Medicine & Science in Sports & Exercise

Validity of Cardiorespiratory Fitness Measured with Fitbit Compared to VO2max Purpose Cardiorespiratory fitness (CRF), broadly defined as the body's ability to utilize oxygen, is a well-established prognostic marker of health, but it is not routinely measured. This may be due to the difficulty of acquiring high-quality CRF measures. The purpose of this study was to independently determine the validity of the Fitbit Charge 2's measure of CRF (Fitbit CRF). Methods 65 healthy adults between the ages of 18 and 45 (55% female, 45% male) were recruited to undergo gold standard VO2 max testing and wear a Fitbit Charge 2 continuously for one week during which they were instructed to complete a qualifying outdoor run to derive the Fitbit CRF (units: mL•Kg-1•min-1). This measure was compared with VO2 max measures (units: mL•Kg-1•min-1) epoched at 15 and 60 seconds. Results Bland Altman analyses revealed that Fitbit CRF had a positive bias of 1.59 mL•Kg-1•min-1 compared to laboratory data epoched at 15 seconds and 0.30 mL•Kg-1•min-1 compared to data epoched at 60 seconds (N=60). F statistics (2.09; 0.08) and p-values (0.133; 0.926) from Bradley-Blackwood tests for the concordance of Fitbit CRF with 15 and 60 second laboratory data, respectively, supports the null hypothesis of equal means and variances indicating there is concordance between the two measures. Mean absolute percentage error was less than 10% for each comparison. Conclusions The Fitbit Charge 2 provides an acceptable level of validity when measuring CRF in young, healthy, and fit adults who are able to run. Further research is required to determine if it is a potentially useful tool in clinical practice and epidemiological research to quantify, categorize, and longitudinally track risk for adverse outcomes. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Corresponding Author: Job G. Godino, PhD, 858-822-3749, jgodino@ucsd.edu, 9500 Gilman Drive #0811, La Jolla, CA 92093 The authors acknowledge funding support for the publication of this work from the Mobilize Center, a National Institutes of Health (NIH) Big Data to Knowledge Center of Excellence supported by NIH grant U54 EB020405. The authors have no conflicts of interest to report. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by ACSM. Accepted for publication: 3 May 2019. © 2019 American College of Sports Medicine

Supraspinal Control of Recurrent Inhibition during Anisometric Contractions Purpose Increase in recurrent inhibition was observed during eccentric compared with isometric and concentric maximal voluntary contractions but the neural mechanisms involved in this specific control of the Renshaw cell activity are unknown. This study was designed to investigate the supraspinal control of the recurrent inhibition during anisometric contractions of the plantar flexor muscles. Methods To that purpose, the paired Hoffmann-reflex (H-reflex) technique permitted to assess changes in homonymous recurrent pathway by comparing the modulations of test and conditioning H-reflexes (H' and H1 respectively) in the soleus muscle (SOL) during maximal and submaximal isometric, concentric and eccentric contractions. Submaximal contraction intensity was set at 50% of the SOL electromyographic activity recorded during maximal isometric contraction. 14 volunteer subjects participated in an experimental session designed to assess the activity of the recurrent inhibition pathway. Results The results indicate that the amplitude of H1 normalized to the maximal M-Wave were similar (p > 0.05) regardless of the muscle contraction type and intensity. Whatever the contraction intensity, the ratio between H' and H1 amplitudes was significantly decreased (p < 0.05) during eccentric compared with isometric and concentric contractions. Furthermore, this ratio was significantly smaller (p < 0.05) during submaximal compared with maximal contractions whatever the muscle contraction type. Conclusion Together, the current results confirm the supraspinal control of the Renshaw cell activity when muscle contraction intensity is modulated and show that this control remains similar for isometric, concentric and eccentric contractions. Data further suggest that recurrent inhibition pathway may serve as variable gain regulator at motoneuronal level to improve resolution in the control of motor output for the SOL during eccentric contractions. CORRESPONDING AUTHOR: Julien Duclay, University Paul Sabatier, Faculty of sport science, 118 route de Narbonne, F-31062 Toulouse Cedex 9, FRANCE. Mail: julien.duclay@univ-tlse3.fr No funding was received for this work. The authors have no conflicts of interest to declare. The results of the present study do not constitute endorsement by the American College of Sports Medicine. The authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Accepted for publication: 14 May 2019. © 2019 American College of Sports Medicine

Optimal Approach to Load Progressions during Strength Training in Older Adults Progressive resistance training (RT) is one of the most effective interventions for reducing age-related deficits in muscle mass and functional capacity. PURPOSE To compare four approaches to load progressions in RT for older adults to determine if an optimal method exists. METHODS 82 healthy community-dwelling older adults (71.8 + 6.2 y) performed 11 weeks of structured RT (2.5 days/week) in treatment groups differing only by the method used to increase training loads. These included percent 1RM (%1RM): standardized loads based on a percentage of the one repetition maximum (1RM); rating of perceived exertion (RPE): loads increased when perceived difficulty falls below 8/10 on the OMNI RES perceived exertion scale; repetition maximum (RM): loads increased when a target number of repetitions can be completed with a given load; repetitions in reserve (RiR): identical to RM except subjects must always maintain >1 'repetition in reserve', thus avoiding the possibility of training to temporary muscular failure. RESULTS Multiple analyses of covariance indicated no significant between-group differences on any strength (chest press 1RM; leg press 1RM) or functional performance outcome (usual walking speed, maximum walking speed, 8 foot timed up-and-go, gallon jug transfer test, 30 second sit-to-stand). The RPE group found the exercise to be significantly more tolerable and enjoyable than subjects in the RiR, RM, and %1RM groups. CONCLUSION Given the RM, RPE, %1RM, and RiR methods appear equally-effective at improving muscular strength and functional performance in an older population, we conclude that the RPE method is optimal because it is likely to be perceived as the most tolerable and enjoyable, which are two important factors determining older adults' continued participation in RT. Corresponding author: Dr. Andrew N.L. Buskard, Laboratory of Neuromuscular Research and Active Aging, Department of Kinesiology and Sport Sciences, University of Miami, 1507 Levante Avenue, Coral Gables, Florida, 33146, USA, Tel: +1 305 284 3105, Fax: +1 305 284 3003, E-mail: andrewbuskard@miami.edu No outside funding was obtained for this study, but equipment and laboratory support were provided by the University of Miami under the auspices of graduate research support for the first author's PhD in exercise physiology. The authors have no professional relationships with companies or manufacturers who will benefit from the results of the study. The results of this study do not constitute an endorsement by the American College of Sports Medicine (ACSM). The results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Accepted for Publication: 8 May 2019 © 2019 American College of Sports Medicine

