Autoimmune blistering diseases treated with glucocorticoids: An international study of steroid-induced myopathy.

BACKGROUND: Patients with autoimmune blistering diseases (AIBDs) are often exposed to chronic glucocorticoid (GC) treatment with many side effects. Glucocorticoid-induced myopathy (GIM) is a well-established side effect, which particularly affects the proximal muscles. The Glucocorticoid Toxicity Index (GTI) is a validated global assessment tool which quantifies GC toxicity over time. OBJECTIVES: This study marks the first study which analyses GIM in patients with AIBDs. The objectives of this study were to utilize the GTI to investigate the nature and prevalence of GIM in AIBD patients and explore potential risk factors. METHODS: This international cohort study was conducted in blistering disease clinics across Australia, China, Greece, Iran, Japan, the Philippines, Turkey and the United States of America between February 2019 and July 2023. The GTI tool was completed by a medical practitioner at each patient visit. Data related to glucocorticoid toxicity were entered into the Steritas GTI 2.0 to generate an aggregate improvement and cumulative worsening score at each visit. RESULTS: The study included 139 patients. There were 132 episodes of myopathy, and 47.5% of patients developed muscle weakness at some point during the study period. Cumulative GC dose correlated positively with myopathy risk, while average dose and treatment duration were not significant. Older age, male gender and obesity more than doubled the likelihood of developing GIM. CONCLUSIONS: GIM is a common side effect experienced by AIBD patients on GC treatment. Muscle weakness is less likely to occur if cumulative GC dose is less than 0.75 mg/kg/day. Studies of exercise programs to mitigate myopathy and newer alternative treatments to reduce cumulative GC dose should be considered.

Updated S2 K guidelines for the management of bullous pemphigoid initiated by the European Academy of Dermatology and Venereology (EADV).

BACKGROUND: Bullous pemphigoid (BP) is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or, most frequently, generalized bullous lesions. A subset of patients only develops excoriations, prurigo-like lesions, and eczematous and/or urticarial erythematous lesions. The disease, which is significantly associated with neurological disorders, has high morbidity and severely impacts the quality of life. OBJECTIVES AND METHODOLOGY: The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology sought to update the guidelines for the management of BP based on new clinical information, and new evidence on diagnostic tools and interventions. The recommendations are either evidence-based or rely on expert opinion. The degree of consent among all task force members was included. RESULTS: Treatment depends on the severity of BP and patients' comorbidities. High-potency topical corticosteroids are recommended as the mainstay of treatment whenever possible. Oral prednisone at a dose of 0.5 mg/kg/day is a recommended alternative. In case of contraindications or resistance to corticosteroids, immunosuppressive therapies, such as methotrexate, azathioprine, mycophenolate mofetil or mycophenolate acid, may be recommended. The use of doxycycline and dapsone is controversial. They may be recommended, in particular, in patients with contraindications to oral corticosteroids. B-cell-depleting therapy and intravenous immunoglobulins may be considered in treatment-resistant cases. Omalizumab and dupilumab have recently shown promising results. The final version of the guideline was consented to by several patient organizations. CONCLUSIONS: The guidelines for the management of BP were updated. They summarize evidence- and expert-based recommendations useful in clinical practice.

S2k guidelines (consensus statement) for diagnosis and therapy of dermatitis herpetiformis initiated by the European Academy of Dermatology and Venereology (EADV).

INTRODUCTION: Dermatitis herpetiformis (DH) is a chronic, pruritic, gluten-induced skin disorder characterized by subepidermal granular IgA deposition and a variable degree of enteropathy identical to that seen in coeliac disease. So far, there has been no European consensus about the management of DH. METHODS: The guidelines were created by small subgroups of a guideline committee consisting of 26 specialists from various medical fields and one patients' representative. The members of the committee then discussed the guidelines and voted for the final version at two consensus meetings. The guidelines were developed under the support of the European Academy of Dermatology and Venereology (EADV) and in collaboration with the European Dermatology Forum (EDF). RESULTS: The guidelines summarize evidence-based and expert-based recommendations (S2 level) for the management of DH (see Appendix). CONCLUSION: These guidelines will improve the quality of management of DH and support dermatologists in their diagnostic and therapeutic decisions.

Updated S2K guidelines on the management of pemphigus vulgaris and foliaceus initiated by the european academy of dermatology and venereology (EADV).

