2 s; international normalized ratio: 3.2; activated partial thromboplastin time: >120 s control-31 s; fibrin degradation product: >800 ng/mL; D-dimer: 4.2 mg/L; fibrinogen: 0.6 g/L). This was accompanied by a sudden increase in size due to infection within the tumor, which got ulcerated and began to discharge a bloody purulent fluid. He was given red blood cell, cryoprecipitate, and fresh frozen plasma transfusions.

Investigations: Doppler – hypoechoic lesion+ heterogeneous echotexture, numerous cystic spaces, weak color Doppler signal- S/O- Hemangioma.MRI- lobulated soft tissue mass 17x16 x9.5 cm with an intensive enhancement, necrotic and hemorrhagic areas, involving flexor and extensor muscles of the arm.Supplied by branches of axillary and brachial arteries.Diagnosed as- Hemangioma , hence was started on propranolol 0.5 mg/kg/ day. At 4 months of age surgery became an imperative lifesaving mode of treatment.  

As the swelling was increasing in size, prednisolone was started at 1 mg/kg/day and slowly escalated to 3 mg/kg/day. However, he presented at 2 months of age with severe anemia and consumptive coagulopathy refractory to medical treatment. Investigations revealed features of consumptive coagulopathy (hemoglobin: 7.3 g/dL; total leukocyte count: 2160/mm ³; platelet count: 76,000/mm ³; prothrombin time: 35.2 s; international normalized ratio: 3.2; activated partial thromboplastin time: >120 s control-31 s; fibrin degradation product: >800 ng/mL; D-dimer: 4.2 mg/L; fibrinogen: 0.6 g/L). This was accompanied by a sudden increase in size due to infection within the tumor, which got ulcerated and began to discharge a bloody purulent fluid. He was given red blood cell, cryoprecipitate, and fresh frozen plasma transfusions.

At that point, at four months of age, surgery became imperative as a lifesaving mode of treatment. The embolization was not considered as the lesion was infected, ulcerated, and was bleeding. After detailed discussion with parents, consent was obtained for excision with a probability of disarticulation of the limb.

Operative procedure: Planned for amputation/ disarticulation. Axillary vessels identified and controlledTumor excised into Flexor and extensor muscles preserved as much as possible. Radial nerve through the tumor was divided and re-anastomosed. Disarticulation was hence avoided.Arm and hand movements preserved at 10mth follow-up. 

Conclusion: A conservative limb salvage surgery is possible even in case of an extensive vascular anomaly.A good vascular control is a must to prevent life threatening hemorrhage in a conservative surgery. 

Aim: Influence of H. pylori infection on HbA1c levels, how importance to eradicate the Infection and control the glucose levels

Objectives: An early discovery of the changes in blood glucose help to prevent or delay the of development of type 2 diabetes and complications. H. Pylori treatment could have an important role in improving insulin resistance.

Hypothesis

We performed a research literature of the PubMed, Cochrane Library, and Chinese BioMedicine. Web Base and Chinese Science and Technology Journals databases databases for studies of the Influence of H pylori infection on HbA1c levels from the last 10 years. This study focuses on.  

Methodology

The data from this study are taken from PubMed, Cochrane Library, and Chinese BioMedicine databases for studies of the Influence of H pylori infection on HbA1c levels from the last 10 years. We selected 5 studies that included 2456 Patients.