The Effect of Growth Restriction on Voluntary Physical Activity Engagement in Mice INTRODUCTION The purpose of this study was to determine the effect of growth-restriction on the biological regulation of physical activity. METHODS Using a cross-fostering, protein restricted nutritive model, mice were growth-restricted during either gestation (GUN; N=3 litters) or postnatal life (PUN; N=3 litters). At 21 days of age, all mice pups were weaned and fed a non-restrictive healthy diet for the remainder of the study. At 45 days of age mice were individually housed in cages with free moving running wheels to assess physical activity engagement. At day 70, mice were euthanized, and the nucleus accumbens was analyzed for dopamine receptor 1 expression. Skeletal muscle fiber type and cross-sectional area of the soleus, extensor digitorom longus, and diaphragm were analyzed by immunohistochemistry. The soleus from the other hind leg was evaluated for calsequestrin 1 and annexin A6 expression. RESULTS The PUN female mice (15,365 ±8,844 revolutions·day-1) had a reduction (P=0.0221) in wheel revolutions per day as compared to the GUN (38,667±8648 revolutions·day-1) and CON females (36,421.0± 6,700 revolutions·day-1). PUN female mice also expressed significantly higher Drd1compared (P=0.0247) to the other groups. PUN female soleus had a higher expression of calsequestrin 1, along with more Type IIb fibers (P=0.0398). CONCLUSION Growth-restriction during lactation reduced physical activity in female mice by reducing the central drive to be active and displayed a more fatigable skeletal muscle phenotype. Address for correspondence: David P. Ferguson, 308 W. Circle Dr. Room 27S, East Lansing, MI, 48824, 517-355-4763, Fergu312@msu.edu This project was funded by Michigan State University Department of Kinesiology Start up funds. The authors have no conflicts of interest to report, and the results of this study are not endorsed by the ACSM. The results of this study are also presented clearly and honestly, without inappropriate data manipulation, fabrication, or falsification. Accepted for Publication: 4 May 2019 © 2019 American College of Sports Medicine

The Longitudinal Associations of Fitness and Motor Skills with Academic Achievement PURPOSE This study aimed to examine both independent and dependent longitudinal associations of physical fitness (PF) components with academic achievement. METHODS 954 4th-7th graders (9-15y [Mage=12.5y], 52% girls) from nine schools throughout Finland participated in a two-year follow-up study. Register-based academic achievement scores (grade point average [GPA]) and PF were assessed in the spring of 2013-2015. Aerobic fitness was measured with a maximal 20-m shuttle run test, muscular fitness with curl-up and push-up tests, and motor skills with a 5-leaps test and a throwing-catching combination test. Structural equation modelling was applied to examine the longitudinal associations adjusting for age, gender, pubertal stage, body fat percentage, learning difficulties and mother's education. RESULTS The change in aerobic and muscular fitness were positively associated with the change in GPA (B=0.27, 99% confidence interval CI=0.06-0.48; B=0.36, CI=0.11-0.63, respectively), while the change in motor skills were not associated with the change in GPA. Better motor skills in year 2 predicted better GPA a year later (B=0.06, CI=0.00-0.11; B=0.06, CI=0.01-0.11), while aerobic and muscular fitness did not predict GPA. GPA in year 1 predicted both aerobic (B=0.08, CI=0.01-0.15) and muscular (B=0.08, CI=0.02-0.15) fitness, and motor skills (B=0.08, CI=0.02-0.15) a year later. CONCLUSION The changes in both aerobic and muscular fitness were positively associated with change in academic achievement during adolescence, while the change in motor skills had only borderline significant association. However, better motor skills, although not systematically, independently predicted better academic achievement one year later, while aerobic or muscular fitness did not. Better academic achievement predicted better motor skills, aerobic and muscular fitness. Developmental changes in adolescence may induce parallel and simultaneous changes in academic achievement and PF. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Corresponding author: Heidi J. Syväoja, LIKES Research Centre for Physical Activity and Health, Jyväskylä, Finland, Rautpohjankatu 8, FI-40700, Finland, tel. +358 (0)400248133, fax +358207629501, heidi.syvaoja@likes.fi This study was funded by the Academy of Finland (grant 273971) and the Finnish Ministry of Education and Culture (OKM/92/626/2013). The authors declare that there are no conflicts of interest. The results of the present study do not constitute endorsement by ACSM. The Authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Accepted for publication: 26 April 2019. © 2019 American College of Sports Medicine

Estimating Tibial Stress throughout the Duration of a Treadmill Run Introduction Stress fractures of the tibia are a problematic injury amongst runners of all levels. Quantifying tibial stress using a modelling approach provides an alternative to invasive assessments that may be used to detect changes in tibial stress during running. This study aimed to assess the repeatability of a tibial stress model and to use this model to quantify changes in tibial stress that occur throughout the course of a 40-minute prolonged treadmill run. Methods Synchronised force and kinematic data were collected during prolonged treadmill running from fourteen recreational male rearfoot runners on two separate occasions. During each session, participants ran at their preferred speed for two consecutive 20-minute runs, separated by a 2-minute pause. The tibia was modelled as a hollow ellipse and bending moments and stresses at the distal 1/3 of the tibia were estimated using beam theory combined with inverse dynamics and musculoskeletal modelling. Results Intraclass correlation coefficients indicated good-to-excellent repeatability for peak stress values between sessions. Peak anterior and posterior stresses increased following 20 minutes of prolonged treadmill running and were 15% and 12% greater respectively after 40 minutes of running compared with the start of the run. Conclusion The hollow elliptical tibial model presented is a repeatable tool that can be utilised to assess within-participant changes in peak tibial stress during running. The increased stresses observed during a prolonged treadmill run may have implications for the development of tibial stress fracture. Corresponding author: Hannah Rice, PhD, Sport and Health Sciences, Richards Building, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK, H.Rice@exeter.ac.uk This research was supported by Brooks Running Company, Seattle, WA, USA. The authors declare no conflicts of interest. The results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by ACSM. Accepted for Publication: 8 May 2019 © 2019 American College of Sports Medicine

Myocardial Adaptations to Competitive Swim Training Purpose Swim training is performed in the prone or supine position and obligates water immersion, factors which may augment cardiac volume-loading more than other endurance sports. At present, prospective data defining the cardiac responses to swim training are lacking. We therefore studied myocardial adaptations among competitive swimmers in order to establish a causal relationship between swim training and left ventricular (LV) remodeling. Methods Collegiate swimmers were studied before and after a 90-day period of training intensification. Transthoracic echocardiography was used to examine LV structural and functional adaptations under resting conditions and during an acute LV afterload challenge generated by isometric handgrip testing (IHGT). A sedentary control population was identically studied with IHGT. Results In response to a discrete period of swim training intensification, athletes (n=17, 47% female, 19±0.4 years old) experienced eccentric LV remodeling, characterized by proportionally more chamber dilation than wall thickening, with attendant enhancements of resting LV systolic (LV twist) and diastolic (early and late phase tissue velocities) function. Compared to baseline and controls, athletes post training demonstrated greater systolic twist impairment during IHGT. However, training induced LV dilation coupled with gains in diastolic function offset this acquired systolic susceptibility to acute afterload resulting in relative preservation of stroke volume during IHGT. Conclusion Swim training, a sport characterized by unique cardiac loading conditions, stimulates eccentric LV remodeling with concomitant augmentation of systolic twist and diastolic relaxation. This volume mediated cardiac remodeling appears to result in greater systolic susceptibility to acute afterload challenge. Further work is required to establish how training-induced changes in function translate to human performance and whether these are accompanied by physiologic trade-offs with relevance to common forms of heart disease. Address for correspondence: Aaron Baggish, M.D. Cardiovascular Performance Program Massachusetts General Hospital 55 Fruit Street, Yawkey 5B Boston, MA, 02114 Email: abaggish@partners.org This study was funded in part by a research grant from the American Heart Association FTF2220328 (A.L.B.). The results of this study are presented clearly, honestly and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by the ACSM. CONFLICTS OF INTEREST: The authors have no conflicts of interest to report. Accepted for publication: 22 April 2019. © 2019 American College of Sports Medicine

