Lived experiences of COVID-19 patients admitted in isolation wards of healthcare centers in Peshawar, Pakistan: A phenomenological perspective

The emergence of COVID-19 caused a significant global threat, affecting populations worldwide. Its impact extended beyond just physical health, as it inflicted severe damage and challenges to individuals' well-being, leading to a deterioration in mental health. The lived experiences of patients hold a paramount position to explore and understand their perception of care which can ultimately strengthen the health system's delivery domain. This study explores the lived experiences of patients in the isolation ward, their recovery, and the quality of care being provided in the hospital and its effects on their mental health.

Study design

A phenomenological qualitative study using in-depth interviews.

Methods

We conducted 11 in-depth interviews of COVID-19 patients admitted to the isolation ward of the public hospitals of Peshawar, Pakistan. Participants who stayed for a minimum of 10 days in an isolation ward were included in this study. Interviews were transcribed and analyzed using NVivo 12 software and generated five themes through inductive analysis.

Results

Five themes emerged from the participants' lived experiences: Heading towards the hospital, Health Care Quality, Impact on Mental Health, Recovering from COVID-19 and Back on one's feet. These included all the positive and negative lived experiences. Socio-environmental factors along with their experiences of the disease itself and with the healthcare providers guided their reaction which was important conciliators in their experiences during the pandemic.

Conclusion

Based on the findings, the environment of isolation had a major influence on the mental well-being of the individuals involved. Considering the important role of the ward environment in shaping patient experiences and outcomes prompts a reevaluation of healthcare practices and policies. By addressing these factors healthcare systems can strive for greater effectiveness, resilience, and compassion in managing the pandemic's impact on patient care.

Subspeciality Interests Among the Ophthalmology Residents: A Mixed-Methods Study

OBJECTIVE

To determine the popular subspeciality choices among ophthalmology residents, to explore the factors affecting that choice, and to identify the obstacles that they face while selecting a subspeciality fellowship.

STUDY DESIGN

Mixed-methods study. Place and Duration of the Study: Department of Ophthalmology of Hayatabad Medical Complex and Lady Reading Hospital, Peshawar, from 1st September to 30th November, 2021.

METHODOLOGY

The qualitative (1st) phase comprised of focussed group discussion (FGD) followed by an online in-depth interview (IDI). Quantitative (2nd) phase was conducted as online survey and consisted of currently enrolled FCPS-ophthalmology residents. Themes were generated and used to modify the pre-designed questionnaire. Questionnaire was piloted and necessary adjustments were made. In the 2nd phase, the online link of the questionnaire was shared with the eligible participants all over the country. For the association between categorical variables, the Pearson Chi-square test was used with significance at p-value <0.05.   Results: Nine participants were recruited in the first phase and three themes were generated. In the second phase, a total of 138 responses were received, among which mean age was 29.37 + 3.9 years, and 74 (53.6%) participants were males. The top three subspeciality choices were cataract and refractive surgery (n = 31, 22.5%), vitreoretinal surgery (n = 30, 21.7%) and orbit and oculoplasty (n = 13, 9.4%). Sixty-two (48.8%) participants stated interest in the career to be the main reason to choose a particular fellowship, and 54 (42.5%) participants identified challenging subspeciality as the main obstacle. An association between gender and the intended subspeciality showed significant results (p = 0.029).

CONCLUSION

Ophthalmology residents of Pakistan have different approaches and motivations for selecting a fellowship programme. Professional needs and scientific reasons are their main motivations.

KEY WORDS

Ophthalmology, Fellowship, Motivations, Career choices, Mentor, Pakistan.

COVID-19 vaccine acceptance and its drivers among Pakistani population

Background & Objective

COVID-19 vaccine has become available within a record time but mere availability will not control the pandemic. High vaccine acceptance is required. The objective was to determine COVID-19 vaccine acceptance and its associated factors among Pakistani population.

Methods

An online survey using google form, was conducted from January 31st to February 9th, 2021 before the start of the mass vaccination in Pakistan. The questionnaire had questions about demographics plus vaccine hesitancy. We received a total of 1156 responses. Data was analyzed using STATA version 14. We employed descriptive statistics and chi square test.

Result

A total of 1156 responses were received. 65% were male and 35% female. Only 6% were uneducated. Thirty percent had tested positive for COVID-19 earlier. Forty-six percent of the respondents would take (acceptance) a vaccine if available. Forty-eight percent and 45% were confident in using USA/UK and Chinese vaccine respectively. Gender and marital status was statistically significantly associated with vaccine acceptance. Concerns about the side effects were 55% while for efficacy it was 69%. Twenty-three percent were concerned about the permissibility of the vaccine on religious grounds.

Conclusion

Gender and marital status was significantly associated with vaccine acceptance. Forty-six percent respondents were willing to take the vaccine. Among the vaccine hesitant group, respondents were worried about the side effects, safety and religious permissibility of vaccine. Policy makers and all the relevant stakeholders should consider low vaccine acceptance as a major bottleneck and should devise strategies to address this major issue in the fight against COVID-19.

Effects of chlorhexidine use on periodontal health during fixed appliance orthodontic treatment: a systematic review and meta-analysis

BACKGROUND

Proper oral hygiene and absence of periodontal inflammation is pre-requisite for orthodontic treatment. Chlorhexidine (CHX) is an established oral antiseptic used in the treatment of periodontal disease, but its role in orthodontic therapy is unclear.

OBJECTIVES

To assess the efficacy of adjunct use of CHX-containing products in maintaining gingival health among orthodontic patients with fixed appliances.

SEARCH METHODS

Five databases were searched without limitations up to August 2021.

SELECTION CRITERIA

Randomized clinical trials (RCTs) assessing Gingival Index (GI) (primary outcome), Plaque Index (PI), Bleeding Index (BI), or Pocket Probing Depth (PPD).

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, and risk of bias assessment were done independently in duplicate. Random-effects meta-analyses of mean differences (MDs) or standardized mean differences (SMDs) with their 95% confidence intervals (CIs) were conducted, followed by sensitivity and Grades of Recommendations, Assessment, Development and Evaluation analysis.

