The use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided.Clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension

Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension p. 63

Hiroyuki Oshika, Yukihide Koyama, Yutaka Usuda, Tomio Andoh

DOI:10.4103/sja.SJA_367_18  

We report a case of intravenous ephedrine administration that abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension and who was subsequently diagnosed postoperatively as having bronchial asthma. A 54-year-old man who had childhood asthma was scheduled for laparoscopic cholecystectomy at our institution. The preanesthetic interview suggested full resolution of his childhood asthma. His capnogram showed an airway obstructive pattern immediately after the initiation of mechanical ventilation. However, after administration of ephedrine due to low blood pressure during surgery, his obstructive capnogram reverted to normal. On postoperative day 3, he was diagnosed as having bronchial asthma. Furthermore, we found that small airway obstruction as indicated in his preoperative pulmonary function test (PFT) had been overlooked. Two important points arise from this case. First, the use of beta-blockers for the treatment of hypertension in patients potentially having obstructive lung disease should be avoided. Second, clinicians should carefully check the preoperative PFT results in detail to ensure that nothing has been overlooked.

Bedside ultrasonography for the confirmation of gastric tube placement in the neonate

Yunus Oktay Atalay, Ahmet Veysel Polat, Elif Ozyazici Ozkan, Leman Tomak, Canan Aygun, Joseph Drew Tobias

DOI:10.4103/sja.SJA_413_18  

Background: Naso/Orogastric tube (NOGT) misplacement can lead to significant complications. Therefore, the assessment of tube position is essential to ensure patient safety. Although radiography is considered the gold standard for determining NOGT location, new methods may be helpful in reducing repetitive radiation exposure, especially for neonates. In this study, we sought to investigate if bedside ultrasonography (BUSG) can be used to verify NOGT placement in neonatal intensive care patients. Materials and Methods: Infants requiring NOGT placement were enrolled. After insertion of the NOGT, the location was first identified using BUSG and then confirmed using abdominal radiography for comparison. Results: The study cohort included 51 infants with an average gestational age of 34 ± 4.9 weeks. BUSG determined the NOGT location correctly with a sensitivity of 92.2%. The location of the NOGT could not be determined by BUSG in four neonates (7.8%). In one infant, the NOGT was positioned in the esophagus, as determined both by BUSG and radiography. Conclusion: BUSG is a promising diagnostic tool for determining NOGT location in neonates, thereby eliminating the need for abdominal radiography.

Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of Postoperative acute kidney injury (AKI) : Hydroxyethyl starch (HES) solutions,Stroke volume variation-guided tetrastarch,Ringer's lactate

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate 

Asha Tyagi, Gaurav Verma, Ankit Luthra, Shubham Lahan, Shukla Das, Gargi Rai, Ashok Kumar Sethi

DOI:10.4103/sja.SJA_410_18  

Background: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. Materials and Methods: Adults scheduled for orthopedic surgery under general anesthesia with >200–300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. Results: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. 

Conclusion: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.

Mitral regurgitation (MR)

Segmentation of jet area to quantity the severity of mitral regurgitation by color Doppler echocardiography p. 134

N Chidambaram, GN Balaji, TS Subashini

DOI:10.4103/jncd.jncd_50_18  

Mitral regurgitation (MR) is a disorder of mitral valve and it is one of the most common causes of cardiovascular morbidity and mortality. Mitral valve allows blood to flow from left atrium, to the left ventricle and Mitral Valve regurgitation results in poor apposition of the valvular leaflets, so that the heart's mitral valve doesn't close tightly, allowing blood to flow backward into the left atrium. Transthoracic Echocardiography (TTE) with Doppler is the widely used non-invasive technology for the detection and evaluation of severity of valvular regurgitation. Proximal isovelocity surface area (PISA) method has been widely accepted by clinicians as a means for grading MR severity. In this paper an alternate method to PISA to automatically quantify mitral valve regurgitation severity is proposed. This work attempts to automatically segment the jet region in color Doppler images using K-Means clustering. Further to quantify mitral regurgitation, jet area parameters and shape features are extracted from the segmented jet region which are then modeled using classifiers such as Support Vector machine (SVM) and Back Propagation Neural Network (BPNN). Quantifying MR with PISA calls for considerable expertise as a number of components must be taken into account to fully assess the severity of mitral regurgitation, however the results of the proposed method indicate that it could be used as an alternate method to automatically assess the severity of mitral regurgitation.

Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures

Osteonecrosis and nonunion as complication of fracture neck femur p. 23

Rudra P. S. Thakur, Alok C Agrawal, Bikas K Sahoo, Vishal K Kujur

DOI:10.4103/jodp.JODP_14_18  

Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. Fixation failure and nonunion are the main modes of failure following fixation of displaced or undisplaced femoral neck fractures. The two problems are difficult to distinguish as most displaced fractures take a long time to heal after fixation, which increases the risk of fixation failure. Avascular necrosis of the femoral head occurs in 9%–18% of patients, between 2 and 8 years postfracture. Risk factors include the degree of fracture displacement, patient age, and delay in surgical treatment.

Vascularity of femoral head

and its assessment after femoral neck fractures p. 1

Harshal Sakale, Alok C Agrawal, Bikram Keshri Kar, Bikas Sahoo, Sandeep K Yadav

DOI:10.4103/jodp.JODP_5_18  

Femoral neck fracture has an annual incidence of 1 per 1000 population; in young patients, functional prognosis is not good due to risk of osteonecrosis. Femoral head vascularity is mostly contributed by retinacular vessels and lateral epiphyseal artery. The vascular impact is due to displacement, interrupting retinacular vessel, interrupting ligament teres vascularization, and increased intracapsular pressure, producing a tamponade effect leading to osteonecrosis. This study reviewed the different methods of assessment of femoral head vascularity after femoral neck fractures. There are many techniques for the assessment of residual femoral head vascularity after femoral neck fractures and for the assessment of post-traumatic osteonecrosis risk. Some invasive techniques are superselective angiography, intraosseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others are noninvasive scintigraphy and conventional or dynamic magnetic resonance imaging (MRI). The future seems to lie with dynamic MRI, which gives new classification of femoral neck fractures, based on a noninvasive assessment of femoral head vascularity.

Orthodontic Rehabilitation

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Complications of mini-implant anchorage A Sumathi Felicita International Journal of Orthodontic Rehabilitation 2018 9(4):133-133

Analysis of facial pattern among 12–16-year-old students in Lagos, Nigeria Olawande A Ajisafe, Babatunde O Ogunbanjo, Kikelomo O Adegbite, Afolabi Oyapero International Journal of Orthodontic Rehabilitation 2018 9(4):134-140 Background: Facial patterns or biotypes have been known to influence the treatment plan of orthodontic patients and analyze the facial patterns described by Ricketts. Determining the facial type is extremely important for orthodontic diagnosis and planning since the muscular and skeletal configuration of each facial type responds differently to the orthodontic treatment. Materials and Methods: A sample of 100 individuals was recruited by multistage sampling from three schools in Ikeja local government, Lagos State. Those aged between 12 and 16 years who met the inclusion criteria were enrolled in the study after obtaining informed consent and assent from the parents and participants. Lateral cephalometric radiographs were taken for all participants, and the final sample after analysis of the radiographs was 84. The error of the cephalometric method was assessed using the intraclass correlation coefficient. Facial axis angle (Ptm-Gn/Ba-N) was used to classify the facial pattern into brachyfacial (<87°), mesofacial (87°–93°), and dolichofacial (>93°) Results: Out of the 84 participants, 60 (71.4%) had mesofacial facial pattern which consisted of 27 (32.1%) males and 33 (39.3%) females. 10 (11.9%) had brachyfacial pattern out of which 9 (10.7%) were male and 1 (1.2%) was a female. This difference between the males and females in the brachyfacial pattern was statistically significant with a P value of 0.014 (P ≤ 0.05). 14 (16.67%) participants had dolichofacial pattern with 5 (6.0%) males and 9 (10.7%) females. Conclusion: The mesofacial pattern had the highest frequency among the facial pattern types studied in this Nigerian population and was found to be more predominant among females. The brachyfacial pattern was seen more frequently in males while the dolichofacial pattern was more prevalent among females. The facial pattern assessment should guide the orthodontist in the use of appropriate mechanics to achieve an overall balanced occlusion and facial profile following orthodontic treatment.