BACKGROUND: Pemphigus encompasses a group of life-threatening autoimmune bullous diseases characterized by blisters and erosions of the mucous membranes and skin. Before the era of immunosuppressive treatment, pemphigus was almost always fatal. Due to its rarity, only few randomized controlled therapeutic trials are available. Recently, rituximab has been approved as first-line treatment for moderate and severe pemphigus vulgaris in Europe and the United States. OBJECTIVES: The Autoimmune blistering diseases Task Force of the European Academy of Dermatology and Venereology (EADV) has initiated a throughout update of the guideline for the management of patients with pemphigus. RESULTS: The guidelines for the management of pemphigus were updated, and the degree of consent among all task force members was included. The final version of the guideline was consented by the European Dermatology Forum (EDF) and several patient organizations.

Sexual and reproductive health of Syrian refugee women in Turkey: a scoping review within the framework of the MISP objectives.

BACKGROUND: Turkey hosts the world's largest community of Syrians displaced by the conflict. The Minimum Initial Service Package (MISP) is a coordinated set of priority reproductive health services. There is not any scoping review assessing the RH situation of Syrian refugees in Turkey within the framework of the MISP objectives. The objectives of this review is to identify the situation of sexual and reproductive health (SRH) among Syrian refugee women in Turkey, and document the health services provided for them in terms of the components of MISP. We hoped to show evidence of gaps and help guide future research to focus on priority areas to improve the range, quality, and access to SRH services and to recommend public health interventions. METHOD: The literature search was conducted in Turkish and English. Multiple electronic databases (Turkish Medline, Google Scholar, PubMed, Web of Science, Medline, Cochrane Database of Systematic Reviews, EBSCOHost, CINAHL, and Embase) were searched from January 2011 to May 2018. References published in the peer-reviewed literature, the grey-literature, and on websites were eligible for inclusion if they had conducted research on one or more of the following SRH topics specifically for Syrian women in Turkey: maternal and neonatal health/antenatal care, HIV and sexually transmitted infections, use of contraceptives, sexual violence, and services delivery and accessibility. References were excluded if any of the following criteria were relevant: not specific to Syrian women refugees in Turkey. Firstly, the titles and abstracts of the articles that were found were examined to determine if they met the eligibility criteria. Secondly, if the abstracts and titles met one or more of the eligibility criteria, the full text of the articles have been examined. Finally, standard forms were prepared and used to summarize the articles narratively. The results of the screening were recorded in Excel spreadsheets for comparison, and any disagreements among the researchers were resolved by consensus. The studies were grouped according to the MISP objectives. RESULTS: A total of 24 publications were eligible for inclusion in the review. Consanguineous marriage rate was 56%. The rate of marriage under age 18 were very high. Mean age at first marriage was found to be between 18 and 20. The rate of antenatal care was inadequate. The rate of using a modern contraceptive method was 24% among married and all age groups of Syrian women. The rates of unmet family planning needs were about 35%. Among patients admitted to gynecology outpatient clinics, about half of the applicants were reported to have abnormal vaginal discharge. The reported rates of sexual violence were about 8%. Only 20% of Syrian women had regular gynecological visits. CONCLUSION: Overall, we conclude that early marriage, low modern contraceptive use, unmet need for contraception, sexual and gender-based violence are the major SRH issues reported. There is a need for further studies to identify the barriers limiting service uptake as well as to document successful practices. Long term strategies to improve the SRH status of Syrian refugee women should be developed with participation of all stakeholders. This review is significant in terms of that it is the first scoping review assessing the RH situation of Syrian refugees in Turkey within the framework of the MISP objectives. Based on the data of this review, relevant policy makers should consider to improve the SRH status of Syrian women refugees in Turkey.

Oral health related quality of life and disease severity in autoimmune bullous diseases.