RESULTS

Twenty RCTs (1001 patients) were included assessing CHX-containing mouthwashes (n = 11), toothpastes (n = 2), gels (n = 3), or varnishes (n = 4) compared to placebo/control (n = 19) or sodium fluoride-products (n = 4). In the short-term, CHX-containing mouthwash was associated with lower GI (n = 9; MD = -0.68; 95% CI = -0.97 to -0.38; P < 0.001; high quality), lower PI (n = 9; MD = -0.65; 95% CI = -0.86 to -0.43; P < 0.001; high quality), lower BI (n = 2; SMD = -1.61; 95% CI = -2.99 to -0.22; P = 0.02; low quality), and lower PPD (n = 2; MD = -0.60 mm; 95% CI = -1.06 to -0.14 mm; P = 0.01; low quality). No considerable benefits were found from the use of CHX-gel or CHX-varnish in terms of GI, PI, or PPD (P > 0.05/low quality in all instances). Use of a CHX-containing toothpaste was more effective in lowering PI (Heintze-index) than adjunct use of fluoride-containing mouthwash (n = 2; MD = -5.24; 95% CI = -10.46 to -0.02; P = 0.04), but not GI (P = 0.68) or BI (P = 0.27), while sensitivity analyses indicated robustness.

CONCLUSIONS

Adjunct use of CHX mouthwash during fixed-appliance treatment is associated with improved gingival inflammation, plaque control, and pocket depths, but caution is warranted and recommendations about CHX use during orthodontic treatment of children/adults should consider the heterogeneous patient response, cost-effectiveness, and potential adverse effects.

REGISTRATION

PROSPERO registration (CRD42021228759).

Short Stature and Celiac Disease in Children (5 to 16 Years) Presenting at a Tertiary Care Hospital in Peshawar

Background: Malabsorption is the typical presentation of celiac disease in early childhood, whereas older children can present with extra-intestinal symptoms including short stature and delay in pubertal development.

Objective: To determine the frequency of celiac disease in shortening of stature in children.

Material and methods: This descriptive, cross-sectional study was conducted at the Pediatric Department in Lady Reading Hospital, Peshawar, on 152 short stature children of both genders aged 5 to 16 years. Children with dysmorphic faces, syndromes, endocrine disorders, and children or their parents who refused to give consent were excluded. Anthropometric measurement was done on standard equipment. Height and weight were plotted on WHO centile charts. All the children fulfilling inclusion criteria were advised serologic anti-tissue transglutaminase antibodies tests.

Results: Overall the frequency of celiac disease was 33.77% (n=51) among the children with short stature. The mean age of the study was 6.71±1.52 years. There were 76 males (50.3%), while there were 75 females 49.7%. The frequency of celiac disease among short stature females was higher (n=28, 54.9%) than short stature males (n=23, 45.1%). However, the results were not statistically significant (P=0.358). The frequency of celiac disease stratified by age group was not statistically significant (P=0.491).

Conclusion: One-third of children having short stature have celiac disease. The frequency of celiac disease in children with short stature has no association with gender and age.

Protocol for a feasibility study of longitudinal surveys to assess the impact of policies on tobacco use among school-going adolescents in South Asia

Background: Smokeless tobacco (ST) use is common among youth in South Asia where 85% of the world’s 300 million ST users live and use the most lethal ST forms. Little is known about the impact of tobacco control policies on the youth ST uptake in those countries. We planned to conduct longitudinal surveys among school going adolescents to evaluate existing tobacco control policies on tobacco uptake and use, and a feasibility study for that prospective, observational cohort study.

Study objectives: (1) To demonstrate the feasibility of selection, recruitment and retention of schools and of study participants; (2) To assess the feasibility and acceptability of the study procedure and study tool (questionnaire); (3) To evaluate if the questionnaire can assess tobacco uptake and use, and their potential predictors.

Methods and analysis: The feasibility study will be conducted in two administrative areas within each of three South Asian countries: Bangladesh, India and Pakistan. We will use both quantitative and qualitative data collection methods. Eight eligible schools will be randomly selected within purposively selected sub-districts from each country. We plan to conduct one baseline and one follow up survey among students of grade 6-8, one year apart. At each time point, data on tobacco uptake and potential predictors will be collected from students via self-administered questionnaires that were designed for the longitudinal study. The qualitative component will be embedded into the study with each round of data collection to assess the acceptability of the study instrument (questionnaire) and data collection methods, via focus group discussions with students and semi-structured interviews with schoolteachers.

Recruitment and retention rates, completeness of the questionnaires, frequencies and associations of tobacco use and explanatory variables will be reported. Data gathered from the focus group and interviews will be analysed using the framework approach.

BACTERIAL SPECTRUM AND ANTIMICROBIAL PATTERN OF BLOOD STREAM INFECTIONS ASSOCIATED WITH NON-TUNNELED DOUBLE LUMEN CATHETER IN HEMODIALYSIS PATIENTS

Objective: To assess Bacterial spectrum and antimicrobial pattern of Blood Stream Infections associated with non-tunneled double lumen catheter in hemodialysis patients. Study Design: Prospective observational study. Place and Duration of Study: Department of Nephrology, Pakistan Emirates Military Hospital Rawalpindi Pakistan; Armed Forces Institute of Pathology Rawalpindi, Pakistan, from May 2019 to Apr 2020. Methodology: A total of 753 patients underwent placement of non-tunneled double lumen catheter (457 femoral, 296 Internal Jugular). Patients with clinically suspected bloodstream infections had their catheters removed with tips being sent for culture along with 2 sets of peripheral blood cultures. Patients were labelled as having bloodstream infection if growth of organism was detected in catheter tip and at least one peripheral blood culture. Susceptibility testing was done for available antimicrobials. Results: One hundred and thirty six (18.06%) incidences or 5.48 bloodstream infections per 1000 catheter days, with confirmed growth on blood cultures were identified. Gram positive infections were seen in 76 (55.88%) individuals with most common organism being coagulase-negative Staphylococcus (28.68%), followed by Staphylococcus aureus (21.32%). These organisms had low resistance rates to Vancomycin (0%), Tigecycline (0%), Doxycycline (6.6%) and Linezolid (9.5%). Gram negative infections were seen in 60 (44.11%) patients with Klebsiella pneumoniae (13.24%) being the most commonly identified pathogen followed by Acinetobacter baumannii (12.50%) and had relatively higher degree of antimicrobial resistance. Conclusion: Gram positive organisms were the most common cause of bloodstream infection in this study and were found susceptible to vancomycin and doxycycline whereas gram-negative organisms had high rates of antimicrobial......