Introduction

Helicobacter pylori is a microaerophilic bacterium that is commonly found in patients with gastrointestinal disorders. It is present in approximately one half of the world's population.   The most of the people who are infected have no symptoms however Helicobacter pylori is capable of causing some digestive problems such as Abdominal Pain (mild to severe), Belching and Gastric reflux, Mild nausea, Irritable Bowel Syndrome, Bloating and distension, Constant bad breath, Hypochlorhydria. Most commonly associated with Peptic Ulcer Disease (PUD) is responsible for the development of 70% of Gastric and 80 to 95% of Duodenal Ulcers, that can may lead to the development of Cancers (Traci L Testerman 2014).  Helicobacter pylori were found high percentage in the polluted well water, contaminated food, faeces, Dental plaque/saliva (Popescu D et al. 2017). Transmission through unclean water person to person, faecal-oral by poor hygiene not properly washing hands after using the toilets, oral-oral by kissing or gastro-oral. This continues to cause inflammation in mononuclear cells that stimulate an initial inflammatory effect, which can lead to duodenal and stomach ulcer. H. Pylori and diabetes mellitus can increase gastrointestinal problems such as dyspepsia, etc. worsening the blood glucose levels and metabolic control by decrease levels of immunity increase risk of H. pylori infections. Diabetes mellitus is a chronic endocrine disorder characterised by high levels of blood glucose (hyperglycaemia) occurring from lacks in insulin secretion, insulin action, or both that globally affected 422million adult people according to World Health Organization (WHO).  Diabetes has a global impact that rises from 4.7% to 8.5% since 1980 in Population.  Past year’s diabetes has increased in low levels and middle-level income countries. 

According to Robert Koch Institute (RKI) in Germany data shows that 6.7 million adults are affected by Diabetes Mellitus in the whole of Germany. The German Federal Ministry of Health (BMG) funds this research to collect data’s to develop of health care policy for the treatment and prevention of diabetes.

Helicobacter pylori and Diabetes :

Diabetes-induced impairment of cellular and humoral immunity may improve a unique sensibility to H. Pylori infection (Borody T et al. 2002). There is no evidence showing that H. Pylori plays a significant role in diabetes, there is more possibility for increased susceptibility to infection in diabetic patients.

diabetes-induced reduction of gastrointestinal motility and acid secretion may promote pathogen colonisation and infection rate in the gut. (Jeon CY et al. 2012).

Changed glucose metabolism may produce chemical changes in the gastric mucosa that promote H. pylori colonisation (de Luis DA et al.1998). All these factors can contribute to H. pylori infection to development of diabetes.

H. Pylori and Insulin secretion :

Decreased insulin secretion is one of the significant causes In Type II Diabetes. Defects in ß cell function characterise progression from normal glucose tolerance to prediabetes and Typ II Diabetes Mellitus (Weyer C et al. 1999). According to the study by Hsieh et al. the Patients with H. pylori infection was more likely to have impaired insulin secretion which may increase the risk for type II Diabetes (Hsieh MC et al. 2013).

Associated factors: H. pylori and Diabetes :

Lifestyle is a significant factor influencing both chronic H. pylori infection and Typ II Diabetes. H. Pylori infection could delay gastric emptying, which can be assumed to cause a mismatch between the onset of insulin action and absorption of carbohydrates in insulin-dependent with diabetes. (Ojetti V et al. 2010)(Burghen GA et al.1992). H. pylori infection has also been associated with platelet activation and aggregation, increases in pro-atherogenic factors such as homocysteine, generation of reactive oxygen species, and increases in lipid peroxides (Stergios A et al. 2012)

Obesity :

Obesity is the primary etiological cause of Type II Diabetes Mellitus with controlled clinical trials determining that a weight loss is sufficient to prevent most obese subjects with impaired glucose tolerance from contracting the disease. (Astrup A et al. 2000)

According to some studies High BMI, Obesity may be associated with an increased incidence of H. pylori colonisation from reduced gastric motility. (Perdichizzi G et al. 1996)

Dyslipidaemia :

In type II Diabetes Obesity, Insulin resistant by defects in Insulin action and hyperglycemia leads to changes in lipoproteins plasma levels. Abnormalities in lipoprotein commonly in type II Diabetes. (Gen Yoshino 1996)

Hypertension :

Hypertension usually has no sign or symptoms. Increase levels of blood pressure are high risk to develop other diseases such as Kidney disease, Diabetic Retinopathy in long-term can cause blindness. Chronic cases with ageing can cause Alzheimer's disease or Dementia. There is a High risk of Stroke and Heart attack.

