Development of Persian version of the Spinal Cord Independence Measure III assessed by interview: a psychometric study.

STUDY DESIGN: Cross-sectional psychometric study. OBJECTIVES: To translate the Spinal Cord Independence Measure III (SCIM-III) into Persian, to evaluate it culturally and to analyze the validity and reliability of the Persian version of the SCIM-III (P-SCIM). SETTING: Brain and Spinal Injury Research Center (BASIR), Tehran, Iran. METHODS: The P-SCIM was developed by forward translation, back-translation, and cultural equivalence assessment procedure. The authors studied: (a) correlation of P-SCIM with the Functional Independence Measure (FIM™) for determining convergence validity, (b) P-SCIM scores in neurological categories for comparison and evaluating discriminative validity, (c) Inter-rater reliability of P-SCIM, (d) Cronbach's alpha for measuring internal consistency of P-SCIM-III. RESULTS: The validity of the scale was supported by a Pearson correlation coefficient of > 0.9 (p < 0.001) between FIM™ and P-SCIM. The Persian SCIM was found to be valid in discriminating different neurological categories. The Inter-rater reliability was concluded by Intraclass correlations of a coefficient > 0.9. Bland-Altman analysis demonstrated good agreement between our raters (mean difference: 0.7, limit of agreement: - 8.09-9.58). Also internal consistency of the scale was shown by Cronbach's alpha to be > 0.7 (0.86). CONCLUSION: P-SCIM-III is a valid and consistent tool for determining functionality in Persian speaking people with spinal cord injury.

Upper lip bite test for prediction of difficult airway: A systematic review.

BACKGROUND AND OBJECTIVE: Upper lip bite test (ULBT) is one of the various bedside tests used for prediction of difficult laryngoscopic intubation. However, its usefulness is not still very clear, and there is controversy regarding its accuracy. The aim of this systematic review was to determine the accuracy of the ULBT for predicting difficult airway including difficult laryngoscopy or difficult tracheal intubation. METHOD: We searched the databases of PubMed, Scopus, and Google scholar for prospective studies published up until October 2016 assessing the accuracy of ULBT in comparison to Cormack-Lehane grading. The selected keywords were "upper lip bite test", "upper lip catch test", "prediction", "difficult airway", "difficult laryngoscopy", "difficult intubation". Inclusion criteria were studies assessing ULBT for prediction of difficult intubation, considering Cormack-Lehane grade III and IV as difficult airway, written in English, and reporting sensitivity, specificity, NPV, PPV, and accuracy. Exclusion criteria were studies not reporting accuracy or not having enough data for its calculation. Based on the mentioned criteria, 27 studies enrolling 18141 patients were included. This systematic review was performed based on the guidelines on conducting systematic reviews of diagnostic studies. RESULTS: Prevalence of airway difficulties according to the direct laryngoscopic view varied from 2.8% to 27% and according to the ULBT was from 2% to 21%. In 11 of the 27 studies, sensitivity of ULBT in prediction of difficult airway was more than 70%. All of the studies except one showed a high specificity for ULBT (>85%). Moreover, these studies indicated a high NPV. Accuracy of ULBT was >85% in 24 out of 27 studies. CONCLUSION: It appears that ULBT is a useful bedside test for evaluation of patient airway before the general anesthesia.

A comparison of the Mallampati test in supine and upright positions with and without phonation in predicting difficult laryngoscopy and intubation: A prospective study.

BACKGROUND AND AIMS: Difficult ventilation and intubation have been recognized as the forerunners of hypoxic brain damage during anesthesia. To overcome catastrophic events during anesthesia, an assessment of the airway before induction is of paramount importance. We designed this study to compare the effect of phonation on the Mallampati test in supine and upright positions as against the traditionally employed test without phonation in serving to predict difficult laryngoscopy and intubation. MATERIAL AND METHODS: In this cross-sectional study, 661 patients aged 16-60 years were recruited during the years 2011 to 2012. The Mallampati test was conducted on patients with and without phonation in both the sitting and supine positions. A blinded observer then performed laryngoscopy and intubation. Difficult intubation was assessed according to the Cormack-Lehane Grading scale. STATISTICAL ANALYSIS USED: Diagnostic statistical measures for each of the four situations - sensitivity, specificity, positive and negative predictive values and accuracy - were calculated. RESULTS: In this study, 28 patients (4.2%) had difficult laryngoscopy and nine patients (1.4%) had difficult intubation. There was no difference in the sensitivity of the Mallampati test as regards prediction of laryngoscopy and intubation in the four different positions, but the upright position along with phonation had the highest specificity. The negative predictive value was above 95% in all the positions; however, the positive predictive value was the highest in the supine position along with phonation. CONCLUSION: Based on our results, the supine position along with phonation had the best correlation in the prediction of difficult laryngoscopy and intubation. We further conclude that phonation significantly improved the Mallampati class in the supine position compared with the upright position.