Novel IL-β12R1 deficiency-mediates recurrent cutaneous leishmaniasis

BACKGROUND

The IL-12/IFN-γ axis plays a vital role in the control of intramacrophagic pathogens including Leishmania infections.

OBJECTIVE

The aim of this study was to investigate genetic defects in the IL-12/IFN-γ axis in cutaneous leishmaniasis patients, using immunological and genetic evaluation.

METHODS

Enzyme-linked immunosorbent assay was used to quantify IFN-γ , while flow cytometry was performed to analyze surface IL-12Rβ1/IL-12Rβ2 expression and phosphorylation of signal transducers as well as the activator of transcription 4 (pSTAT4). Sequencing was carried out for genetic analysis.

RESULTS

The peripheral blood mononuclear cells from the two patients (P1 and P2) demonstrated impaired production of IFN-γ. Furthermore, abolishment of the surface expression of Il-12Rβ1 was observed in lymphocytes, with consequent impairment of STAT4 phosphorylation in the lymphocytes of P1 and P2. IL-12Rββ1 deficiency was identified, which was caused by a novel homozygous missense mutation (c.485>T/p.P162L) and a novel homozygous nonsense mutation (c.805G>T/P.E269*) in the IL-12Rβ2 gene of P1 and P2, respectively. In silico analyses predicted these novel mutations as being pathogenic, causing truncated proteins, with consequent inactivation.

CONCLUSION

Our data have expanded the phenotype and mutation spectra associated with IL-12Rβ1 deficiency, and suggest that patients with CL should be screened for mutations in genes of the IL-12/IFN-γ axis.

Prevalence of Parental refusal rate and its associated factors in routine immunization by using WHO Vaccine Hesitancy tool: A Cross sectional study at district Bannu, KP, Pakistan

OBJECTIVE

To determine the vaccination refusal rate, associated factors and perceptions of parents who refused routine immunization for their children using the World Health Organization (WHO) SAGE Working Group on Vaccine Hesitancy Survey Tool.

MATERIALS AND METHODS

A cross-sectional survey was conducted using multi-stage cluster sampling in Bannu District, Khyber Pakhtunkhwa Province, Pakistan from March 2019 to July 2019. A WHO validated questionaire was used. The outcome variable was parental refusal of routine immunization of their children. Logistic regression was performed for associations, and multi-regression was applied to identify any confounders.

RESULTS

Of 610 parents, 170 (27.9%) refused vaccination of their children. Of these, the majority of mothers had no education [n = 145 (85.3%); p = 0.03], and mothers were less likely to own a mobile phone than fathers [24 (14.1%) vs 152 (89.4%); p ≤ 0.001]. The vaccination refusal rate was higher in parents with food security [n = 88 (51.8%)] compared with parents with minimal food insecurity [n = 62 (36.5%)] and high food insecurity [20 (11.8%); p ≤ 0.05)]. On multi-variate logistic regression, fathers who were employed [adjusted odds ratio (OR) 0.59, 95% confidence interval (CI) 0.37-0.94; p = 0.02] and had a high level of education (adjusted OR 0.21, 95% CI 0.08-0.50; p ≤ 0.001) were less likely to refuse vaccination of their children. Parents with high food insecurity were more likely to refuse vaccination of their children (adjusted OR 2.2, 95% CI 1.0-0.50; p = 0.04) compared with parents with minimal food insecurity (adjusted OR 1.6, 95% CI 1.0-2.5; p = 0.02).

CONCLUSION

The vaccination refusal rate was very high among parents, and this was associated with inability to read or write, no education, owning a mobile phone, unemployment and food security.

Potential Chikungunya Epidemics In Pakistan: Act Before It's Too Late

First Chikungunya outbreak occurred in Karachi, Pakistan in 2016. Chikungunya is transmitted by the Aedes mosquito which is also transmits Dengue fever. The first Dengue fever outbreak of Pakistan also occurred in Karachi in 1994. In the past 23 years the disease has spread to all parts of the country. This is comprehensible as there is a lot of travelling between Karachi and other parts of the country which increases the chances of spread of the virus. Based on the precedent of Dengue fever in Pakistan, if appropriate preventive measures are not taken to control Chikungunya, it will only be a matter of time before it hits other parts of the country. At the same time International Health Regulations has to be practiced with all its zest to avoid introduction of diseases like Zika virus and yellow fever, which are also transmitted by Aedes.

Leishmaniasis in Northern Syria during Civil War

Since the onset of the ongoing civil war in Syria, the governmental surveillance system for leishmaniasis has lost access to provinces of northern Syria. The MENTOR Initiative, an international not-for-profit organization, was commissioned to implement an integrated leishmaniasis control program, providing an opportunity to reassess the epidemiology of leishmaniasis in northern Syria. Epidemiologic data and biologic samples for molecular species diagnostics were collected from collaborating local health centers. Incidence peaked in March 2015 at 7,743 estimated monthly cases. High levels of transmission were observed in traditional endemic regions but extended to previously hypoendemic regions, such as Al-Raqqa and Al-Hasakah. Incidence decreased to 3,209 in July 2015. Data indicate that the prewar trend of increasing incidence of cutaneous leishmaniasis accelerated during the beginning of armed conflict but declined after implementation of the comprehensive control program by the MENTOR Initiative. Molecular analysis revealed a spectrum of Leishmania species and sporadic cases of visceral leishmaniasis.

Outbreak of Crimean-Congo haemorrhagic fever with atypical clinical presentation in the Karak District of Khyber Pakhtunkhwa, Pakistan

Background

Crimean-Congo haemorrhagic fever (CCHF) is a potentially fatal disease endemic in Pakistan. The causative virus is transmitted by the bite of Hyalomma ticks or by contact with infected blood or tissue. First cases of the disease were reported in Pakistan in 1976 but regular outbreaks have been observed since the year 2000. A huge agricultural base with more than 175 million livestock, the concomitant presence of Hyalomma ticks and a lack of precautionary measures to prevent transmission lead to a considerable risk for exposed populations to contract CCHF in Pakistan. At the same time, secondary cases contracted by nosocomial transmission are reported from hospitals.