A strong association between obesity was shown in multiple studies. According to the study by D Segula 2014, One of the largest cohorts studied 82473 revealed a positive association between BMI and hypertension at the age of 18 years and midlife. There was also marked an increase in hypertension risk with weight gain. Framingham study showed that the relative risk in overweight men and women were  1.46  and  1.75,  respectively, after adjusting for age. Furthermore, weight reduction of obese females at the age of 18 had led to a reduction in the risk of hypertension. In older populations, hypertension and obesity continue to relate predictably as has been shown in the Honolulu Heart Program and Japanese data survey. (D Segula 2014)

What is Glycated Haemoglobin (Hemoglobin A1C)?

In red blood cells contains a Protein called Haemoglobin (Hb) which carries O2. Glucose in bloodstream connects to the protein Haemoglobin in red blood cells and forms glycated haemoglobin. Haemoglobin in red blood cells bind with the glucose and stays for 3 Months. HbA1c test shows average blood glucose levels in the past 3 Months.

Pathogenetic Mechanisms in H. Pylori and Diabetes

In Cong He, Zhen Yang, and Nong-Hua Lu 2014 studies wrote that  '' there is no concrete evidence demonstrating that H. pylori play a role in diabetes, the possibility for a causal relationship is an intriguing issue deserving discussion. There are several lines of evidence to implicate increased susceptibility to infection in diabetic patients. Firstly, a diabetes-induced impairment of cellular and humoral immunity may enhance an individual’s sensitivity to H. pylori infection. (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited in Borody T, Ren Z, Pang G, Clancy R 2002 p. 3032-7) Secondly, diabetes-induced reduction of gastrointestinal motility and acid secretion may promote pathogen colonisation and infection rate in the gut. (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Christie Y. Jeon et al. 2012 p.520-525) Thirdly, altered glucose metabolism may produce chemical changes in the gastric mucosa that promote H. pylori colonisation (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited de Luis DA et al.1998 p 143-6).

Finally, individuals with diabetes are more frequently exposed to pathogens than their healthy counterparts as they regularly attend hospital settings (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Gentile S et al.1998 41-8). However, there are also indications that H. pylori infection may contribute to the development of diabetes. Whereas insulin insensitivity is an early phenomenon, pancreatic β-cell function declines gradually over time before the onset of clinical hyperglycemia, the result of many factors that can be influenced by infection, such as insulin resistance (IR), glucotoxicity, lipotoxicity, β-cell dysfunction, chronic inflammation, and genetic and epigenetic factors(Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Donath MY et al. 2011 p 98–107 & Stumvoll M et al. 2005 p 1333–1346).

H. PYLORI ERADICATION AND DIABETES

According to Cong He, Zhen Yang & Nong-Hua Lu 2014 studies ''There are limited and conflicting data regarding the effect of H. pylori eradication on glucose metabolism and insulin sensitivity (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Park SH et al. 2005 p 508–513, Wada Y et al. 2013 p 41–43, Gen R et al 2010 p190–196). However, it may be beneficial for patients at risk of diabetes to be checked for the presence of H. pylori infection, as a report by Zojaji et al. (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited  Zojaji H et al. 2013 p36–40) showed that H. pylori treatment could improve the mean HbA1c and the metabolic abnormalities in patients with T2DM. Additionally, Gen et al. (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Gen R et al. 2010 p190–196) demonstrated that successful H. pylori eradication significantly decreased fasting insulin and HOMA-IR levels. Other studies focused on the effects of eradication on H. pylori-stimulated inflammatory cytokines. Some reports indicate that CRP levels are decreased after H. pylori eradication, suggesting a beneficial effect on low-grade inflammation (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Longo-Mbenza B et al. 2007 p229–238 & Gen R et al. 2010 p190–196) However, there are also reports showing no effect of H. pylori eradication on mean HOMA-IR and CRP levels (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Park SH et al. 2005 p 508–513) or HbA1c levels(Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Wada Y et al. 2013 p 41–43). Recently, Vafaeimanesh et al. (Cong He, Zhen Yang & Nong-Hua Lu 2014 cited Vafaeimanesh J et al. 2013 p 55–58) found that in patients with T2DM, the mean decrease in HbA1c and fasting plasma glucose levels in eradicated cases was similar to non-eradicated subjects three and six months after treatment.