Norms for anterior–posterior assessment of jaw relationship in Maharashtra population Niyati B Potode, Twinkle D Bajaj, Amol A Verulkar, Swapnil B Wankhade, Ratndeep A Lohakpure, Jimmy K Sangatani International Journal of Orthodontic Rehabilitation 2018 9(4):141-144 Background: Regularly used parameters for anteroposterior assessment of jaw relationships are ANB angle and Wits appraisal, and recently, beta angle, Yen angle, and W angle are introduced. ANB angle depends on the cranial landmarks and is affected by various factors and often can be misleading. The Wits appraisal does not depend on cranial landmarks, but still has the problem of correctly identifying the functional occlusal plane, which can sometimes be impossible. To overcome these problems, a new measurement, beta angle, was developed at Tufts University. The present study was carried out on Maharashtra population to derive norms of beta angle. Materials and Methods: For selection of sample, the lateral cephalograms were selected from the available patient's records, and the sample was divided into three groups based on the ANB angle, Wits appraisal, and profile. Conclusion: The norms of beta angle are between 28.5° and 36.5° in skeletal Class I pattern, <28.5° in skeletal Class II pattern, and >36.5° in skeletal Class III pattern.

Evaluation of the effect of moisture and saliva on the shear bond strength of brackets bonded with conventional bonding system and moisture insensitive primer: An in vitro study I Girish Kumar, A Bhagyalakshmi, BM Shivalinga, N Raghunath International Journal of Orthodontic Rehabilitation 2018 9(4):145-154 Introduction: Bonding of orthodontic attachments with acid etching is the most commonly used orthodontic procedure. However, there are certain limitations with acid etching procedure like/moisture contamination, etching time, the concentration of adhesive, etc., Moisture insensitive primers (MIPs) were introduced to overcome these limitations. Objectives: The aim of this study is to compare the shear bond strength of orthodontic brackets bonded with a MIP (Transbond MIP, 3M Unitek) against a conventional primer (Transbond XT, 3M Unitek) when contaminated with saliva – in vitro study. Methodology: Sixty maxillary premolars extracted for orthodontic purpose or due to periodontal involvement with sound buccal surfaces were collected, cleaned thoroughly, and stored in 0.1% (wt/vol) thymol at room temperature for 2 weeks. Following materials were used: Transbond XT Light cure adhesive (3M unitek), Transbond XT primer (3m unitek), Transbond MIP primer (3M unitek), and Metal brackets (3M unitek). A commercially available artificial saliva (AQWET, CIPLA) was used for contamination purpose. Ivoclarbluephase N LED light curing unit were used for curing purpose. Results: Mean bond strength was well above the clinically acceptable bond strength values indicating the use of these hydrophilic bonding materials in contaminated environments (8.5 Mpa for Transbond XT and 9.25 Mpa for Transbond MIP). On comparison of bond strengths of MIP and XT when contaminated with saliva, statistically significant values were obtained with contamination with saliva after primer application. There was a statistically significant increase in the bond strength after primer application (P = 0.233) and before and after primer application (P = 0.027*). Transbond MIP can be used to achieve adequate bond strength in saliva contaminated condition. Conclusion: Under dry condition, the shear bond strength of conventional primer (TRANSBOND XT) was significantly increased when compared to MIP. Under wet conditions MIP (TRANSBOND MIP) showed the highest shear bond strength and hence can be considered as a material of choice in wet conditions.

An overview of evidence-based dentistry and randomized controlled trials: Importance in the current orthodontic research Jasleen Kaur, Harpreet Kaur, Shikha Virdi International Journal of Orthodontic Rehabilitation 2018 9(4):155-158 Evidence-based dentistry (EBD) was developed to help dental care professionals in incorporating the current, valid, and bias-free research into their clinical practice. It is equally important to review and critically appraise the evidence before its adoption into clinical decision-making. In orthodontics, as there are emerging innumerable appliances, materials, and treatment approaches, there is an urgent need to conduct new trials to determine their effectiveness. Recently, randomized controlled trials (RCTs) are considered as the most powerful and strongest research design for the comparison of various treatment interventions. This article gives a brief overview about EBD and RCTs and their importance in the field of orthodontics.

Orthodontic consideration with patients with bleeding disorders Vaidehi N Arekar, Pushpak Ladhe, Apurva Nikte, Pawankumar Dnyandeo Tekale International Journal of Orthodontic Rehabilitation 2018 9(4):159-162 Orthodontist must be aware of the impact of bleeding disorders on the management of orthodontic treatment. Initial recognition of a bleeding disorder, which may indicate the presence of a systemic pathologic process, may occur in dental practice. Patients should be queried about any previous unusual bleeding episode after surgery or injury, spontaneous bleeding, and easy or frequent bruising. The purpose of this paper is to review bleeding disorders and their effects on the delivery of orthodontic treatment.