Case presentation

Here we present an outbreak of CCHF with four of six patients succumbing to the disease before the suspicion for CCHF was raised. Importantly, the main clinical features of these cases were gastrointestinal symptoms without any clinical signs of bleeding. Only the last two patients in this outbreak presented with typical signs of bleeding disorder and were then confirmed being infected by CCHF. Confirmation of diagnosis was done at the National Institute of Health by real-time RT-PCR.

Conclusions

This case series highlights the importance of early clinical suspicion for CCHF in exposed individuals and the need for improved precautionary measures against the spread of CCHF within the Pakistani population and hospitals.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0499-z) contains supplementary material, which is available to authorized users.

Health-related quality of life after maxillectomy: obturator rehabilitation compared with flap reconstruction

Health-related quality of life (QoL) reported by patients has the potential to improve care after ablative surgery of the midface, as existing treatment algorithms still generally revolve around outcomes assessed traditionally only by clinicians. Decisions in particular relate to reconstruction with a flap compared with rehabilitation with an obturator, the need for adjuvant treatment, and morbidity related to the size of the defect. We prospectively collected health-related QoL assessments for 39 consecutive patients treated by maxillectomy between 01 January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire, and who had a mean (SD) duration of follow-up of 14 (4). We made sub-group analyses using paired t tests and analysis of variance (ANOVA) to compare reconstruction with a flap with rehabilitation with obturators, size of the vertical defect, and whether adjuvant treatment with radiotherapy or chemoradiotherapy adversely affected it. Overall there was a significant decrease in health-related QoL after treatment compared with before (p<0.001), but there was no significant difference in the effects of any of the paired reconstructive and rehabilitation treatments on it. Obturators remain an important option for rehabilitation in selected patients in addition to reconstruction with a flap. We found that neither increasing the size of the vertical defect (in an attempt to ensure clear margins) nor the use of postoperative radiotherapy seemed to have any adverse effect on QoL. More patients are required before we can conclude that the potential survival benefits of such measures may outweigh any adverse effects.

Evaluation of biochemical markers during somatic embryogenesis in Silybum marianum L

In present report effects of explants type, basal media and plant growth regulators (PGRs) were tested for induction of indirect somatic embryogenesis in medicinally important plant Silybum marianum L. Leaf, petiole and root explants were exploited in vitro on B5 (Gamborg), SH (Schenk and Hildebrandt) and MS (Murashige and Skoog) media for induction of embryogenic callus followed by somatic embryogenesis. Highest callus induction frequency (76 ± 4.8 %) was recorded when petiole explants of in vitro derived plantlets were cultured on B5 medium supplemented with 1.5 mg l⁻¹ 2,4-dichlorophenoxyacetic acid (2,4_D) in combination with 1.5 mg l⁻¹ Thidiazuron (TDZ). Induction and multiplication of somatic embryos were observed, when the embryogenic calluses were sub-cultured on to B5 medium containing 0.5 mg l⁻¹ 2,4-D plus 1.5 mg l⁻¹ TDZ. At this PGRs treatment, 77 % of the cultures responded with 39.1 somatic embryos per callus. Furthermore, MS0 medium was indicated more reponsive for growth and maturation of somatic embryos. Analysis of biochemical markers during various growth phases in somatic embryogenesis revealed that somatic embryos exhibited highest level of total carbohydrate, starch, ascorbic acid and total free amino acids. However, higher protein levels were detected in non-embryogenic callus. Nevertheless, considerable amount of silymarin (4.1 mg g⁻¹ DW) was detected in somatic embryos than other growth phases. Thus, the present study concluded that biochemical and physiological changes during embryogenesis are influenced by interplay of explants type, basal media and PGRs.

Effect of mild medical hypothermia on in vitro growth of Plasmodium falciparum and the activity of anti-malarial drugs

Background

Cerebral malaria remains a medical emergency with high mortality. Hypo-perfusion due to obstructed blood vessels in the brain is thought to play a key role in the pathophysiology of cerebral malaria leading to neurological impairment, long-term neuro-cognitive sequelae and, potentially, death. Due to the rapid reversibility of vascular obstruction caused by sequestered Plasmodium falciparum, it is hypothesized that mild medical hypothermia—a standard intervention for other medical emergencies—may improve clinical outcome. This preclinical in vitro study was performed to assess the impact of mild hypothermia on parasite growth and the intrinsic activity of anti-malarials drugs.

Methods

Three laboratory-adapted clones and two clinical isolates were used for growth assays and standardized drug sensitivity assessments using the standard HRP2 assay. All assays were performed in parallel under normothermic (37 °C), mild hypothermic (32 °C), and hyperthermic (41 °C) conditions.

Results

Parasite growth was higher under standard temperature condition than under hypo- or hyperthermia (growth ratio 0.85; IQR 0.25–1.06 and 0.09; IQR 0.05–0.32, respectively). Chloroquine and mefloquine had comparable in vitro activity under mild hypothermic conditions (ratios for IC50 at 37 °C/32 °C: 0.88; 95 % CI 0.25–1.50 and 0.86; 95 % CI 0.36–1.36, respectively) whereas dihydroartemisinin was more active under mild hypothermic conditions (ratio for IC50 at 37 °C/32 °C: 0.27; 95 % CI 0.19–0.27). Hyperthermia led by itself to almost complete growth inhibition and precluded further testing of the activity of anti-malarial drugs.

Conclusion

This preclinical evaluation demonstrates that mild medical hypothermia inhibits in vitro growth of P. falciparum and enhances the pharmacodynamic activity of artemisinin derivatives. Based on these preclinical pharmacodynamic data, the further clinical development of mild medical hypothermia as adjunctive treatment to parenteral artesunate for cerebral malaria is warranted.

An ethno botanical perspective of traditional medicinal plants from the Khattak tribe of Chonthra Karak, Pakistan

ETHNO PHARMACOLOGICAL RELEVANCE

The present study was carried out with an aim to gather, evaluate and analyze the ethno botanical information of medicinal uses of the plant species possessed by the native Khattak tribe of the Chonthra, district Karak Pakistan. The region with poor documentation of traditional knowledge, preserving the local traditional knowledge, reporting new as well as rarely reported medicinal properties of medicinal plants, to be tested experimentally for validation.