Surgical management of idiopathic acute cervical kyphosis; A case-based review of an extremely rare entity.

INTRODUCTION AND IMPORTANCE: Acute idiopathic cervical kyphosis (AICK) represents a rare entity, and its management remains controversial. Preoperative surgical planning and individual decision-making seem necessary. To date, there is a lack of sufficient evidence and clear guidelines. CASE PRESENTATION: A 21-year-old male was referred with a progressive cervical deformity detected 3 months earlier. The patient suffered from severe progressive myelopathy and represented neither neck trauma nor a familial history of similar expected conditions. His cervical imaging revealed 95 degrees of cervical kyphosis. After 3 separate surgical sessions for 360-degree fixation, the cervical kyphosis was reduced by 90 degrees. No facet dislocation was observed, and laminectomy was unnecessary. Post-operative neurological examination detected significant improvement. Six months and 2-year follow-ups were favorable. To the authors' knowledge, the current case had the most extensive degree of cervical kyphosis reported in the literature. CLINICAL DISCUSSION: Multistage correction of AICK would result in a favorable outcome and reduce the risk of complications. Particular attention should be paid to the wide inter-spinous spaces in high grades of kyphosis during sub-periosteal dissection to prevent iatrogenic spinal cord injuries. CONCLUSION: The present work may provide the first report on the role of cervical postural habits in patients with opiate substance abuse disorder, which could have triggered cervical kyphosis in this particular patient. Multistage correction of AICK would result in a favorable outcome and reduce the risk of complications.

Contributions of Medieval Islamic physicians to the history of tracheostomy.

Tracheostomy was first described by Greco-Roman physicians, including Paulus of Aegina. Medieval Islamic clinicians extended the Greco-Roman ideas with substantial contributions to the field of surgery, including tracheostomy. Although Al-Zahrawi (936-1013 CE) stated that he had not heard or read of any Islamic physicians having performed tracheostomy, there is evidence that many prominent Islamic surgeons did practice this lifesaving procedure during medieval times. Throughout the Islamic Golden Age, Muslim physicians advanced the practice of tracheostomy with many modifications of the procedure, instrumentation, and adjuvant medicinal prescriptions.

Upper lip bite test compared to modified Mallampati test in predicting difficult airway in obstetrics: A prospective observational study.

Difficult airway and intubation can have dangerous sequela for patients if not managed promptly. This issue is even more challenging among obstetric patients. Several studies have aimed to determine whether the test to predict a difficult airway or difficult intubation, is higher in accuracy. This study aims to compare the upper lip bite test with the modified Mallampati test in predicting difficult airway among obstetric patients. During this prospective observational study, 184 adult pregnant women, with ASA physical status of II, were enrolled. Difficult intubations of Cormack-Lehane grade III and IV were defined as difficult airways and difficult intubation in this study. Upper lip bite test, modified Mallampati test, thyromental distance and sternomental distance were noted for all patients. Modified Mallampati test, upper lip bite test and sternomental distance had highest specificity. Based on regression analysis, body mass index and Cormack-Lehane grade have a significant association. Modified Mallampati test was the most accurate test for predicting difficult airway. The best cut-off points of thyromental distance and sternomental distance in our study were 5cm and 15cm, respectively, by receiver operating characteristic curve analysis. Based on the results of the present study, it can be concluded that in the obstetric population, modified Mallampati test is practically the best test for predicting difficult airway. However, combining this test with upper lip bite test, thyromental distance and sternomental distance might result in better diagnostic accuracy.