Objective To report the results of a systematic review of national eHealth policies of different countries in relation to patient consent in patient data processing in electronic health records Method eHealth policies of 19 (14.07%) countries are reviewed with regard to patient consent, from a total of 135 countries that are indexed in the World Health Organization Directory of eHealth Policies. 68 (50.37%) policies were excluded based on language and 67 policies in English were selected for further consideration. These 67 (49.62%) policies were further evaluated resulting in exclusion of 43 (31.85%) policies due to policies being outdated and 5 (3.70%) due to broken links. Finally, a total of 19 (14.07%) countries were selected for the review. Results 57.89% out of 19 countries require patients’ informed consent to store patient data, 26.32% allow selective storage of patient data as defined by the patient, 89.47% require patients’ informed consent when sharing or transferring or accessing patient data, 68.42% of the countries allow patients access their own EHR, 73.68% facilitate correction/modification in EHR, and 26.32% facilitate deletion of patient records. 89.47% of countries highlight mechanisms to assure privacy and security of EHR. Conclusion Policymakers’ emphasis on various ethical concerns raised by EHRs has been increased highlighting patient rights related to eHealth as well as the requirement for compliance to different standards and regulations. eHealth policies must address requiring patients’ informed consent in processing of patient data whereas patients have the ability to grant or withhold consent to different processing operations related to their EHR. Furthermore, facilitating patients with access to their own records, facilitating patients with modification, correction and deletion of EHR are widely discussed topics.The questions on consent referred to an individual's electronic health record, which was described in the survey as ‘computer records with complete and detailed health information’. Although the removal of name and address might not ensure anonymity, we used these measures here as being most relevant to conceptions of personal identity, to denote the difference between identifiable and de-identified records. By mentioning that these identifiers would be removed, we also refer to situations were these would not be visible by, for example, researchers performing database queries.

Additional questions captured socio-demographic characteristics and other personal information (birth year, sex, ethnicity, highest educational qualification attained, confidence with computers), as well as patterns of personal healthcare use (types of health services accessed in the six months before the survey).

Only respondents who provided complete data across all independent and dependent variables of interest were included in the final sample (N = 3157). We examined the frequencies of the missing values and used Pearson's Chi-squared test to establish whether differences existed between the analysis sample and the missing sample in the socio-demographic factors, and the distribution of responses on the three questions of interest. Using logistic regression we determined whether certain factors were associated with an individual's inclusion in the final analysis sample.

Descriptive statistics were used to summarise the characteristics of respondents included in the survey sample, and to examine the distribution of responses on the three questions of interest. We examined bivariate associations between the three outcome variables, and between each of the outcome questions and the independent variables, using Pearson's Chi-squared test. Using a multivariate regression model, the associations between each of two outcome questions (consent for de-identified EHRs use and awareness of EHRs) and the socio-demographics and healthcare use were analysed, adjusting the regression analysis for potential clustering at each of the recruitment sites. As a theoretically important consideration, prior awareness of EHRs was also included as an independent variable in the multivariate model for consent preferences. Each regression model was assessed using Hosmer-Lemeshow's goodness of fit test, specifying a grouping of 10. We reported all results at the 95% significance level, and performed the analysis using Stata IC version 11. Full details of the study protocol and the original survey questionnaire have been published elsewhere [49].

In relation to public and patient views on consent options for data sharing, this study illustrates that the majority of respondents (91%) would expect to be explicitly asked for consent before their identifiable EHR is accessed, regardless of the reason for access—including for use by healthcare professionals. When sharing de-identified records (name and address removed), fewer participants (51%) said they would expect explicit consent to be sought before data sharing for care, research and healthcare planning. Socio-demographic factors and personal characteristics were further associated with consent preferences. Respondents who identified themselves as belonging to an ethnic group other than ‘White British’, or who were less confident with computers, and those with lower educational qualifications were more likely to expect to be asked for explicit consent before their de-identified records were accessed.

In terms of awareness of EHRs, many participants reported having heard of EHRs before taking part in the survey. However, a sizable minority (41%) reported not being aware of EHRs. Older respondents were more likely to have heard of integrated records. Individuals who identified themselves as belonging to non-White British ethnic groups were less likely to report being aware of EHRs. Those with lower educational qualifications and those reporting less confidence in using computers were also less likely to report having heard of EHRs. Participants who had interacted more with health services seemed to be more exposed to information about EHRs, and the NHS was the second most frequent source of information. Awareness of EHRs was associated with a greater likelihood of reporting acceptance of implicit consent as a model to govern de-identified health information sharing.