MATERIAL AND METHOD

The medicinal uses of existing plant species were documented by oral communication with 103 people, all over above 60 years of age, born and residing in Chonthra. Information was gathered by semi-structured interviews with further analysis by indices like Relative frequency citation RFC and Medicinal use value MUV.

RESULTS

The study resulted with medicinal information on 66 plants species belonging to 34 families (using against 58 health related problems with 83 different preparations mainly administered orally and topical). The dominant families include Brasicaceae and Limiaceae. Withania coagulans and Pegnum harmala were the plant species quoted 100% by the informants with RFC values 1 each. The MUV were scattered between 1.24 and 0.03. The highest MUV were W. coagulans 1.24, Pegnum harmala 1.18, Fagonia cretica 1.14. This study for the first time include Nepeta lagopsis to the ethnobotanical wealth.

CONCLUSIONS

This study was an extension to the ethnobotanical research conducted in Khyber Pakhtunkhwa (KPK) Pakistan. The target area being small and less number of plants with limited traditional knowledge can serve basis for further work focusing on rarely or non- reported plant species of pharmacological and phytochemical importance with active metabolite capable of broadening the sources of new drugs.

Adherence of patients to long-term medication: a cross-sectional study of antihypertensive regimens in Austria

OBJECTIVE

The objective of this study was to evaluate adherence and causes for non-adherence to antihypertensive therapy in Austrian patients. A special focus was placed on social parameters and behavioural theories.

METHODS

Patients were invited via advertisements in community pharmacies in Austria to complete an online survey. Inclusion criteria were an age of 18 years or older, a diagnosis of arterial hypertension and a current prescription of antihypertensive medication. Adherence was measured by the four-item Morisky scale. Non-adherence was defined by at least one point in the Morisky scale. Several demographic, social and behavioural parameters were analysed as potential co-variables associated with adherence.

RESULTS

A total of 323 patients completed the online survey, of which 109 (33.7%) met the criteria for non-adherence. In a multivariable model, self-efficacy and age were associated with adherence, whereas intention and barriers were linked to non-adherence; 56 patients (17.3%) were classified as intentionally non-adherent.

CONCLUSION

This study demonstrates that non-adherence affects an important proportion of patients in the treatment of arterial hypertension. Young age was a particularly important risk factor for non-adherence, and this patient population is, therefore, in need of special attention. Modifiable risk factors were identified that could help improving the treatment of arterial hypertension and potentially other chronic conditions.

Evaluation of intermittent preventive treatment of malaria against group B Streptococcus colonization in pregnant women: a nested analysis of a randomized controlled clinical trial of sulfadoxine/pyrimethamine versus mefloquine

OBJECTIVES

Streptococcus agalactiae constitutes an important cause of neonatal infections in sub-Saharan Africa. Sulfadoxine/pyrimethamine-the current intermittent preventive treatment of malaria in pregnancy (IPTp)-has proven in vitro activity against group B Streptococcus (GBS). Because of specific drug resistance to sulfadoxine/pyrimethamine, mefloquine-an antimalarial without in vitro activity against GBS-was evaluated as a potential alternative. This study assessed the potential of sulfadoxine/pyrimethamine-IPTp to reduce the prevalence of GBS colonization in pregnant women in Gabon when compared with the inactive control mefloquine-IPTp.

METHODS

Pregnant women participating in a randomized controlled clinical trial evaluating mefloquine-IPTp versus sulfadoxine/pyrimethamine-IPTp were invited to participate and recto-vaginal swabs were collected at delivery for detection of GBS colonization. Prevalence of recto-vaginal GBS colonization was compared between IPTp regimens and risk factor and birth outcome analyses were computed.

RESULTS

Among 549 participants, 106 were positive for GBS colonization at delivery (19%; 95% CI = 16%-23%). Prevalence of maternal GBS colonization showed no significant difference between the two IPTp regimens (mefloquine-IPTp: 67 of 366 women = 18%; 95% CI = 14%-22%; sulfadoxine/pyrimethamine-IPTp: 39 of 183 women = 21%; 95% CI = 15%-27%). Risk factor analysis for GBS colonization demonstrated a significant association with illiteracy (adjusted OR = 2.03; 95% CI = 1.25-3.30). GBS colonization had no impact on birth outcome, anaemia at delivery, gestational age and birth weight.

CONCLUSIONS

Sulfadoxine/pyrimethamine did not reduce colonization rates when used as the IPTp drug during pregnancy. Illiteracy was associated with GBS colonization.

Characterization of immunomodulatory activities of honey glycoproteins and glycopeptides

Recent evidence suggests an important role for natural honey in modulating immune response. To identify active components responsible, this study investigated the immunomodulatory properties of glycoproteins and glycopeptides fractionated from Ziziphus honey. Honey proteins/peptides were fractionated by size exclusion chromatography into five peaks with molecular masses in the range of 2-450 kDa. The fractionated proteins exhibited potent, concentration-dependent inhibition of reactive oxygen species production in zymosan-activated human neutrophils (IC50 = 6-14 ng/mL) and murine macrophages (IC50 = 2-9 ng/mL). Honey proteins significantly suppressed the nitric oxide production by LPS-activated murine macrophages (IC50 = 96-450 ng/mL). Moreover, honey proteins inhibited the phagocytosis latex bead macrophages. The production of pro-inflammatory cytokines IL-1β and TNF-α by human monocytic cell line in the presence of honey proteins was analyzed. Honey proteins did not affect the production of IL-1β; however, TNF-α production was significantly suppressed. These findings indicated that honey glycoproteins and glycopeptides significantly interfere with molecules of the innate immune system.

In vitro activity of immunosuppressive drugs against Plasmodium falciparum

Background

Solid organ transplant recipients are particularly vulnerable for infectious diseases due to prolonged immunosuppressive treatment. Residents of endemic regions and travellers may be exposed to malaria and may, therefore, require prolonged antimalarial chemoprophylaxis. The hypothesis of this study was that certain immunosuppressive drugs may exert clinically relevant anti-malarial activity. It was therefore designed to assess the intrinsic anti-malarial activity of everolimus, mycophenolic acid, and rapamycin against Plasmodium falciparum in an in vitro model.