BACKGROUND: There is an increased risk of long-term dental and periodontal disease in autoimmune bullous diseases (AIBD). AIMS: In this cross-sectional study, we aimed to determine whether the oral health-related quality of life status (OHRQoL) was associated with disease severity and activity in patients with AIBD. SUBJECTS AND METHODS: 67 patients with AIBD were enrolled in this study. Autoimmune Bullous Skin Disorder Intensity Score (ABSIS) was used to evaluate the disease severity. The score was categorized as a significant course (≥17) and moderate course (<17). Oral health impact profile-14 (OHIP-14) questionnaire was filled to assess the OHRQoL. Self-reported oral health status and oral lesion related pain score were also evaluated in the study group. RESULTS: OHIP-14 score was significantly higher in active patients (42.28 ± 13.66) than inactive patients (29.08 ± 12.25) (P = 0.004) and it was correlated with the pain score (6.33 ± 2.78; r = 0.409, P = 0.013). Furthermore, OHIP-14 score was higher in patients with a significant disease course (45.18 ± 15.08) (P = 0.010) than in patients with a moderate course (36.09 ± 9.73). CONCLUSIONS: OHRQoL may be useful in the disease management and treatment. Since it can be affected by both presence of oral erosions and disease severity, a collaboration between dermatologists and dentists could be crucial to the disease management in AIBD.

Evaluation of oxidative stress in patients with recalcitrant warts.

BACKGROUND: Warts are benign conditions of the skin and mucosa caused by human papilloma viruses (HPV) that affect many people worldwide. OBJECTIVE: The aim of this study was to evaluate OS by TOS/TAS, levels of 8-hydroxy-2-deoxyguanosine (8-OHdG) an indicator of DNA damage, and also protein oxidation levels by determining the dynamic serum thiol/disulphide homeostasis in patients with warts. We also aimed to investigate whether there is a relationship between thiol/disulphide homeostasis, recalcitrance of warts and DNA damage. METHODS: Forty patients of age ≥18 years, having recalcitrant genital and/or non-genital warts that persisted for more than 2 years, 40 patients with warts that persisted for <2 years and 40 healthy controls were enrolled in the study. Blood TAS, TOS, OSI, 8-OHdG and dynamic thiol/disulphide homeostasis were evaluated. RESULTS: Significant differences were detected between the groups in the levels of 8-OHdG, TOS, OSI, total thiol, native thiol, reduced thiol, as well as native thiol/total thiol ratio, disulphide/total thiol ratio and disulphide/native thiol ratio. Compared with the controls, patients with recalcitrant warts had significantly higher levels of 8-OHdG, TOS and OSI levels. Total thiol and native thiol levels were significantly lower in patients with recalcitrant warts compared with patients with warts that persisted for <2 years. Disulphide levels were significantly higher in the latter group of patients compared with patients with recalcitrant warts and controls. Native thiol/total thiol ratio was significantly higher in both patient groups compared with controls whereas disulphide/total thiol and disulphide/native thiol ratios were significantly lower in both patient groups than in controls. CONCLUSION: Our findings suggest that impairment of thiol disulphide homeostasis in patients with recalcitrant warts may lead to increased OS and DNA damage. Thus, antioxidant administration with thiol containing proteins may help in the regression of warts and thereby prevent carcinogenesis.

Inter-rater reliability of the BIOCHIP indirect immunofluorescence dermatology mosaic in bullous pemphigoid and pemphigus patients.

BACKGROUND: The BIOCHIP (Dermatology Mosaic 7; EUROIMMUN, Lubeck, Germany) is a novel multiplex indirect immunofluorescence (IIF) technique used in the serological diagnosis of bullous pemphigoid (BP) and pemphigus. OBJECTIVE: To validate the accuracy and inter-rater reliability (IRR) of the BIOCHIP in the diagnosis of BP, pemphigus foliaceus (PF) and pemphigus vulgaris (PV). METHODS: Sera from patients with BP (n = 38), PF (n = 8), PV (n = 23), control patients (n = 64) and healthy control volunteers (n = 39) were tested. Sera were collected and analysed during the course of the disease at 1-5 different time points. The BIOCHIP was performed for all patients, digital images were captured of each incubated field, and the images were shared with 10 dermatologists experienced in reading IF from around the world to report. There were 312 BIOCHIP slides consisting of 1872 photos in total. All patients were de-identified. Fleiss Kappa was used to estimate the IRR. RESULTS: Fleiss Kappa was computed for each category (Oesophagus, Oesophagus immunofluorescence pattern, Salt-Split Skin (SSS), SSS immunofluorescence location, BP180, BP230, Dsg 1 and Ds3). The inter-rater agreement between the 10 raters varied between fair and moderate for all categories. Those that demonstrated fair concordance included monkey oesophagus (k = 0.257, P < 0.0001), oesophagus pattern (k = 0.357, P < 0.0001), Dsg1 (k = 0.390, P < 0.0001) and BP230 (k = 0.281, P < 0.0001). Moderate agreement was demonstrated for SSS (k = 0.416, P < 0.0001), SSS immunofluorescence location (k = 0.505, P < 0.0001), Dsg3 (k = 0.437, P < 0.0001) and BP180 (k = 0.559, P < 0.0001). CONCLUSION: The BIOCHIP mosaic-based immunofluorescence test is a simple, time and effort saving test that can aid in the diagnosis and screening of BP, PV and PF. However, the level of agreement was relatively low. The authors found the most common causes to be variable levels of training, indicating the presence of a learning curve in the interpretation of the results and ambiguous staining patterns leading to incongruent results.