As participants reported not being aware of EHRs before the survey, some could have been formulating their views at the time of completing the questionnaire. Responses might have also depended.

Vinegar has been adopted as favoring dating from around 3000 BC in Asian, European and other traditional cuisines of the world .As evidences accumulated, vinegar was proved to exhibit therapeutic properties, including blood pressure reduction , antioxidant activity , antibacterial activity , reduction in the effects of diabetes and prevention of cardiovascular disease . It is also used as a kind of accessory documented in Lei’s treatise on processing of drugs (LeigongpaozhiLun) (618–907 AD). Numerous Chinese medicines such as Frankincense, Rhizoma Corydalis were believed to enhance the promoting blood circulation therapeutic efficiency after preparation by vinegar . Fruitful researches have been carried on the herbal enhancement of therapeutic efficiency after processing ,but there are few relative reports concerning the blood circulation bioactivity of vinegar Vinegar accumulate an overwhelming variety of metabolites that play nondeductible roles in health benefit. During recent years, many studies employed GC–MS technique for quality control and determination of vinegar. Alcohols, organic acids, amino acids, carbohydrates, esters and various micro-constituents were proved to present in vinegar [8]. The previous results showed that the contents of most conventional ingredients (organic acids, free amino acids, carbohydrates) were increased during aging process. Tetramethylpyrazine (TMPZ), a kind of alkaloid metabolites yielding during aging process of vinegar, was used in clinical trials since the 1970s [9]. Reports indicate that TMPZ reduces arterial resistance  and increases coronary and cerebral blood flow . A number of alkaloid metabolites are developed as clinical drugs found to have significant biological activities (e.g  berberine and paclitaxel) . Hence variation of alkaloid metabolites should not be overlooked for their exhibit notable function properties.

Rice vinegar (RV) and white vinegar (WV) as daily favoring, have also used as accessory in traditional Chinese medicine processing. As we know, the promoting blood circulation efficiency could be enhanced when herbs processed by vinegar. Number of reports focused on health benefits derived by consumption of vinegar. However, few concerned the blood circulation bioactivity.

 In this paper, a metabolomics guided strategy was proposed to elaborate on the chemical constituents’ variation of two kinds of vinegar. GC–MS coupled with multivariate statistical analysis were conducted to analyze the chemical components in RV and WV and discriminate these two kinds of vinegar. The anti-platelet activities in vitro were investigated by whole blood aggregometry platelet test. And the anticoagulant activities were monitored by the whole blood viscosity, plasma viscosity, packed cell volume, prothrombin time, and four coagulation tests (PT, TT, APTT, FIB) in vivo .Results were found by keen observation of GC–MS conditions Chromatographic parameters such as column type, carrier gas flow, temperature rate, and ion source temperature were adjusted to be able to obtain the best separation for the compounds. The Rxi-50 capillary column obtained the best separation. The carrier gas at flow rate of 1.0 mL/min and the 250 °C ion source temperature were proved to be the most suitable. Established chromatographic conditions and mass spectra conditions are listed in “Gas chromatography–mass spectrometry analysis’’. Metabolic profiles of RV and WV Five batches of WV and RV with aging time of 1, 4, 5, 7, 14, 20, 30  months were analyzed. Representative GC– MS fingerprints are presented in Fig.  1. A total of 53 compounds were detected, including different kinds of alcohol, organic acids, amino acids, aldehydes, phenols, ketones, heterocyclic, which were same as those reported in literatures [1, 20]. PCA and OPLS-DA were utilized to classify the metabolic phenotypes and identify the differentiating metabolites. A PCA score plot for first and second principal components was utilized to depict the general variation among the samples of two dosage forms (R2 X  =  0.78, Q2 =  0.987).

Gynecomastia Treatment by Lyposuction with gland excision and H.H Method

Dr. Haider Ali Muslim AL Rahmahi