The Physiological Roles of Carnosine and β-Alanine in Exercising Human Skeletal Muscle Carnosine (β-alanyl-L-histidine) plays an important role in exercise performance and skeletal muscle homeostasis. Dietary supplementation with the rate-limiting precursor β-alanine leads to an increase in skeletal muscle carnosine content, which further potentiates its effects. There is significant interest in carnosine and β-alanine across athletic and clinical populations. Traditionally, attention has been given to performance outcomes with less focus on the underlying mechanism(s). Putative physiological roles in human skeletal muscle include acting as an intracellular pH buffer, modulating energy metabolism, regulating Ca2+ handling and myofilament sensitivity, and scavenging of reactive species. Emerging evidence shows that carnosine could also act as a cytoplasmic Ca2+–H+ exchanger and form stable conjugates with exercise-induced reactive aldehydes. The enigmatic nature of carnosine means there is still much to learn regarding its actions and applications in exercise, health and disease. In this review, we examine the research relating to each physiological role attributed to carnosine, and its precursor β-alanine, in exercising human skeletal muscle. Corresponding Author: Prof. Craig Sale, Nottingham Trent University, Erasmus Darwin Building, Clifton Lane, Nottingham, United Kingdom, NG11 8NS. Tel: 0115 8483505, craig.sale@ntu.ac.uk No funding was received for writing this manuscript. GGA has been supported financially by Fundação de Amparo à Pesquisa do Estado de São Paulo (FASESP; grant number: 2014/11948-8). MDT has received a British Council award to support a studentship focused on research into carnosine (grant number: 209524711). JJM, GGA, and MDT collectively declare that they have no competing interests. CS has received β-alanine supplements free of charge from Natural Alternatives International (NAI) for use in experimental investigations; NAI have also supported open access page charges for some manuscripts. The review is presented honestly, and without fabrication, falsification, or inappropriate data manipulation. The viewpoints expressed in the review do not constitute endorsement by the American College of Sports Medicine. Accepted for Publication: 29 April 2019 © 2019 American College of Sports Medicine

Effects of Instrument-assisted Soft Tissue Mobilization on Musculoskeletal Properties Purpose Instrument-assisted soft tissue mobilization (IASTM) has been reported to improve joint range of motion (flexibility). However, it is not clear whether this change in the joint range of motion is accompanied by any alterations in the mechanical and/or neural properties. This study aimed to investigate the effects of IASTM in plantar flexors and Achilles tendon on the mechanical and neural properties of them. Methods This randomized, controlled, crossover study included 14 healthy volunteers (11 men and 3 women, 21–32 y). IASTM was performed on the skin over the posterior part of the lower leg for 5 min and targeted the soft tissues (gastrocnemii, soleus, and tibialis posterior muscles; overlying deep fascia; and Achilles tendon). As a control condition, the same participants rested for 5 min between pre and post measurements without IASTM on a separate day. The maximal ankle joint dorsiflexion angle (dorsiflexion range of motion), peak passive torque (stretch tolerance), and ankle joint stiffness (slope of the relationship between passive torque and ankle joint angle) during measurement of dorsiflexion range of motion and muscle stiffness of the triceps surae (using shear wave elastography) were measured before and immediately after the interventions. Results Following IASTM, the dorsiflexion range of motion significantly increased by 10.7 ± 10.8% and ankle joint stiffness significantly decreased by -6.2 ± 10.1%. However, peak passive torque and muscle stiffness did not change. All variables remained unchanged in the repeated measurements of controls. Conclusion IASTM can improve joint range of motion, without affecting the mechanical and neural properties of the treated muscles. Corresponding author: Naoki Ikeda, Faculty of Sport Sciences, Waseda University, Mikajima 2-579-15, Tokorozawa, Saitama 359-1192, Japan, Phone: +81-4-2947-6766, Fax: +81-4-2947-6766, E-mail: n.ikeda2@kurenai.waseda.jp This study was supported by JSPS KAKENHI (grant number 16H01870). The results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation, and the results of the present study do not constitute endorsement by the American College of Sports Medicine. The authors declare no conflict of interest. None of the authors has a professional relationship with any company or manufacturer who will benefit from the results of the present study. Accepted for Publication: 8 April 2019 © 2019 American College of Sports Medicine

Low-Carbohydrate Training Increases Protein Requirements of Endurance Athletes Introduction Training with low-carbohydrate (CHO) availability enhances markers of aerobic adaptation and has become popular to periodize throughout an endurance-training program. However, exercise-induced amino acid oxidation is increased with low muscle glycogen, which may limit substrate availability for post-exercise protein synthesis. We aimed to determine the impact of training with low-CHO availability on estimates of dietary protein requirements. Methods Eight endurance-trained males (27±4y, 75±10kg, 67±10ml·kg body mass-1·min-1) completed two trials matched for energy and macronutrient composition but with differing CHO periodization. In the low-CHO availability trial (LOW), participants consumed 7.8g CHO·kg-1 prior to evening high-intensity interval training (HIIT; 10 x 5 min at 10-km race pace, 1 min rest) and subsequently withheld CHO post-exercise (0.2g·kg-1). In the high-CHO availability trial (HIGH), participants consumed 3g CHO·kg-1during the day before HIIT, and consumed 5g CHO·kg-1that evening to promote muscle glycogen resynthesis. A 10km run (~80% HRmax) was performed the following morning, fasted (LOW) or 1h after consuming 1.2g CHO·kg-1 (HIGH). Whole-body phenylalanine flux (PheRa) and oxidation (PheOx) were determined over 8h of recovery via oral [13C]phenylalanine ingestion, according to standard indicator amino acid oxidation methodology, while consuming sufficient energy, 7.8g CHO·kg-1·d-1, and suboptimal protein (0.93g·kg-1·d-1). Results Fat oxidation (indirect calorimetry) during the 10-km run was higher in LOW compared to HIGH (0.99±0.35 vs. 0.60±0.26 g·min-1, p<0.05). PheRa during recovery was not different between trials (p>0.05) whereas PheOX (reciprocal of protein synthesis) was higher in LOW compared to HIGH (8.8±2.7 vs. 7.9±2.4 umol·kg-1·h-1, p<0.05), suggesting a greater amino acid requirement to support rates of whole-body protein synthesis. Conclusion Our findings suggest that performing endurance exercise with low-CHO availability increases protein requirements of endurance athletes. Address for Correspondence: Daniel R. Moore, Assistant Professor, Faculty of Kinesiology and Physical Education, University of Toronto, 100 Devonshire Place Toronto, ON M5S 2C9, CANADA, Tel:416-946-4088, Email: dr.moore@utoronto.ca This study was supported by grants to DRM from Ajinomoto Innovation Alliance Program, Canadian Foundations for Innovation and Ontario Research Fund. JBG held a Canadian Institutes of Health Research Postdoctoral Fellowship. The results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. The results of the present study do not constitute endorsement by ACSM. The authors report no conflicts of interest. Accepted for Publication: 6 May 2019 © 2019 American College of Sports Medicine