Turkish Women's Knowledge, Attitudes, and Behaviors on Wet-Nursing, Milk Sharing and Human Milk Banking.

Purpose The aim of this study was to determine Turkish women's knowledge, attitudes, and behaviors on wet-nursing, milk sharing, and human milk banking in a primary care setting located in a semi-rural area. Description Donated human milk is a feasible option for feeding infants and children. Currently, there is a debate on the topic starts with the preparations to launch a human milk bank in a large city in Turkey. Several previous papers reported women's opinions in large hospital based studies. Little is known about women's views and practice on donated human milk in the rural areas of Turkey. Assessment The study sample was recruited among married women aged 15-49 years who had given birth within the past 5 years and who were in a family health center for any reason in Honaz, Denizli, Turkey. A total of 240 women were included in the study. The data were collected by questionnaire created by the researchers and consisting of two parts: sociodemographic characteristics, and women's knowledge, attitudes, and behaviors on wet-nursing, milk sharing and human milk banking. Results Thirty women (12.5%) had had a wet-nurse; 20 women (8.7%) wet-nursed babies before; and 17 (7.2%) of the women's children had a wet-nurse. If necessary, 80.9 and 78.3% were willing to accept to do wet-nursing and milk sharing, respectively. 150 (62.5%) heard of human milk banks; 55 (22.9%) approved of the establishment of milk banks. However, only 46 women (19.1%) were willing to donate to the bank. Possibility of marriages between milk siblings (76.8%) was the main reason for not considering the donation. Women's education was another factor affecting their opinion on breast milk sharing and donation to human milk banks. Less educated women were sympathetic to milk sharing (p = 0.02), however, more educated mothers had a propensity to donate to milk banks (p = 0.02). Conclusion Wet-nursing decreased over the years in Turkey, but still an ongoing small child feeding method. Most of the women tend to become a wet nurse or do milk sharing if it is needed, but they are hesitant to donate their milk to human milk banks, mostly due to religious concerns.

The effect of intrathecal sufentanil preconditioning against myocardial ischemia-reperfusion injury.

OBJECTIVES: We aimed to investigate the cardioprotective effect and hemodynamic response of intrathecally administered sufentanil on myocardial IR injury. BACKGROUND: Sufentanil, mu opioid receptor agonist, intravenously administered during clinical and experimental studies, has been shown to have a cardioprotective effect on myocardial ischemia-reperfusion injury. METHODS: Thirty-two New Zealand type rabbits, which were anesthetized, were divided into four equal groups: sham, ischemia-reperfusion, sufentanil and ischemia-reperfusion+sufentanil. Sufentanil was administered intrathecally prior to ischemia. Hemodynamic parameters were monitored by electrocardiography and invasive arterial blood pressure measurements. In the ischemia-reperfusion groups, the degree of myocardial infarct was determined as the ratio of ischemic region to the risk area by a 1 % 2,3,5-triphenyl tetrazolium chloride staining. RESULTS: The mean infarct size in the ischemia-reperfusion group was 47.5 ± 7.0 %, whereas that of the ischemia-reperfusion+sufentanil group was found to be 34.2 ± 4.7 %, indicating a statistically significant difference (p = 0.002). The heart rate was different between the ischemia-reperfusion and the sufentanil groups for baseline measurement and between the ischemia-reperfusion and the ischemia-reperfusion+sufentanil groups at the 120th minutes measurement (p < 0.05). CONCLUSION: Intrathecal sufentanil appears to have a cardioprotective effect against myocardial ischemia--reperfusion injury in the experimental rabbit model (Tab. 1, Fig. 2, Ref. 19).