Methods

Three laboratory adapted clones of P. falciparum and two isolates were used to assess the potential of mycophenolic acid, rapamycin and everolimus to inhibit in vitro growth of P. falciparum. The standard histidine rich protein 2 assay was employed and inhibitory drug concentrations (IC) were computed by non-linear regression analysis.

Results

All drugs were associated with complete inhibition of P. falciparum growth in in vitro assays. Mycophenolic acid demonstrated IC₅₀ and IC₉₀ values of 5.4 μmol/L and 15.3 μmol/L. Rapamycin inhibited P. falciparum growth at 7.2 μmol/L (IC₅₀) and 12.5 μmol/L (IC₉₀), respectively. Finally, everolimus displayed IC₅₀ and IC₉₀ values of 6.2 μmol/L and 11.5 μmol/L. There was no difference in in vitro activity against chloroquine sensitive or chloroquine resistant parasites.

Conclusions

All immunosuppressive drugs evaluated in this in vitro study demonstrated activity against P. falciparum. Inhibitory concentrations of mycophenolic acid are within clinically achievable plasma concentrations when used in solid organ transplant recipients. Further in vivo evaluation of mycophenolic acid either alone or in combination regimens may prove promising for the concomitant prevention of P. falciparum in solid organ transplant recipients living or travelling in malaria endemic regions.

The use of foam sclerotherapy to treat low-flow vascular malformations of the head and neck

Liquid sclerotherapy, laser and surgery have been used in the treatment of head and neck vascular anomalies with variable success for many years. A multidisciplinary team consisting of plastic surgery, maxillofacial surgery and interventional radiology currently treats such lesions by converting liquid sclerosant into foam. Foam sclerotherapy is currently used successfully to treat varicosities of the lower limbs and in this study, we present four cases in which 3% sodium tetradecyl sulfate has been used to treat low-flow vascular malformations in the head and neck.

Development and in-vitro characterization of fish oil oleogels containing benzoyl peroxide and salicylic acid as keratolytic agents

Topical keratolytic agents such as benzoyl peroxide (BP) and salicylic acid (SA) are one of the common treatments for inflammatory skin diseases. However, the amount of drug delivery through the skin is limited due to the stratum corneum. The purposes of this study were to investigate the ability of fish oil to act as penetration enhancer for topical keratolytic agents and to determine the suitable gelator for formulating stable fish oil oleogels. 2 types of gelling agents, beeswax and sorbitan monostearate (Span 60), were used to formulate oleogels. To investigate the efficacy of fish oil oleogel permeation, commercial hydrogels of benzoyl peroxide (BP) and salicylic acid (SA) were used as control, and comparative analysis was performed using Franz diffusion cell. Stability of oleogels was determined by physical assessments at 20°C and 40°C storage. Benzoyl peroxide (BP) fish oil oleogels containing beeswax were considered as better formulations in terms of drug permeation and cumulative drug release. All the results were found to be statistically significant (p<0.05, ANOVA) and it was concluded that the beeswax-fish oil combination in oleogel can prove to be beneficial in terms of permeation across the skin and stability.

Influence of beta-cyclodextrin and chitosan in the formulation of a colon-specific drug delivery system

The increase in diseases of the colon underscores the need to develop cost-effective site-directed therapies. We formulated a polysaccharide-based matrix system that could release ibuprofen under conditions simulating those in the colon by employing a wet granulation method. Tablets were prepared in a series of formulations containing a polysaccharide (beta-cyclodextrin and chitosan) matrix system along with ethylcellulose. We characterized physicochemical properties and performed an in vitro drug release assay in the absence and presence of digestive enzymes to assess the ability of the polysaccharides to function as a protective barrier against the upper gastrointestinal environment. Fourier transform infrared spectroscopy studies revealed no chemical interaction between ibuprofen and polysaccharides; however, spectrum analysis suggested the formation of an inclusion complex of beta-cyclodextrin with ibuprofen. The formulations contained 50% ethylcellulose and 50% beta-cyclodextrins (1:1) were proven to be the better formulation that slowly released the drug until 24 h (101.04 ± 0.65% maximum drug release in which 83.08 ± 0.89% drug was released in colonic medium) showed better drug release profiles than the formulations containing chitosan. We conclude that a beta-cyclodextrin drug carrier system may represent an effective approach for treatment of diseases of the colon.

The strong prognostic value of KELIM, a model-based parameter from CA 125 kinetics in ovarian cancer: data from CALYPSO trial (a GINECO-GCIG study)

BACKGROUND

Unexpected results were recently reported about the poor surrogacy of Gynecologic Cancer Intergroup (GCIG) defined CA-125 response in recurrent ovarian cancer (ROC) patients. Mathematical modeling may help describe CA-125 decline dynamically and discriminate prognostic kinetic parameters.

METHODS

Data from CALYPSO phase III trial comparing 2 carboplatin-based regimens in ROC patients were analyzed. Based on population kinetic approach, serum [CA-125] concentration-time profiles during first 50 treatment days were fit to a semi-mechanistic model with following parameters: "d[CA-125]/dt=(KPROD∗exp (BETA∗t))∗Effect-KELIM∗[CA-125]" with time, t; tumor growth rate, BETA; CA-125 tumor production rate, KPROD; CA-125 elimination rate, KELIM and K-dependent treatment indirect Effect. The predictive values of kinetic parameters were tested regarding progression-free survival (PFS) against other reported prognostic factors.

RESULTS

Individual CA-125 kinetic profiles from 895 patients were modeled. Three kinetic parameters categorized by medians had predictive values using univariate analyses: K; KPROD and KELIM (all P<0.001). Using Cox multivariate analysis, 5 independent predictors of PFS remained significant: GCIG CA-125 response (favoring carboplatin-paclitaxel arm), treatment arm, platinum free-interval, measurable lesions and KELIM (HR=0.53; 95% CI 0.45-0.61; P<0.001).

CONCLUSIONS

Mathematical modeling of CA-125 kinetics in ROC patients enables understanding of the time-change components during chemotherapy. The contradictory surrogacy of GCIG-defined CA-125 response was confirmed. The modeled CA-125 elimination rate KELIM, potentially assessable in routine, may have promising predictive value regarding PFS. Further validation of this predictive marker is warranted.