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Dermatology

Retraction: The measurement of serum tumor necrosis factor-alpha levels in patients with lichen planus Indian Journal of Dermatology 2019 64(3):165-165

Guidelines on management of atopic dermatitis in India: An evidence-based review and an expert consensus Murlidhar Rajagopalan, Abhishek De, Kiran Godse, DS Krupa Shankar, Vijay Zawar, Nidhi Sharma, Samipa Mukherjee, Aarti Sarda, Sandipan Dhar Indian Journal of Dermatology 2019 64(3):166-181 Background: Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin condition that affects all age groups. There was a dearth of consensus document on AD for Indian practitioners. This article aims to provide an evidence-based consensus statement for the management of AD with a special reference to the Indian context. This guideline includes updated definition, etiological factors, classification, and management of atopic dermatitis. Methodology: The preparation of guidelines was done in multiple phases. Indian Dermatology Expert Board Members (DEBM), recommended by the Skin Allergy Society of India, prepared 26 evidence-based recommendations for AD. An extensive literature search was done in MEDLINE, Google scholar, Cochrane, and other resources. Articles published in the past 10 years were reviewed and recommendations were graded based on the quality of evidence as per GRADE. After forming the initial structure, DEBM met in Mumbai and gave their decisions on an agree and disagree scale with an Indian perspective. Finally, their suggestions were compiled for preparing the article. After DEBM finalized the draft, a treatment algorithm was formulated for the management of AD. Results: DEBM suggested a working definition for AD. The panel agreed that moisturizers should be used as mainstay of therapy and should be continued in all lines of therapy and in maintenance phase. Topical corticosteroids and topical calcineurin inhibitors should be considered as the first line of treatment. Among systemic therapies, cyclosporin should be considered first line, followed by azathioprine, methotrexate, and mycophenolate mofetil. Phototherapy can be an effecive alternative. Empirical food restriction was recommended against. Conclusion: These guidelines should form a reference for the management of patients with AD in an evidence-based manner.

Evaluation of HCP5 and Chemokine C receptor type 5 gene polymorphisms in Indian psoriatic patients Deepa Rajesh, Sudeep Nagraj, KS Praveen Kumar, A V Moideen Kutty, Sharath Balakrishna Indian Journal of Dermatology 2019 64(3):182-186 Background: Genetic variations associated with nonprogression of HIV infection to AIDS are enriched in psoriasis patients. HCP5 gene 335 T > G and chemokine C receptor type 5 (CCR5) gene Δ32 polymorphisms are associated with HIV nonprogression phenotype. Aim: The aim of this study was to determine the association of HCP5 gene 335 T > G (rs2395029) and CCR5 gene Δ32 (rs333) polymorphisms with psoriasis vulgaris (PV). Materials and Methods: Genotype of HCP5 gene 335 T > G and CCR5 gene Δ32 polymorphisms were determined by polymerase chain reaction (PCR)-restriction fragment length polymorphism and allele-specific PCR methods, respectively. Results: The frequency of HCP5 gene 335 T > G SNP was ~7 times higher in PV patients than in the control group (P = 1.49 × 10–8; odds ratio [OR] = 10.2; 0.95 confidence interval [CI]: 3.9–26.8). OR for the occurrence of HCP5 335 G allele in either homozygous or heterozygous genotype in PV patients was 13.1 (0.95 CI: 4.7–36.1). The strength of association was higher with moderate-to-severe subgroup (P = 3.29 × 10–9; OR = 18.4; 0.95 CI: 6.2–54.9) than with mild subgroup (P = 2.1 × 10–4; OR = 8.3; 0.95 CI: 2.6–23.3). In addition, the strength of association was higher with Type I (P = 9.53 × 10–8; OR = 15.3; 0.95 CI: 5.1–46.5) than with Type II subgroup (P = 6.8 × 10–6; OR = 11.0; 0.95 CI: 3.6–33.9). Type I gene Δ32 polymorphism was observed neither among psoriatic nor among healthy individuals. Conclusions: Our results indicate that HCP5 gene 335 T > G polymorphism and not CCR5 gene Δ32 polymorphism is associated with the increased risk of developing PV.

Investigation of immunovascular polymorphisms and intersections in psoriasis Buket Er Urganci, Ibrahim Acikbas, F Rezzan Er Indian Journal of Dermatology 2019 64(3):187-191 Background: Psoriasis is a chronic, inflammatory skin disease. The etiology of the disease is unknown. It is a polygenic and multifactorial disease, which interacts with genetic and environmental factors. Genetic factors (polymorphism/mutation) can alter the immune system and normal physiologically functioning keratinocytes to pathological or predisposition levels. Aims: We aimed to investigate psoriasis at a different and novel window by searching for vascular and immunological variations and intersections in psoriasis. We investigated the main vascular and hypoxic controlling factors, which are vascular endothelial growth factor (VEGF) and hypoxia inducible factor 1 alpha (HIF-1α), as well as immunological and serotonergic factors, such as TNF-α, IL-10, and 5HT2A, which could connect each other to the pathogenesis of psoriasis. Subjects and Methods: Nine single nucleotide polymorphisms (SNPs) in five genes were genotyped by mini-array format in 300 subjects: VEGF (rs2010963, rs833061, and rs1570360), HIF-1α (rs11549465), TNF-α (rs361525, rs1799964, and rs1800629), IL-10 (rs1800896), and 5HT2A (rs6311). Results: An association was found between rs1800629 (TNF-α) and Type I psoriasis, and rs833061 (VEGF) and Type II psoriasis. Haplotype analysis suggests that the coexistence of the polymorphisms rs1799964 (TNF-α), rs2010963 (VEGF), rs833061 (VEGF), and rs6311 (5HT2A) may be a protective factor for psoriasis. Conclusion: Our results suggest that the vascular component of the studied vasculo-immunologic variation is more relevant in the pathogenesis of psoriasis.

Peroxisome proliferator-activated receptor-γ gene polymorphism in psoriasis and its relation to obesity, metabolic syndrome, and narrowband ultraviolet B response: A case–control study in Egyptian patients Iman Seleit, Ola Ahmed Bakry, Eman Abd El Gayed, Mai Ghanem Indian Journal of Dermatology 2019 64(3):192-200 Background: Psoriasis is a common dermatologic disease with multifactorial etiology in which genetic factors play a major role. Peroxisome proliferator-activated receptor (PPAR)-γ is expressed in keratinocytes and is known to affect cell maturation and differentiation in addition to its role in inflammation. Aim: To study the association between PPAR-γ gene polymorphism and psoriasis vulgaris in Egyptian patients to explore if this polymorphism influenced disease risk or clinical presentation. Methods: Forty-five patients with psoriasis vulgaris and 45 age, sex and body mass index matched healthy volunteers who have no present, past or family history of psoriasis as a control group were enrolled. Selected cases included obese and nonobese participants. Detection of PPAR-γ gene polymorphism was done with restriction fragment length polymorphism polymerase chain reaction. Narrow-band ultraviolet B (NBUVB) was given for every case three times/week for 12 weeks. Results: Homopolymorphism, heteropolymorphism, and Ala allele were significantly associated with cases (P = 0.01, P = 0.01, and P = 0.004, respectively) and increased risk of occurrence of psoriasis by 5.25, 3.65, and 3.37 folds, respectively. Heteropolymorphism was significantly associated with nonobese cases compared to obese ones (P = 0.01). Ala allele was significantly associated with obese cases (P = 0.001) and increased risk of occurrence of psoriasis in obese participants by 1.14 folds. Homopolymorphism, heteropolymorphism, and Ala allele were more prevalent among obese cases without metabolic syndrome (MS) than obese cases with MS but without statistical significance. Percentage of decrease of mean Psoriasis Area and Severity Index score before and after 3 months of treatment with NBUVB was higher in cases with heteropolymorphism with no significant difference between homo- and heteropolymorphism. Conclusion: PPAR-γ gene polymorphism is associated with and increased the risk of psoriasis and its associated obesity in Egyptian patients. It has no role in NBUVB response in those patients. Future large-scale studies on different populations are recommended.