Serological diagnostics in the detection of IgG autoantibodies against human collagen VII in epidermolysis bullosa acquisita: a multicentre analysis.

BACKGROUND: Epidermolysis bullosa acquisita (EBA) is a rare, potentially devastating autoimmune disease of the skin. IgG autoantibodies directed against type VII collagen (Col7), the major component of anchoring fibrils, induce skin fragility leading to cutaneous and mucocutaneous blister formation, which is mostly of a scarring phenotype. Thus, powerful and reproducible diagnostic assays are critical to establish the diagnosis of EBA early to avoid irreversible sequelae. OBJECTIVES: The present international, retrospective multicentre study included a large cohort of patients with EBA and evaluated the diagnostic power of four different diagnostic assays for the detection of anti-Col7 IgG autoantibodies. METHODS: Overall, 95 EBA sera and 200 control sera consisting of 100 bullous pemphigoid sera, 50 pemphigus vulgaris sera and 50 sera of healthy controls were tested for anti-Col7 IgG autoantibodies using indirect immunofluorescence (IIF), two commercial enzyme-linked immunosorbent assay (ELISA) systems and Western blot (WB) analysis. EBA sera were taken from patients with positive direct immunofluorescence and IgG reactivity in at least one of the immunoserological assays (IIF, ELISA, WB). RESULTS: A Col7-NC1/NC2 ELISA (MBL, Nagoya, Japan) showed the highest sensitivity (97·9%), followed by a Col7-NC1 ELISA (Euroimmun, Lübeck, Germany) (89·5%), WB with Col7-NC1 (85·3%), and IIF on saline-split human skin (74·7%). The specificities of both ELISA systems were comparable (NC1 98·7%, NC1/NC2 99·3%). Furthermore, WB was more sensitive than IIF, which was more specific. CONCLUSIONS: The two commercially available ELISA systems allow for a highly sensitive and specific diagnosis of EBA. The sensitivity of the Col7-NC1/NC2 ELISA is significantly higher compared with the ELISA based on the Col7-NC1 domain only.

Ocular blast injuries related to explosive military ammunition.

OBJECTIVES: To report the clinical features of ocular injuries associated with explosive military ammunition in insurgent attacks in Turkey. METHODS: The medical records of 48 casualties who were treated for ocular injuries sustained in insurgent attacks at the Combat Region Hospitals in Turkey were retrospectively reviewed. The reviewed data included initial visual acuity, type of explosive military ammunition (ie, improvised explosive device, mine, hand grenade and rocket-propelled grenade), type of globe injury (open-globe vs closed-globe injury), traumatised globe zones, the presence/absence of an intraocular foreign body, medical interventions, status during the explosion and injuries to other parts of the body. The visual acuity differences between different explosive materials and between 'on-foot' and 'inside-vehicle' casualties were investigated. RESULTS: A total of 83 injured eyes were analysed. The mean patient age was 24.5±6.6 years. The mean initial logarithm of the minimum angle of resolution visual acuity was 0.60±0.63. The injuries were due to improvised explosive devices in 28 cases (58.3%), land mines in 16 cases (33.3%), and hand grenades and rocket-propelled grenades in 2 cases each (4.2%). Forty-seven eyes (56.6%) had open-globe injuries. The most frequently involved zones were zone 1 (50.0%) in closed-globe injuries and all zones (31.9%) in open-globe injuries. Intraocular foreign bodies were present in 45/47 (95.7%) eyes with open-globe injuries. Twelve (14.4%) eyes with no light perception were enucleated, and two (2.4%) eviscerated. The difference in the visual acuities between the on-foot and inside-vehicle casualties and between the injuries that were caused by the different types of explosive ammunitions was also insignificant (p=0.271 and 0.394, respectively). CONCLUSIONS: The clinical results for eye injuries caused by explosive military ammunition sustained during insurgent attacks in Turkey are disappointing irrespective of the explosive material. The use of protective eyeglasses might improve the outcomes and should be encouraged.

Management of bullous pemphigoid: the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology.