A biochemical and histopathologic study showing protection and treatment of gentamicin-induced nephrotoxicity in rabbits using vitamin C

Gentamicin and vitamin C have been proposed as nephrotoxic and antioxidant, respectively. This study involved biochemical and histopathologic investigation showing protection and treatment of gentamicin-induced nephrotoxicity in rabbits using vitamin C for 26 days hypothesizing that whether vitamin C would inhibit or decrease the raised serum urea and creatinine levels. This study was conducted on 25 healthy male albino rabbits (average weight 1.5±0.2 kg), classified into 5 groups: group A, B, C, D and E for nephrocurative (study-I) and nephroprotective (study-II) studies. Control group of rabbits (group A) received only the vehicle of gentamicin ampoule. In study-I, gentamicin sulphate (GS 80 mg/kg, i.m.) was administered to group B and C rabbits for ten days, then group C rabbits received vitamin C 250 mg/Kg for remaining 16 days. Group D and E received GS 80 mg/kg and GS 80 mg/kg i.m.-vitamin C 250 mg/kg orally, respectively during whole period (26 days) of study-II. After 26 days, various biochemical parameters, i.e. serum creatinine, blood urea nitrogen (BUN), and serum antioxidant activity, and histopathologic investigations were made. Nephrotoxicity was observed in rabbit groups B, C and D as evident from significant (p<0.05) high levels of serum creatinine and BUN and low serum antioxidant levels as compared to the levels of control group. Decrease in the levels of serum creatinine and BUN along with the increase in serum antioxidant activity was observed after vitamin C treatment in group C. While, renal-protective role of vitamin C was seen in group E as compared to the control. In conclusion, Gentamicin induced nephrotoxicity can be attenuated or treated using vitamin C.

Non-Hodgkins Lymphoma presenting as Garcin’s Syndrome

An 80 year old man presented with a twelve month history of progressive multiple unilateral cranial nerve palsies. A gadolinium enhanced MRI scan of his head and neck was performed. This showed an extra-axial enhancing lesion, which enveloped the hemi-mandible at the level of the left inferior alveolar nerve, and a dumbbell shaped lesion within the cerebellopontine angle. An incisional biopsy was performed to gain a tissue diagnosis, which demonstrated a Non-Hodgkin’s Lymphoma. The combination of signs, symptoms and radiological findings enabled a diagnosis of Garcin’s Syndrome secondary to Non-Hodgkin’s Lymphoma.

Surgical Technique for Retroperitoneoscopic Nephrectomy: A case report

A case of right non-functioning kidney secondary to chronic pyelonephritis is presented. The successful management through retroperitoneoscopic nephrectomy is described, emphasising the technique of this minimally invasive therapeutic option.

Traumatic pseudolipoma: herniation of buccal fat pad, a report of two cases

Traumatic pseudolipoma is a term used to describe intra-oral herniation of the buccal fat pad. A tear of the buccinator muscle and buccal mucosa allows the buccal fat pad to extrude into the oral cavity. Initially, the lesion can suggest a more sinister cause, but a history of trauma, an absence of mass before the accident, anatomical site and fatty appearance should suggest a diagnosis of traumatic herniation of buccal fat pad. This injury is rare, but two cases presented to the authors' hospital over a period of 3 months.

Function preservation with multimodality treatment in locally advanced oral tongue cancer

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Background: Total or near total glossectomy with postoperative radiation is a standard treatment option for locally advanced squamous cell carcinoma oral tongue (LASCCOT). However, the procedure is controversial due to dismal cure rates and major functional deficits that impact on speech, deglutition and quality of life. We evaluated function preservation and survival outcome in LASCCOT treated with induction chemotherapy, limited surgery, and postoperative radiation/chemoradiation. Methods: We retrospectively identified 15 patients with LASCCOT treated with induction chemotherapy, limited surgery and postoperative radiation/chemoradiation at our institution between 04/07 - 04–08. M67%:F33% median age 50 years. Pretreatment AJCC stage as assessed on MRI was T2N+ (tumour crossing midline) 13%, T3N0 20%, T3N+ 47%, and T4N+ 20%. Prior to surgery induction chemotherapy, consisting of cisplatin 75 mg/m2 day 1 and gemcitabine 1 mg/m2 day 1 and 8 every three weeks for 2 cycles was given. Four to six weeks following second cycle of chemotherapy local excision of residual primary tumor with ipsilateral modified neck dissection was performed. Postoperative radiation dose was 60Gy/30 fractions. Post therapy pathological stage was ypT0N0 20%, ypT1N0 20%, ypT1N+ 40%, ypT2N+ 13%, and ypT3N+ 7%. Patients with ypN+ disease received concomitant 3 weekly cisplatin 75 mg/m2 with radiation. Results: Overall and disease free survival at 20 months was 60%. Twelve patients (80%) are alive and 3 patients (20%) have died of disease at 9, 14 and 14 months (locoregional failure 1 and distant metastasis 2 patients). In patients alive without disease assessment of deglutition and speech at the time of last follow up showed all patients on full oral diet with spontaneous intelligible speech. Conclusions: Multimodality treatment with induction chemotherapy, limited surgery and post operative radiation/chemoradiation may allow selected LASCCOT patients to avoid morbid surgery and preserve tongue function without compromising survival. This approach merits further investigation in clinical trials.

No significant financial relationships to disclose.