Preserving Resilience for Prevention of Burnout in Anesthesiology Residents as Frontline Healthcare Workers During the COVID-19 Outbreak: A Report of Real-Life Experiences of Professionalism and Mentoring in Medical Education.

Objective: During the COVID-19 pandemic, burnout of healthcare workers, including anesthetists, has become a critical issue. This study aimed to provide a practical framework for decreasing and preventing burnout among anesthesiology residents through preserving their good mental health. Materials and methods: Since the onset of the COVID-19 outbreak, anesthesiology residents have been members of medical teams with the attending staff, senior residents, and partner residents. Besides, the following measures were taken to reduce burnout: providing financial support for the attending staff to procure personal protective equipment (PPE), rearrangement of work schedules to reduce the workload, holding training sessions in virtual meetings, and improving the social network system for reducing burnout. Results: The interventional program could help anesthesiology residents to adapt to or cope with the healthcare system status and also prevent burnout. Moreover, development of empathy, integrity, and cohesion in the healthcare system motivated the staff to comply with the principles of medical professionalism. Conclusion: During the current health crisis due to COVID-19, it is essential to implement specific interventional and training programs for decreasing or preventing burnout among healthcare workers.

Teamwork in Cranial Base Surgery: A Feasible Task or a Utopian Dream.

In the past decade or perhaps a little earlier than that the concept of teamwork evolved among the circles of surgeons especially among those involved in complicated and time consuming surgeries. Skull base surgeries were one of those surgeries where the role of teamwork was acutely felt owing to innumerable specialties involved in the consummation of such surgeries. Although teamwork in this specialty is the need of the hour but, achieving the spirit of teamwork is not that easy and perhaps a challenging task. This manuscript tackles the much needed demand of teamwork in this arena of surgery and unveils whether such a teamwork is achievable or is just an utopian dream.

Activation of the Renin-angiotensin System could Cause Hypertension During Fasting in Muslims in the Month of Ramadhan.

We are of the opinion that fasting in Muslims during the month of Ramadhan could cause hypertension secondary to dehydration that inevitably follows. Dehydration initiates a cascade of hormonal events that finally culminate in hypertension. This hypothesis however needs to be tested in a randomized trial to be confirmed.

Tests with proven value in diagnosis of COVID-19.

COVID-19 has literally ravaged the entire world. People from all walks of life are badly affected because of compulsory lockdown around the world. Timely diagnosis is a problem as there is no single test that can achieve the highest acceptable sensitivity. Some of the tests are indeed costly and footing the bill by the governments can cause a tremendous load on the Treasury. As it stands, the current tests are beyond patient means and, thus, the patient would never have it performed. Lastly, there is no consensus as to whether everyone should be tested for COVID-19 and not based on presence of clinical features. Unfortunately, since the disease has been declared a pandemic, all should be considered to be infected unless provenother-wise by the tests that are performed.

A Note About the Ancestral Origin of Abu Al Husain Ibn Abdullah Ibn Sina, Avicenna (980-1037 CE).

Avicenna, a great physician and polymath, made a tremendous contribution to our present-day medicine. His ancestral origin has been the subject of debate. In this short and concise article, we have endeavored to trace his ancestral roots and bring to light his exact origin and nationality.

The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study.

BACKGROUND: Accuracy of upper lip bite test (ULBT) has been compared with the Mallampati classification. In this study, we investigated whether the combination of the ULBT classification with sternomental distance (SMD), thyromental distance (TMD), and interincisor distance (IID) or a composite score can improve the ability to predict easy laryngoscopy and intubation compared with each test alone. METHODS: In a prospective study, 380 patients who were scheduled for elective surgery were selected randomly and enrolled in the study. Before inducing anesthesia, the airways were assessed, and ULBT class, SMD, TMD, and IID determined. Laryngoscopic view according to the Cormack and Lehane grading system was determined after induction of anesthesia and Grades 3 and 4 defined as "difficult intubation." By using receiver operating characteristic analysis, the best cutoff points of the tests were calculated. Finally, sensitivity, specificity, positive and negative predictive values and accuracy of these tests and their combinations with the ULBT were calculated. RESULTS: The prevalence of difficult intubation was 5% (n = 19). Class III ULBT, IID <4.5 cm, TMD <6.5 cm, and SMD <13 cm were defined as predictors of difficult intubation. There was no significant difference regarding difficult intubation based on gender (P < 0.05), whereas there were significant differences between the older tests and laryngeal view (P < 0.05, Mc-Nemar test). Specificity and accuracy of the ULBT were significantly higher than TMD, SMD, and IID individually (specificity was 91.69%, 82.27%, 70.64%, and 82.27%, respectively, and accuracy was 91.05%, 71.32%, 81.84%, and 76.58%, respectively). The combination of the ULBT with SMD provided the highest sensitivity. CONCLUSION: We conclude that the specificity and accuracy of the ULBT is significantly higher than the other tests and is more accurate in airway assessment. However, the ULBT in conjunction with the other tests could more reliably predict easy laryngoscopy or intubation.