Advanced glycation end products, a potential link between psoriasis and cardiovascular disease: A case–control study Tulin Ergun, Vildan Yazici, Dilek Yavuz, Dilek Seckin-Gencosmanoglu, Gulsen Ozen, Andac Salman, Haner Direskeneli, Nevsun Inanc Indian Journal of Dermatology 2019 64(3):201-206 Context: Advanced glycation end products (AGEs) promote oxidative stress and inflammation by altering structure and function of proteins. They are excessively produced mainly in hyperglycemia, chronic inflammation and are involved in the development of atherosclerosis and cardiovascular disease. Aims: The aim of this study was to investigate whether skin AGEs levels were increased and had relation to premature atherosclerosis in patients with psoriasis. Subjects and Methods: Fifty-two psoriasis patients and 20 healthy controls (HC) were included. AGEs were determined by skin autofluorescence (SAF) analysis. High-sensitive C-reactive protein (hsCRP) and carotid intima-media thickness (CIMT) were also investigated. Physical activity and dietary patterns were determined. Statistical Analysis Used: Fisher's exact test, two-sample t-tests, Mann–Whitney-U test, Pearson correlation, Spearman correlation, and Wilcoxon test. Results: SAFs were increased in psoriasis patients (1.8 arbitrary units [AUs]) compared to that in HC (1.6 AUs) (P = 0.057). Median CIMT values of HC and psoriasis groups were 0.43 (0.28–0.79), and 0.59 (0.44–0.98) respectively and the differences were significant (P = 0.001); hsCRP levels were not different between groups. Conclusions: Skin AGE accumulation was found to have a correlation with CIMT in psoriasis patients providing evidence for the role of AGEs in premature atherosclerosis.

Evaluation of serum adenosine deaminase and inflammatory markers in psoriatic patients Yousry M Moustafa, Moustafa Ahmed Elsaied, Ehsan M Abd-Elaaty, Rasha A Elsayed Indian Journal of Dermatology 2019 64(3):207-212 Background: Adenosine deaminase (ADA) is an enzyme involved in purine metabolism and it is a marker of nonspecific T-cell activation. Few studies have shown high levels of ADA in the epidermis and sera of psoriatic patients. Other inflammatory markers such as high-sensitive C-reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), and serum uric acid (SUA) have shown correlations with psoriasis area severity index (PASI) score. The correlation between ADA and PASI score is still a matter of debate. Aims: The aim of this study was to evaluate serum ADA, hsCRP, SUA, and ESR in psoriatic patients and their correlation with PASI score. Patients and Methods: This study included 60 psoriatic patients divided according to PASI score into three groups (mild, moderate, and severe) each containing 20 patients. PASI score <10 was defined as mild, (10–20) moderate, and >20 severe. Twenty healthy subjects of matched age and sex were included as control. Serum ADA, hsCRP, SUA, and ESR were evaluated for patients and controls. Correlations of ADA, hsCRP, SUA, and ESR with PASI scores were done. Results: While ADA, hsCRP, SUA, and ESR showed a significant increase in psoriatic patients compared with that of the controls (P<001), they showed no significant difference between different psoriatic groups (P>0.05) and no correlations with PASI score (P>0.05). The frequency of joint affection increased with increasing severity of psoriasis (5%, 10%, and 25% in mild, moderate, and severe psoriasis, respectively). Conclusion: Serum ADA, hsCRP, SUA, and ESR showed higher levels among psoriatic patients than in controls. The increased ADA in psoriatic patients supports the role of T-cell activation and proliferative disorder in the pathogenesis of psoriasis. No significant correlations were found between these biomarkers and PASI score. Further studies are needed to validate these biomarkers as diagnostic and prognostic factors in psoriasis.

Fixed tapering dosage of acitretin in patients with psoriasis: A short-term analysis of clinical efficacy and its effects on biochemical parameters Varadraj V Pai, Diksha Phadke, Pankaj Shukla, Krupeksha Naik Indian Journal of Dermatology 2019 64(3):213-216 Background: Acitretin is a widely used systemic retinoid in the treatment of psoriasis. Dosage of acitretin in not weight adjusted due to certain interindividual variations. Objective: To evaluate the clinical efficacy and effects on biochemical parameters of fixed tapering dosage of acitretin in patients with psoriasis administered over a period of 4 weeks. Materials and Methods: This was an observational study. The study included patients of psoriasis vulgaris in the age group of 18 and 65 years with a psoriasis area severity index (PASI) score of >10 which was not responsive to topical therapy and phototherapy. Patients were given oral acitretin daily at a dose of 25 mg BD for 2 weeks, which was later tapered to 25 mg OD for another 2 weeks. The clinical efficacy and biochemical parameters were assessed. Results: Out of the 18 patients, PASI 75 was achieved in 66% of the patients by the end of the third week. Significant elevations were noted in serum lipids during 4 weeks, which returned to normal limits or near baseline levels at the end of 4 weeks. Conclusion: Fixed tapering dose of acitretin is effective in psoriasis with minimal clinical and biochemical adverse events

Phakomatosis pigmentovascularis: A clinical profile of 11 Indian patients Abhijit Dutta, Sudip Kumar Ghosh, Debabrata Bandyopadhyay, Dibyendu Bikash Bhanja, Surajit Kumar Biswas Indian Journal of Dermatology 2019 64(3):217-223 Introduction: Phakomatosis pigmentovascularis (PPV) is a rare congenital syndrome characterized by the simultaneous presence of capillary malformation and pigmentary nevi. The objective of our study was to describe the clinical characteristics of a series of Indian patients presenting with this rare entity. Materials and Methods: It was a record-based descriptive case series. Results: A total of 11 patients with PPV (9 females, 2 males, age range: 7 days to 45 years; mean 11.6 years) were studied. Port wine stain was present in 10 (91%) patients and one patient (9%) had cutis marmorata telangiectatica congenita. Isolated nevi of Ota and Mongolian spots were seen in 4 (36%) patients each. Simultaneous presence of both Mongolian spots and nevus of Ota was present in 1 (9%) patient. The combination of Mongolian spots and bilateral palatal hyper-melanosis was noticed in 2 (18%) patients. Café au lait macule was present in one patient. Bilateral ocular melanosis was found in 3 (27%) patients. Unilateral ocular melanosis was noticed in 4 (36%) patients. Two patients (18%) had history of seizure disorder and intracranial vascular anomalies on MRI imaging. Two patients (18%) had features of Klippel-Trenaunay syndrome. According to the traditional classification, three patients had PPV type 2b, one patient had PPV type 5b, and seven patients had PPV type 2a. According to the Happle's classification, 10 patients had PPV of cesio flammea type, and one patient had PPV of cesio marmorata type. Limitations: We could not perform genetic study of the patients. Conclusion: Our findings emphasize the importance of detailed systemic evaluation including ocular examination and brain imaging in every patient of PPV.