Primary squamous cell carcinoma of the oral cavity at presentation in Pakistan

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Background: Squamous cell carcinoma of oral cavity (SCCOC) is characterized by marked geographical differences in frequency and site distribution. Pakistan is situated within the high risk zone on the global oral cancer map. However, no reliable data exists on oral cancer in this area. Our aim was to determine clinicopathological features and patterns at presentation of primary SCCOC in a comprehensive cancer centre in Pakistan. Methods: Demographic, risk factors, pathological and AJCC staging data for SCCOC treated at Shaukat Khanum Memorial Hospital for the period November 2003-October 2008 were obtained from the head and neck unit database. Results: The database identified 666 patients with biopsy proven primary SCCOC. Mean age was 53 years (range 12 - 90 years). Male (428): Female (238) ratio was M64%:F36%. The occurrence of major risk factors for oral cancer specifically smoking, betel quid chewing, naswar (smokeless tobacco) and alcohol use in males (428) was 45% (193), 28% (118), 29% (126), 3% (13), and in females (238) was 8% (20), 29% (68), 13% (30), 0% (0), respectively. Thirty-eight percent (411/666) had no association with tobacco, betel quid or alcohol use. Subsite within oral cavity; anterior tongue 41.1% (274), buccal mucosa 26.6% (177), lower gingival and alveolus 19.5% (130), upper gingival and alveolus 4.1% (27), lips 3.6% (24), retromolar trigone 2.9% (19), hard palate 1.7% (11), and floor mouth 0.6 (4). Broder's/World Health Organization histological grade; grade I 52% (334), grade II 34% (226), grade III 7% (49), and unknown 5% (36). According to AJCC 2002 system 0.2% (1), 10.8% (72), 12.2% (81), 13.2% (88), and 63.7% (420) had stage 0, I, II, III, and IV, respectively. Conclusions: Approximately 80% of patients with primary SCCOC present with stage III or IV disease with anterior tongue as the most common subsite in our hospital. While tobacco and betel quid chewing can be attributed to development of SCCOC in a significant proportion of patients, nearly 38% are unlinked to typical risks factors suggesting other environmental and genetic agents as etiological factors in this region.

No significant financial relationships to disclose.

Trimodality treatment (TMT) for locally advanced esophageal cancer in Pakistan; Analysis of prognostic factors influencing survival

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Background: The prognosis of patients with locally advanced esophageal cancer is poor. TMT for locally advanced esophageal cancer is being utilized with increasing frequency. In this study, we investigate the prognostic factors influencing survival in patients with locally advanced esophageal cancer following TMT. Methods: The study included 22 patients with esophageal carcinoma treated between January 2003 and December 2005 at Shaukat Khanum Memorial Hospital and Research Centre. Median age was 49 years (range 26 - 68). There were 15 (68%) males and 7 (32%) females. All patients had EGD with biopsy and CT chest. Twelve (54.5%) had squamous cell carcinoma and 10 (45.5%) patients had adenocarcinoma. Five patients (23%) had tumour in the middle third and 17 (77%) had lower/gastroesophageal lesions. Preoperative radiation consisted of 50.4 Gy / 28 fractions with concomitant chemotherapy day 1 and 29 (Cisplatin 75 mg/m2 day 1 and infusional 5FU 1000 mg/m2 day 1–5). Esophagectomy was done at 6 - 12 weeks following chemoradiation. The pathologic down-staging was evaluated by the 5-score tumor regression grade (TRG) of Mandard. Results: Post TMT pathologic TNM stage was; Stage 0 in 8 pts (36%), stage II in 5 pts (23%) and stage III in 9 pts (41%). 13 (59%) pts had R0 and 9 (41%) pts had R1 resection. The 4-year disease free survival was 29% with a median survival of 19 months. The number of patients with TRG score 1, 2, 3, 4 and 5 were 7 (32%), 4 (18%), 5 (23%), 2 (9%) and 4 (18%) respectively. Tumor regression grade 1–2 (p=.0016) and negative circumferential margins >2 mm (p=.0019) had a positive influence on DFS. Age (< 50 vs ≥ 50 years), sex, hemoglobin at presentation (≤ 12 vs > 12 gm/dl), tumor site (middle vs lower/GE junction), pathological nodal status (node positive vs node negative) and histological subtype (squamous cell vs adenocarcinoma) did not influence survival (p= 0.92, p= 0.82, p= 0.69, p= 0.79, p= 0.41 and p= 0.32 respectively). Conclusions: TMT results in prolonged disease free survival in patients with complete response or microscopic residual foci (TRG 1–2). Positive or circumferential margins <2mm is associated with poor prognosis.

No significant financial relationships to disclose.

Cisplatin plus gemcitabine (GC) as induction chemotherapy in locally advanced head and neck cancer (HANC)

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Background: Cisplatin/infusional 5-fluorouracil chemotherapy is routinely administered as standard induction chemotherapy in advanced HANC. However, the optimum treatment remains to be defined. Gemcitabine is an active agent in HANC and few studies have evaluated induction GC in HANC. We have explored the activity and toxicity of GC as induction treatment in HANC and report the results. Methods: From August 2005 to September 2006, 55 patients with locally advanced HANC had induction chemotherapy with GC at Shaukat Khanum Memorial Cancer Hospital and Research Centre. We reviewed the medical records and prospectively collected data to determine activity and toxicity of induction GC. M:F ratio was 64%:36% with a median age of 50 years (range 19–80). All patients had histologically confirmed squamous cell carcinoma. The site of disease was nasopharynx, paranasal sinuses, oral cavity, oropharynx, larynx and hyopharynx in 4% (2), 11% (6), 51% (21), 2% (1), 11% (6) and 22% (11) respectively. According to AJCC staging 7% (4) had stage III and 93% (51) had stage IVa/IVb disease (T3N0 7%, T3N+ 2%, T4N0 38% and T4N+ 53%). Induction chemotherapy consisted of 2 cycles of cisplatin 75 mg/m2 day 1 and gemcitabine 1000 mg/m2 day 1 and 8 with treatment repeated three weekly. Fifty-three (94%) patients received 2 cycles as planned. Toxicity was scored after each cycle according to the NCI.CTC criteria. Response was assessed following completion of induction chemotherapy by clinical examination/MRI scan. Results: All patients were available for assessment of toxicity and response. A total of 111 cycles were delivered. The response rates are: complete 24% (13), partial 62% (34), no response 7% (4) and progression 7% (4). The overall response rate was 86% (complete 24%, partial 62%). No treatment related deaths occurred. Haematological G3/G4 toxicity included neutropenia (13%/7%) and thrombocytopenia (5%/0%). The non-haematological toxicity observed (nausea, vomiting and diarrhoea) was only G1/G2. Conclusions: GC is well tolerated with low toxicity and high anti tumour activity as neoadjuvant chemotherapy treatment in squamous cell head and neck cancer. Combination GC arm should be included in future trials.

No significant financial relationships to disclose.

Links between anaesthetic modality and nerve damage during lower third molar surgery

OBJECTIVE

To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery.

DESIGN

Two centre prospective longitudinal study.

SETTING

The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital.

SUBJECTS

A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery.

RESULTS

614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use ofa lingual retractor chi2 = 11.559, p = 0.003 was more significant than eruption status chi2 = 12.935, p = 0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator.

CONCLUSIONS

There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.