Bullous pemphigoid is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or generalized bullous lesions. In up to 20% of affected patients, bullae may be completely absent, and only excoriations, prurigo-like lesions, eczematous lesions, urticated lesions and/or infiltrated plaques are observed. The disease is significantly associated with neurological disorders. The morbidity of bullous pemphigoid and its impact on quality of life are significant. So far, a limited number of national treatment guidelines have been proposed, but no common European consensus has emerged. Our consensus for the treatment of bullous pemphigoid has been developed under the guidance of the European Dermatology Forum in collaboration with the European Academy of Dermatology and Venereology. It summarizes evidence-based and expert-based recommendations.

Pemphigus. S2 Guideline for diagnosis and treatment--guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV).

BACKGROUND: Pemphigus encompasses a group of life-threatening autoimmune bullous diseases characterized by blisters and erosions of the mucous membranes and skin. Before the era of immunosuppressive treatment, the prognosis of pemphigus was almost fatal. Due to its rarity, only few prospective controlled therapeutic trials are available. OBJECTIVES: For this reason, a group of European dermatologists with a long-standing interest and expertise in basic and clinical pemphigus research has sought to define diagnostic and therapeutic guidelines for the management of patients with pemphigus. RESULTS: This group identified the statements of major agreement or disagreement regarding the diagnostic and therapeutic management of pemphigus. The revised final version of the pemphigus guideline was finally passed on to the European Dermatology Forum (EDF) for a final consensus with the European Academy of Dermatology and Venereology (EADV) and the European Union of Medical Specialists (UEMS).

Homocysteine levels and bad obstetric outcome among female operating room personnel occupationally exposed to nitrous oxide.

It is known that nitrous oxide (N2O) inactivates vitamin B12 and causes hyperhomocysteinemia. The personnel working at the operating theatres are repeatedly exposed to N2O in the ambient air. This prompted us to investigate the biochemical indices of vitamin B12 metabolic status among female personnel working under various levels of N2O exposure. In this study, the homocysteine and folic acid levels were assessed and bad obstetric outcome was questioned. Sixty operating theatre female personnel were examined. Vitamin B12 and folic acid, total homocysteine level, anticardiolipin IgM, IgG, antiphospholipid IgM, IgG levels were measured in serum. A questionnaire inquiring about obstetric history was given. The serum concentration of folic acid was 10 ± 3.3 nmol liter-1. The vitamin B12 level was 332 ± 134 pmol liter-1, the serum concentration of homocysteine was 9.1 ± 2.4 nmol liter-1 and all were within normal ranges. There was no difference regarding homocysteine, folic acid, vitamin B12 levels and the obstetric history between the subjects who had abortus history and the subjects who had not abortus history. Exposure to N2O in healthcare workers was not associated with alterations of homocysteine, folic acid status and bad obstetric outcome (Tab. 4, Ref. 18).

Evaluation of muscle fatigue of wheelchair basketball players with spinal cord injury using recurrence quantification analysis of surface EMG.

Wheelchair basketball is the most popular exercise activity among individuals with spinal cord injury (SCI). The purpose of this study was to investigate muscular endurance and fatigue in wheelchair basketball athletes with SCI using surface electromyography (SEMG) and maximal torque values. SEMG characteristics of 10 wheelchair basketball players (WBP) were compared to 13 able-bodied basketball players and 12 sedentary able-bodied subjects. Participants performed sustained isometric elbow flexion at 50% maximal voluntary contraction until exhaustion. Elbow flexion torque and SEMG signals were recorded from three elbow flexor muscles: biceps brachii longus, biceps brachii brevis and brachioradialis. SEMG signals were clustered into 0.5-s epochs with 50% overlap. Root mean square (RMS) and median frequency (MDF) of SEMG signals were calculated for each muscle and epoch as traditional fatigue monitoring. Recurrence quantification analysis was used to extract the percentage of determinism (%DET) of SEMG signals. The slope of the %DET for basketball players and WBP showed slower increase with time than the sedentary able-bodied control group for three different elbow flexor muscles, while no difference was observed for the slope of the %DET between basketball and WBP. This result indicated that the athletes are less fatigable during the task effort than the nonathletes. Normalized MDF slope decay exhibited similar results between the groups as %DET, while the slope of the normalized RMS failed to show any significant differences among the groups (p > 0.05). MDF and %DET could be useful for the evaluation of muscle fatigue in wheelchair basketball training. No conclusions about special training for WBP could be determined.