Nutrition and orthodontics Jeevan M Khatri, Vijaymala D Kolhe International Journal of Orthodontic Rehabilitation 2018 9(4):163-167 Orthodontic patients avoid many types of food, particularly fruits, raw vegetables, and other hard and tough foods, as they cannot chew these properly because of pressure sensitivity of the teeth in the initial 3–5 days period after routine. As a result, such individuals consume significantly less proteins and other key nutrients, fiber, calcium, nonhem iron, and some vitamins. This article presents an overview of the relationship between diet and orthodontic treatment. The nutritional guidelines to obtain good oral and general health in orthodontic patients are discussed.

Treatment of Class II division 1 malocclusion using forsus fatigue-resistant device S B V Ramana Reddy, Venkata Naga Sravanthi Jonnalagadda International Journal of Orthodontic Rehabilitation 2018 9(4):168-172 Functional orthopedic appliances are mostly used to treat Class II malocclusion originated from mandibular retrusion. Removable or fixed functional appliances are available to advance the mandible. Fixed appliances can be treated in tandem with multibarcket therapy, thus making it a single-phase treatment. The major disadvantage of fixed functional appliances is proclination of lower anterior teeth. To reduce this proclination, miniplates or miniimplants are being used; negative torque is added to the lower incisors. Despite these additions, the proclination could not be eliminated but minimized. This case report documents the successful treatment of skeletal Class II in late stages of puberty using forsus fatigue resistance appliance with soldered hooks placed distal to the lower canines.

Orthopaedic Diseases and Traumatology

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Vascularity of femoral head and its assessment after femoral neck fractures Harshal Sakale, Alok C Agrawal, Bikram Keshri Kar, Bikas Sahoo, Sandeep K Yadav Journal of Orthopaedic Diseases and Traumatology 2018 1(1):1-4 Femoral neck fracture has an annual incidence of 1 per 1000 population; in young patients, functional prognosis is not good due to risk of osteonecrosis. Femoral head vascularity is mostly contributed by retinacular vessels and lateral epiphyseal artery. The vascular impact is due to displacement, interrupting retinacular vessel, interrupting ligament teres vascularization, and increased intracapsular pressure, producing a tamponade effect leading to osteonecrosis. This study reviewed the different methods of assessment of femoral head vascularity after femoral neck fractures. There are many techniques for the assessment of residual femoral head vascularity after femoral neck fractures and for the assessment of post-traumatic osteonecrosis risk. Some invasive techniques are superselective angiography, intraosseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others are noninvasive scintigraphy and conventional or dynamic magnetic resonance imaging (MRI). The future seems to lie with dynamic MRI, which gives new classification of femoral neck fractures, based on a noninvasive assessment of femoral head vascularity.

Classification of fracture neck of femur Bikas Sahoo, Alok C Agrawal, Bikram K Kar, Harshal Sakale, Sandeep K Yadav, Sameer Mittal Journal of Orthopaedic Diseases and Traumatology 2018 1(1):5-7 There are numerous classification systems for fracture neck of femur in adults. A fracture classification is proposed either for taxonomical purpose, characterization, guiding intervention, or predicting outcomes of intervention. The classifications described in this chapter are needed to decide on choice of implant, stability, acceptability of reduction, vascularity and long term prognosis.

Early management of fracture neck of femur Abhishek Jain, Alok C Agrawal, Bikas K Sahoo, Sandeep K Yadav, Bikram Keshri Kar, Harshal S Sakale Journal of Orthopaedic Diseases and Traumatology 2018 1(1):8-10 Femoral neck fracture is considered a medical emergency as an early fixation helps in getting an accurate reduction, preservation of blood supply, removal of tamponade within the capsule, and early mobilization. This article deals with the science of early management of femoral neck fractures.

Pediatric fracture neck of femur Sandeep K Yadav, Alok C Agrawal, Bikram Keshri Kar, Harshal S Sakale, Bikas Sahoo, Rahul K Chandan Journal of Orthopaedic Diseases and Traumatology 2018 1(1):11-14 The incidence of hip fractures in children about 1% of total pediatric fractures. The most common cause is a high-energy trauma, such as motor vehicle accidents and falls from a height. In old cases, magnetic resonance imaging (MRI) may be needed to assess the vascularity of femoral head. Hip fractures can have deep impact on the development of hip. Vascularity of femoral head plays a vital role in the management of femoral neck fracture. The paper deals with the cited complications related to femoral neck fracture like avascular necrosis (AVN), nonunion, mal-union, and premature closure of the proximal femoral physis, leading to leg length discrepancy.