Upper lip bite test as a predictor of difficult mask ventilation: a prospective study.

BACKGROUND: Oxygenation and ventilation by means of bag-mask and ambubag play a significant role in maintaining an optimal oxygen saturation of blood and hence the essence of life itself. Predicting difficulty in mask ventilation is again of paramount importance at the time of induction of anesthesia, and in emergency situations. In this study we aimed at evaluating factors that could help in predicting the difficulty of bag-mask ventilation. METHODS: In a prospective study, 200 patients were allocated into two groups, 100 each. First group with a ULBT class I, and the other group with ULBT class II and III. Factors such as height, weight, gender, past history of snoring, neck circumference, Mallampati class, sternomental and thyromental distances were then evaluated in each of the patients in the two groups in order to arrive at their impact on the incidence of difficult mask ventilation. Data were analyzed using Chi-square, student t-test and Fisher's exact tests depending upon the situation. A p < 0.05 was considered to be statistically significant. RESULTS: The results revealed that negative predictive value (NPV) of ULBT class, history of snoring and neck circumference were 86%, 83%, 81%, respectively. A combination of these three predictors had an NPV of 95%. CONCLUSION: ULBT class alone was of value in predicting difficulty in mask ventilation, but a combination of the three tests significantly improved the predictive value.

Evaluation of pediatric CPR course on knowledge of pediatric residents--before and after ACLS course.

An evaluation was conducted on the knowledge gained by pediatric residents on CPR, before and after a PALS (Pediatric Advanced Cardiac Life Support) course. Following an examination of all pediatric residents at Tehran University of Medical Sciences, they were divided into two groups: non-trained (Group 1) and a group scheduled to undergone training (Group 2). A course on ACLS was conducted. Examination were performed before and after the ACLS course. The mean of the examination prior to the course in Group 1 and 2 was low, reflecting no significant differences between the Groups. Examination after the ACLS course showed a statistically significant improvement in Group 2 (P < or = 0.05). It is concluded that knowledge of pediatric residents was low before ACLS course and enhanced after the course.

Cardiac decompensation in a patient with Eisenmenger syndrome undergoing T5-T7 levels laminectomy in the sitting position.

Although several different anesthetic techniques have been employed for noncardiac surgery in Eisenmenger syndrome (ES), the best anesthetic technique is still controversial. A17-year-old male with ES and an epidural abscess at the T5- T7 levels was scheduled to undergo laminectomy in the sitting position. Anesthesia was induced by ketamane and maintained with an opioid-isoflurane technique. A few minutes after extubation, respiratory distress appeared and the patient was reintubated. He was transferred to the intensive care unit (ICU) and maintained on spontaneous intermittent mandatory ventilation and pressure support for 24 hours, and discharged fully recovered on the 4th postoperative day. To our knowledge this is the first case where the sitting position has been adopted for evacuation of an epidural abscess at the T5-T7 levels in a patient with ES. We recommend late extubation and an overnight observation in the ICU for such patients to prevent dangerous sequelae.

Anesthetic Considerations in Cobb Syndrome: A Case Report.

Cutaneomeningospinal angiomatosis, popularly known as Cobb syndrome, is a rare clinical disorder predominantly presenting with a vascular skin lesion and a spinal angioma at the same dermatomal level. Several case reports and case series have reported on the surgical management of this syndrome, but we failed to find any information about its anesthetic considerations in the Medline database. Our case report describes the perioperative anesthetic management of a 46-year-old man with Cobb syndrome.