Abnormal serum copper and zinc levels in patients with psoriasis: A meta-analysis Li Lei, Juan Su, Junchen Chen, Wangqing Chen, Xiang Chen, Cong Peng Indian Journal of Dermatology 2019 64(3):224-230 Background: Copper and zinc are important trace elements involved in the development of psoriasis. However, reports regarding changes in serum copper and zinc levels in patients with psoriasis have been inconsistent. Aims: This meta-analysis was designed to analyze changes in serum copper and zinc levels between patients with psoriasis and a healthy population. Materials and Methods: English and Chinese literature from international and national electronic databases from 1988 to May 2016 was analyzed. Studies that performed a comparative analysis of serum copper and zinc levels between patients with psoriasis and healthy controls were included in the meta-analysis. The random-effects model was used to calculate the overall combined estimates of serum copper and zinc levels between patients with psoriasis and healthy individuals. Results: Fifteen references were included in this study, including 1324 patients with psoriasis and 1324 healthy controls. Compared with healthy controls, serum copper levels were significantly increased (Z = 4.02, P < 0.0001; standardized mean difference [SMD], 1.23; 95% confidence interval [CI], 0.63 to 1.82), and serum zinc levels were significantly decreased (Z = 2.95, P < 0.0001; SMD, −1.35; 95% CI, −2.25 to − 0.45) in patients with psoriasis. Conclusions: In conclusion, increased serum copper and decreased serum zinc levels were generally observed in patients with psoriasis. Treatments to normalize the serum copper and zinc levels may improve the outcome of psoriasis patients.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Clinical Sciences

Insulin therapy in patients with type 2 diabetes mellitus Ifedayo Adeola Odeniyi, Oluwarotimi Bolaji Olopade, Olufemi Adetola Fasanmade Journal of Clinical Sciences 2019 16(2):43-48 Diabetes mellitus is a disease of metabolic dysregulation, most notably abnormal glucose metabolism, accompanied by characteristic long-term complications. The complications that are specific to diabetes include retinopathy, nephropathy, and neuropathy. To achieve glycemic goals in patients with Type 2 diabetes when multiple pharmacologic agents are failing, the early introduction of insulin is key. Our objective is to assist clinicians in designing individualized management plans for insulin therapy in patients with Type 2 diabetes mellitus. We searched Medline, PubMed, journal articles, WHO publications, and reputable textbooks relating to diabetes mellitus and insulin therapy using publications from 1992 to 2016. With the progression of Type 2 diabetes, there is ultimately progressive loss of pancreatic beta-cell function and endogenous insulin secretion. At this stage, most patients require exogenous insulin therapy to achieve optimal glucose control. Choosing from the wide variety of glucose-lowering interventions currently available could be a challenge for the health-care provider and the patients in terms of effectiveness, tolerability, and cost of the various diabetes treatments. However, these should not be the case as risk reductions in long-term complications were related to the levels of glycemic control achieved, rather than to a specific glucose-lowering agent. The challenges of initiating and intensifying insulin therapy are quite enormous and could be daunting to health-care givers. Glycemic treatment should be stepwise with swift introduction of successive interventions after treatment failure (i.e., A1C ≥7.0%). Insulin should be initiated when A1C is ≥7.0% after 2–3 months of dual oral therapy.

Depression-related knowledge, attitude, and help-seeking behavior among residents of Surulere Local Government Area, Lagos State, Nigeria Chinenye C Egwuonwu, Oluchi J Kanma-Okafor, Adedoyin O Ogunyemi, Hammed O Yusuf, Joseph D Adeyemi Journal of Clinical Sciences 2019 16(2):49-56 Context: Worldwide, depression leads among the causes of ill-health and disability. Therefore, it is a major public health concern. Aim: This study was carried out to determine depression-related knowledge, attitude, and help-seeking behavior among residents of Surulere Local Government Area, Lagos state, Nigeria. Settings and Design: This was a descriptive cross-sectional study. A total of 422 respondents were recruited using the multistage sampling technique. Subjects and Methods: An adapted, pretested, semi-structured, and interviewer-administered questionnaire was used to collect data. Statistical Analysis Used: Data were analyzed using EPI Info Version 7 statistical software. Results: The proportion of respondents with depressive symptoms such as loss of interest in usual activities was 30.6%. Majority of the respondents had good knowledge of depression (90.0%), positive attitude (93.2%), and good help-seeking behavior (87.9%) toward depression. Marital status was not significantly associated with the presence of depressive symptoms. However, there was a statistically significant association between employment status and the presence of depressive symptoms (P = 0.001) and the help-seeking behavior toward depression (P = 0.013); the level of education on the other hand showed a statistically significant association with both knowledge and attitude (P = 0.003, P ≤ 0.001, respectively). Conclusion: Most of the respondents had good knowledge, positive attitude, and good help-seeking behavior toward depression; however, mental health services may not be readily available. There is therefore a need to ensure the availability of good mental health services as well as public enlightenment on where and how to access these services. These can prove very useful in tackling the rising prevalence of mental health disorders.

"Hidden fluid" in the critically ill patient: A wake-up call Babatunde Babasola Osinaike, Arinola A Sanusi, Shete Kunle Phillips Journal of Clinical Sciences 2019 16(2):57-60 Background and Aim: Fluid overload and unfavorable outcomes in critically ill patients have been demonstrated in many clinical settings, such as acute lung injury/acute respiratory distress syndrome, septic patients, and those with acute kidney injury. Fluid overload has been reported in up to 70% of patients admitted to the intensive care unit (ICU). Fluid optimization strategies are often used to prevent fluid overload. Less obvious sources of fluid intake are often overlooked. The aim of this study was to determine the contribution of intravenous medications to daily fluid intake and balance in our ICU. Methodology: We conducted a retrospective study on adult patients admitted to the ICU of the University College Hospital, Ibadan, from January to December 2015. Daily ICU record charts were reviewed to determine the sources and volumes of various fluids for the study patients. Fluid other than intravenous fluid, enteral feeds, and blood/blood products were categorized as hidden fluid. These were mainly intravenous medications. Data were analyzed using the Statistical Package for the Scientific Solutions Version 20. Results: A total of 286 patients were admitted during the study year. There were 26 nonadults (≤16 years) excluded, and the records of 74 patients were not available. The mean daily volume of drug solutions (473.4 ml) was about 16% of the mean daily intake (2846.1 ml). The percentage of hidden fluid was highest in the neurology group (26.7%). No group had <10%. The use of vasopressor was significantly associated with higher volume of hidden fluid (P = 0.001). Hidden fluid constituted 13% of the total fluid administered during the study period. Conclusion: Intravenous drug solutions were important contributions to fluid intake and balance in our review. ICU clinician should always consider this when calculating daily fluid maintenance. Further study is needed to determine their contribution to the development of fluid overload and ICU mortality.