Comparison of Flexiblade and Macintosh laryngoscopes: cervical extension angles during orotracheal intubation.

SUMMARY: The Flexiblade(TM) is a new laryngoscope with a flexible blade, a handle and a lever, allowing gradual flexion over the distal half of the blade. In this study, we aimed to compare cervical vertebral movements during tracheal intubation with the Flexiblade and Macintosh laryngoscope in 32 patients undergoing elective surgery requiring general anaesthesia (n = 16 per group). Fluoroscopic images of cervical movement were captured before, during and after intubation and evaluated by a radiologist. C1-C2 cervical vertebral movement was significantly reduced during the intubation in the Flexiblade group (p < 0.0001). C2-C3 cervical movement was similar in both groups (p = 0.81). No significant differences were noted in success rates for intubation, oxygen saturation levels, haemodynamic variables or intubation-related injury. The decreased extension angle between C1-C2 during Flexiblade laryngoscopy compared with Macintosh laryngoscopy may be an advantage where neurological damage with cervical movement is a concern.

Topical ketamine and morphine for post-tonsillectomy pain.

BACKGROUND AND OBJECTIVES: Tonsillectomy is frequently associated with postoperative pain of considerable duration, which is usually accompanied by the substantial consumption of both opioid and non-opioid analgesics. Despite the use of different surgical and anaesthetic techniques in the search for safe and effective post-tonsillectomy pain relief, this problem remains a clinical dilemma. The aim of the current study was to evaluate the potential effects of topically administered ketamine and morphine by an oral rinse into the tonsillar fossae. METHODS: In all, 60 children, 15 for each group, aged between 3 and 12 yr scheduled for tonsillectomy were randomly assigned to one of four groups. Study drugs were administered to both tonsillar fossae for 5 min. Group K received 0.4 mL (20 mg) ketamine in 10 mL artificial saliva, Group KM received 0.4 mL (20 mg) ketamine + 5 mL (20 mg) 4 per thousand morphine aqueous solution in 5 mL artificial saliva, Group M received 5 mL (20 mg) 4 per thousand morphine aqueous solution in 5 mL artificial saliva, Group C received only 10 mL artificial saliva. Postoperative pain, nausea, vomiting, sedation and bleeding were evaluated. RESULTS: Pain scores were higher in the control group at arrival in the recovery ward (P < 0.05). Morphine and ketamine groups had longer effective analgesia time than the morphine + ketamine and control groups. The 24-h analgesic consumption was significantly higher in the control group. CONCLUSION: Topical ketamine and morphine seems to be a safe and easy analgesic approach for decreasing adenotonsillectomy pain.

Dexmedetomidine and postoperative shivering in patients undergoing elective abdominal hysterectomy.

BACKGROUND: Post-anaesthetic shivering is one of the most common complications, occurring in 5-65% of patients recovering from general anaesthesia and 33% of patients receiving epidural anaesthesia. Our objective was to investigate the efficacy of intraoperative dexmedetomidine infusion on postoperative shivering. METHODS: Ninety female patients, ASA I-II, 35-60 yr old, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo-oophorectomy were randomized into two groups. After endotracheal intubation one group received normal saline infusion and the other received dexmedetomidine as a loading dose of 1 microg kg(-1) for 10 min followed by a maintenance infusion of 0.4 microg kg(-1) h(-1). In the recovery room, pain was assessed using a 100 mm visual analogue scale and those patients who had a pain score of more than 40 mm were administered 1 mg kg(-1) intramuscular diclofenac sodium. Patients with shivering grades more than 2 were administered 25 mg intravenous meperidine. Patients were protected with passive insulation covers. RESULTS: Post-anaesthetic shivering was observed in 21 patients in the saline group and in seven patients in the dexmedetomidine group (P = 0.001). Shivering occurred more often in the saline group. The Ramsay Sedation Scores were higher in the dexmedetomidine group during the first postoperative hour. Pain scores were higher in the saline group for 30 min after the operation. The need for intraoperative atropine was higher in the dexmedetomidine group. Intraoperative fentanyl use was higher in the saline group. Perioperative tympanic temperatures were not different between the groups whereas postoperative measurements were lower in the dexmedetomidine group (P < 0.05). CONCLUSION: Intraoperative dexmedetomidine infusion may be effective in the prevention of post-anaesthetic shivering.