Easy endotracheal intubation of a patient suffering from both Cushing's and Nelson's syndromes predicted by the upper lip bite test despite a Mallampati Class 4 airway.

A 31-yr-old woman with concurrent Cushing's and Nelson's syndromes was scheduled for transsphenoidal hypophysectomy. The patient had generalized edema, morbid obesity, and a history of sleep apnea. Her Mallampati assessment was Class 4, suggesting very difficult intubation, but the upper lip bite test predicted easy intubation. After rapid sequence induction, there was a Class 1 view on laryngoscopy, and intubation was accomplished easily.

Ventilator associated pneumonia or ventilator induced pneumonia.

Ventilator associated pneumonia currently in vogue seems to have some pitfalls as far as the nomenclature is concerned and thus it imparts an erroneous impression to the reader. As the driving force is in fact the ventilator, the phraseology should preferably be changed to ventilator induced pneumonia to convey the in depth meaning of the term thus evading the terminology currently in practice. A new and emerging paradigm dealing with all side effects of mechanical ventilation can be helpful to solve this etymological conflict.

Chemotherapy alters cisatracurium induced neuromuscular blockade characteristics: A prospective cohort study.

STUDY OBJECTIVE: To compare the characteristics of NMDR induced muscle paralysis in breast cancer patients with and without a history of recent chemotherapy with cyclophosphamide, doxorubicin and 5-fluorouracil (CAF) regimen. DESIGN: This is a non-randomized prospective cohort study. SETTING: Operating room of a university-affiliated teaching hospital. PATIENTS: Out of a total of 50 patients who had undergone mastectomy, 22 patients were allocated to the "Chemo group" and 28 patients to the "Non-Chemo group", based on a valid history of recent chemotherapy. INTERVENTION: After induction of anesthesia with thiopental and cisatracurium, neuromuscular monitoring was started for all patients. MEASUREMENTS: Initially the time to 100% single-twitch (ST) suppression was measured. Then, the time for the appearance of the first response to post-tetanic count (PTC) stimulation, Train-of-Four (TOF) stimulation, and TOF50% were measured consequently. MAIN RESULTS: Time to get STzero was significantly longer in the Chemo group than in the Non-chemo group. Time for the appearance of the first response of PTC and TOF and TOF50% was significantly shorter in the Chemo group than the other group. The mean duration of intense block was 27.66 minutes in the Chemo group versus 42.47 minutes in the Non-chemo group. CONCLUSION: This research demonstrated that in patients having undergone chemotherapy, the effect of NDMRs starts with a longer lag time and finishes earlier too. Thus, these patients are ready for intubation after a longer time. Moreover, we have to repeat cisatracurium injections after shorter intervals to maintain the desired level of blockade.

A prospective randomized trial of tapered-cuff endotracheal tubes with intermittent subglottic suctioning in preventing ventilator-associated pneumonia in critically ill patients.

BACKGROUND: Endotracheal tube placement is necessary for the control of the airway in patients who are mechanically ventilated. However, prolonged duration of endotracheal tube placement contributes to the development of ventilator-associated pneumonias (VAPs). The aim of this study was to evaluate whether subglottic suctioning using TaperGuard EVAC tubes was effective in decreasing the frequency of VAP. METHODS: A total of 276 mechanically ventilated patients for more than 72 hours were randomly assigned to group E (EVAC tube) and group C (conventional tube). All patients received routine care including VAP prevention measures during their intensive care unit stay. In group E, subglottic suctioning was performed every 6 hours. Outcome variables included incidence VAP, intensive care unit length of stay, and mortality. RESULTS: Frequency of intraluminal suction, mechanical ventilation-free days, reintubation, the ratio of arterial oxygen partial pressure to fractional inspired oxygen and mortality rate were similar between the 2 groups (P > .05). The mean cuff pressure in group E was significantly less than that in group C (P < .001). Ventilator-associated pneumonia was significantly less in group E compared with group C (P = .015). CONCLUSION: The use of intermittent subglottic secretion suctioning was associated with a significant decrease in the incidence of the VAP in critically ill patients. However, larger multicenter trials are required to arrive at a concrete decision on routine usage of TaperGuard tubes in critical care settings.