Awareness and practice of testicular self-examination among regular undergraduate male health sciences university students, Debre Tabor, Northwest Ethiopia Biresaw Wassihun Alemu, Shegaw Zeleke Baih Journal of Clinical Sciences 2019 16(2):61-67 Background: Testicular cancer (TC) is the most common cancer among 15–35-year-old males and the incidence is increasing. This form of cancer is easily diagnosable by testicular self-examination (TSE) and is 96% curable if detected early. Objective: To assess awareness and practice of testicular self-examination among regular undergraduate Male Health Sciences University students, Debre Tabor, North West Ethiopia. Patients and Methods: An institution-based cross-sectional study design was conducted. The study participants were stratified based on their year of study and selected by simple random sampling method. Pretested and structured self-administered questionnaire were used. The data were entered to EpiData version 3.1 statistical software and exported to Statistical Package for the Social Sciences version 22.0 for analysis. Both bivariate and multivariate logistic regression analysis were performed to identify associated factors. P <0.05 with 95% confidence level was used to declare statistical significance. Results: A total of 225 respondents were participated with a response rate of 97.3%. Of the respondents, 53% had poor knowledge toward TC and 78% had poor practice toward TSE. The major reason 64.0% for poor practice of TSEs was inability to carry out the examination. Students in clinical year were more knowledgeable toward TSE with adjusted odds ratio (AOR = 5.27 [95% confidence interval (CI); 2.04, 13.66]) as compared to preclinical year and students in clinical year had good practice toward TSE with (AOR = 2.71 [95% CI; 1.10, 6.68]) than preclinical year of study. Conclusion: knowledge and practice of TSE among respondents were poor. The reason not to perform TSE, as revealed in the study was not caring the examination and lack of knowledge toward TSE. They are unaware of their risk for TC, which is the most common neoplasm in this age group. Providing regular health education toward TSE is important to improve the knowledge of.

Management of Wilm's tumor at the Lagos University Teaching Hospital (a 10-year retrospective study) Adetutu B Mabadeje-Isowo, Anthonia C Sowunmi, Abdulrasaq R Oyesegun, Adeniyi Adenipekun, Kingsley K Ketiku, Uchenna Samuel Okoro Journal of Clinical Sciences 2019 16(2):68-73 Background: Wilms' tumor (WT), also known as nephroblastoma, is the most frequently diagnosed renal tumor in children, accounting for 6% of all childhood tumors. It is relatively more common in blacks and majority of cases are diagnosed within the first 3 years of life. Aim: The study aimed to review the prevalence, pattern of presentation, and management outcome of WT at the Lagos University Teaching Hospital (LUTH). Methodology: This is a retrospective study of patients diagnosed with WT at LUTH between January 2004 and December 2013. Results: A total of 108 patients were retrieved for this study. Sixty (55.56%) patients were male and 48 (44.44%) were female with a male-to-female ratio of 1.25:1. The age range was from 9 months to 11 years with a mean age of 4 (standard deviation: ±2.37) years. The most common mode of presentation was an abdominal mass, and 66.67% of the patients presented with Stages III–V. Fifty percent of the patients had complete response following treatment (chemotherapy [CHT]) and 33 (30.6%) patients had partial response (i.e., 30% reduction in tumor size). Twenty-one (19.4%) patients had a progression of disease despite the treatment. Eleven (20.37%) had recurrence after 5 years of completing their treatment. Disease-free survival rate at 5-year posttreatment was 31.48%. Conclusion: Most of the patients presented with advanced disease at diagnosis resulting in poor response and survival. Early presentation and diagnosis will improve the results. Combination treatment with surgery and CHT gives the best results.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Neurosurgical Anesthesiology

Subanesthetic Dose of Ketamine Improved CFA-induced Inflammatory Pain and Depression-like Behaviors Via Caveolin-1 in Mice Background: Ketamine, a commonly used nonbarbiturate anesthetic drug, possesses antidepressant properties at subanesthetic doses; however, the underlying mechanisms remain unclear. Materials and Methods: The analgesic and antidepressant effects of ketamine were explored using a complete Freund adjuvant (CFA)-induced peripheral inflammatory pain model in vivo. Mice were first divided into sham or CFA injection group randomly, and were observed for mechanical hyperalgesia, depression-like behavior, and mRNA expression of caveolin-1. Then ketamine was administered in CFA-treated mice at day 7. Results: The behavioral testing results revealed mechanical hyperalgesia and depression in mice from days 7 to 21 after CFA injection. Ketamine reversed depression-like behaviors induced by CFA injection. It also restored the brain-regional expression levels of caveolin-1 in CFA-treated mice. In addition, caveolin-1 mRNA and protein expression were increased in the prefrontal cortex and nucleus accumbens of CFA-treated mice. However, ketamine reversed the increase in caveolin-1 expression in the ipsilateral and contralateral prefrontal cortex and nucleus accumbens, supporting the distinct roles of specific brain regions in the regulation of pain and depression-like behaviors. Conclusions: In CFA-treated mice that exhibited pain behavior and depression-like behavior, ketamine reversed depression-like behavior. The prefrontal cortex and nucleus accumbens are the important brain regions in this regulation network. Despite these findings, other molecules and their mechanisms in the signal pathway, as well as other regions of the brain in the pain matrix, require further exploration. J.L. and R.H. contributed equally to this work. J.W. and Q.Z. are co-first authors. This work was funded by the Beijing Municipal Administration of Hospitals' Ascent Plan (code number DFL20180502) and Clinical Medicine Development of Special Funding Support (code number ZYLX201708). R.H. is a member of the Editorial Board of the Journal of Neurosurgical Anethesiology. The authors have no conflicts of interest to disclose. Address correspondence to: Ruquan Han, MD, PhD. E-mail: ruquan.han@ccmu.edu.cn. Received November 21, 2018 Accepted April 8, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Editorial No abstract available

Standardized Accreditation of Neuroanesthesiology Fellowship Programs Worldwide: The International Council on Perioperative Neuroscience Training (ICPNT) No abstract available

Remifentanil Patient-controlled Analgesia in Awake Craniotomy: An Introduction of an Innovative Technique No abstract available

Effect of Daytime Versus Night-Time on Outcome in Patients Undergoing Emergent Neurosurgical Procedures Background: Timing of neurosurgical procedures is controversial. Challenges identified with night-time surgeries include physician fatigue and sleep deprivation, and fewer staff and resources compared with daytime surgery. These might contribute to medical errors and complications, and, hence, worse patient outcomes. Methods: This single center retrospective study of 304 patients who underwent emergent neurosurgical procedures between January 1, 2010 and December 31, 2016 included 2 groups based on the timing of surgery: daytime (7:00 AM to 6:59 PM) and night-time (7:00 PM to 6:59 AM) surgery groups. Patient demographics, diagnosis, surgical characteristics, complications, and neurological outcome were obtained from the medical records. Results: There was no difference in patient demographics, intraoperative complications, and length of surgery between the 2 groups. Although there was no statistically significant difference in neurological outcome between the 2 groups at hospital discharge and 1 month postdischarge, there was a higher proportion of patients in the night-time surgical group with unfavorable neurological outcome (Glasgow Outcome Score 1 to 3) at both these times. There were differences in hospital length of stay, location of postoperative management (postanesthesia care unit or intensive care unit), midline shift, baseline Glasgow Coma Scale score, and acuity of surgery between the 2 groups. Logistic regression analysis showed that age, baseline Glasgow Coma Scale score, surgery acuity status, procedure type, and intraoperative complications influenced neurological outcome. Conclusions: This study found no difference in the rate of unfavorable neurological outcome in patients undergoing emergent neurosurgical procedures during the daytime and night-time. However, our findings cannot exclude the possibility of an association between timing of surgery and outcome given its limitations, including small sample size and omission of potentially confounding variables. Further well-designed prospective trials are warranted to confirm our findings. This study is a part of Bachelor of Science (Medicine) project thesis of A.H.Q., and he received a stipend from the University of Manitoba to conduct this research project. This project is funded by Anesthesia Oversight Committee, Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Canada. T.C. (primary supervisor) received the above-mentioned grant. Support was provided solely from institutional and/or departmental sources. Presented at: Neuroanesthesia Rounds, August 15, 2018, University of Manitoba; Bachelor of Science (Medicine) Research Symposium, August 23, 2018, University of Manitoba. The authors have no conflicts of interest to disclose. Address correspondence to: Tumul Chowdhury, MD, DM, FRCPC. E-mail: tumul.chowdhury@umanitoba.ca. Received September 9, 2018 Accepted March 12, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Language Monitoring in Brain Surgery Under General Anesthesia Background: Awake surgeries for cerebral lesion resection have several limitations including patient fear, discomfort, or pain. This study aimed to determine whether components of language function could be measured under general anesthesia. In this study, the occurrence of mismatch negativity (MMN) was searched in evoked potentials for phonological sounds. Materials and Methods: Five normal hearing, French native speaker, awake volunteers participated in evaluating the phonological task (4 females and 1 male). Eleven normal-hearing, French native speaker patients (6 left and 5 right hemisphere lesions) participated at the time of their tumor neurosurgery (3 females and 8 males). Repetitions of the standard syllable /pa/ with the insertion of 1 deviant /po/ were presented through earphones. The difference between averaged epochs of standards and deviants syllables determined the MMN. During surgery, total intravenous anesthesia was performed with propofol and synthetic opioid sufentanil. The bispectral index was targeted (40 to 60). Results: The MMN was found in all awake volunteers and validated by an N250 component. In the patient group, the electroencephalogram analysis was not possible in 4 of 11 patients because of anesthesia being too deep, burst suppression, or a high level of noise (>40 μV). Significant N250 response was obtained in 5 of 7 (71.4%) patients under general anesthesia. The 2 other patients also showed MMN which did not reach significance. Conclusions: To our knowledge, this is the first demonstration that phonological processing can be measured during brain surgery under general anesthesia, suggesting that some language processing persists under the condition of unconsciousness. These results encourage further study of language processing under general anesthesia with the goal of making intraoperative neuromonitoring. Supported by the University Hospital of Geneva (in particular with the fund PRD no. 10-2015-I "Advanced electrophysiological monitoring in neurosurgery"). The authors have no conflicts of interest to disclose. Address correspondence to: Colette Boëx, PhD. E-mail: colette.boex@hcuge.ch. Received December 7, 2018 Accepted March 13, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

The Role of Near-infrared Spectroscopy in Cerebral Autoregulation Monitoring No abstract available

Comparison of 2 Automated Pupillometry Devices in Critically Ill Patients Background: Automated pupillometry may help detect early cerebral disturbances in critically ill patients. It remains unclear whether different automated pupillometry devices can detect pupillary abnormalities with similar accuracy. The aim of this study was to compare the performance of 2 commercially available automated pupillometry devices—Neurolight Algiscan (NL) and NPi-200 (NP) versus standard pupillary light reflex (PLR) examination in an unselected cohort of critically ill patients. Materials and Methods: This prospective study included all adult (>18 y) patients admitted to the intensive care unit of a university hospital over a 20-day period. Measurements were made consecutively with each method once during the intensive care unit stay in each patient. To assess sensitivity and specificity, we calculated areas under the curve of the receiver operating characteristic curve. Results: A total of 112 patients were included in the study. There was a significant correlation between the 2 automated pupillometry devices for pupil size, constriction to light stimulation, and constriction velocity but not for pupillary latency. The mean bias for pupil size measured by the NL and the NP devices was −0.12 (limit of agreement [LoA], −1.29 to 1.06) mm, for pupil constriction −1.0% (LoA, −9.3% to 7.2%), and for latency 0.02 (LoA, −0.22 to 0.25) ms. There was a significant correlation between pupil size evaluated by clinical examination and that using the NL or NP. The areas under the curves for pupil constriction measured by NL and NP were 0.93 and 0.91, respectively, to detect clinically reactive pupils. Conclusions: Although there was a significant correlation between NL and NP values as well as with clinical examination of the PLR, the 2 devices were not always interchangeable, especially for the evaluation of pupillary latency. F.S.T., B.M.S., and S.P.: conceived and designed the study. F.S.T., B.M.S., S.P., and J.C.: selected the population. B.M.S., F.S.T., S.P., J.C., and J.L.V.: screened and collected data from the population. F.S.T., M.O., and C.R.: conduced the statistical analysis. F.S.T., M.O., and C.R.: wrote the first draft of the manuscript. J.L.V., J.C., B.M.S., and S.P.: revised the text for intellectual content. All the coauthors read and approved the final text. M.O. has received lectures fees from Neuroptics. The remaining authors have no funding or conflicts of interest to disclose. Address correspondence to: Fabio S. Taccone, MD, PhD. E-mail: ftaccone@ulb.ac.be. Received November 17, 2018 Accepted March 8, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Bilateral Ultrasound-guided Erector Spinae Plane Block for Postoperative Analgesia in Lumbar Spine Surgery: A Randomized Control Trial Background: Major lumbar spine surgery causes severe postoperative pain. The primary objective of this randomized controlled study was to compare the effect of ultrasound (US)-guided erector spinae plane (ESP) block on 24-hour postoperative cumulative opioid requirements with standard (opioid-based) analgesia. Postoperative pain control and patient satisfaction were also assessed. Materials and Methods: Adults scheduled for elective lumbar spine surgery under general anesthesia were randomly assigned to the following (and they are): Control group-no preoperative ESP block, or ESP block group-preoperative bilateral US-guided ESP block. Both groups received standard general anesthesia during surgery. Postoperative pain score, number of patients requiring rescue analgesia, and total morphine consumption during the first 24 postoperative hours were recorded. Patient satisfaction was assessed 24 hours after surgery. Results: Postoperative morphine consumption was significantly lower in patients in the ESP group compared with those in the control group (1.4±1.5 vs. 7.2±2.0 mg, respectively; P<0.001). All patients in the control group required supplemental morphine compared with only 9 (45%) in the ESP block group (P=0.002). Pain scores immediately after surgery (P=0.002) and at 6 hours after surgery (P=0.040) were lower in the ESP block group compared with the control group. Patient satisfaction scores were more favorable in the block group (P<0.0001). Conclusions: US-guided ESP block reduces postoperative opioid requirement and improves patient satisfaction compared with standard analgesia in lumbar spine surgery patients. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Swati Singh, MD. E-mail: deepakswat@yahoo.com. Received November 24, 2018 Accepted March 13, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved

Intraoperative-evoked Potential Monitoring: From Homemade to Automated Systems No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com