Delayed diagnosed femoral neck fractures Bikram K Kar, Alok C Agrawal, Sandeep K Yadav, Harshal Sakale, Bikas Sahoo Journal of Orthopaedic Diseases and Traumatology 2018 1(1):15-20 Treatment of displaced femoral neck fractures includes internal fixation with/without graft supplementation or internal fixation plus osteotomy or arthroplasty. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in patients with displaced femoral neck fractures who present delayed, treated either by internal fixation or arthroplasty. The purpose of our study was to summarize the management protocol of fracture of neck of femur when they present at different duration and at different stage.

Neglected fracture neck of femur: Our experience Alok C Agrawal Journal of Orthopaedic Diseases and Traumatology 2018 1(1):21-22 Fracture neck of femur continues to be neglected in rural India. Several salvage options tried in the past are now out of local interest in favor of some sort of arthroplasty. Although the long-term viability of this policy is not known, only the future will guide to a definite path.

Osteonecrosis and nonunion as complication of fracture neck femur Rudra P. S. Thakur, Alok C Agrawal, Bikas K Sahoo, Vishal K Kujur Journal of Orthopaedic Diseases and Traumatology 2018 1(1):23-28 Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. Fixation failure and nonunion are the main modes of failure following fixation of displaced or undisplaced femoral neck fractures. The two problems are difficult to distinguish as most displaced fractures take a long time to heal after fixation, which increases the risk of fixation failure. Avascular necrosis of the femoral head occurs in 9%–18% of patients, between 2 and 8 years postfracture. Risk factors include the degree of fracture displacement, patient age, and delay in surgical treatment.

Failure of fixation of fracture neck of femur and remedies for management Sameer Mittal, Alok C Agrawal, Bikram K Kar, Harshal Sakale, Bikas Sahoo, Sandeep K Yadav Journal of Orthopaedic Diseases and Traumatology 2018 1(1):29-32 Failure of fixation is common complication of fracture neck of femur, more common in displaced fractures than in undisplaced fractures. Early diagnosis and treatment of fixation failure is very important for good outcome. Physiological age of patient, status of the hip joint, viability of the femoral head, and presence of occult infection are the factors that should be considered before deciding the suitable salvage procedure. In patients younger than 50 years, preservation of the femoral head is preferred as salvage treatment. Hemiarthroplasty or total hip arthroplasty is the choice of salvage for femoral neck fracture nonunions in physiologically older patients.

Do we need internal fixation devices for giant cell tumors around knee joint? An outcome study Ritesh Runu, Vidya Sagar, Ashutosh Kumar, Arnab Sinha, Santosh Kumar Journal of Orthopaedic Diseases and Traumatology 2018 1(1):33-37 Introduction: Giant cell tumors around the knee joint are the most common aggressive benign tumors. Several limb sparing and limb ablation surgeries are practiced with varying level of success. Here we present an original outcome study conducted on 14 patients with giant cell tumor around the knee joint, treated with intralesional curettage, bone grafting and bone cementing with or without internal fixation. Material and Methods: This is a retrospective study carried out in an institutional set up. Fourteen patients were operated and Internal fixation was used in five cases. the patients were followed up for 2 years minimum. Results: Total fourteen patients were treated with giant cell tumors around knee joint. Phenol cauterization showed reduced recurrence compared to no phenol cauterization. Collapse was noted in cases done with curettage and only cementing or only bone grafting. plating group showed no collapse. No collapse was noted in cases with subchondral bone more than 5 mm. Conclusion: For giant cell tumor, campannaci grade III, internal fixation is suggested if subchondral bone is less than 5 mm and articular involvement is more than 50%.

Dome osteotomy in cubitus varus: Our results Ashutosh Kumar, Vidya Sagar, Pawan Kumar, Deepak Kumar, Ritesh Runu, Gaurav Khemka Journal of Orthopaedic Diseases and Traumatology 2018 1(1):38-42 Introduction: Cubitus varus (gunstock deformity) is the most common complication of supracondylar fracture of the humerus. Several osteotomies and various fixation techniques are described for its correction. The most commonly used is the lateral closing-wedge osteotomy, also known as French osteotomy with variable results. Persistent lateral condyle prominence leads to cosmetically unacceptable appearance and poor patient satisfaction. To avoid this problem, dome osteotomy is performed. We have evaluated results of dome osteotomy in our population. Material and Methods: This was a retrospective study carried out in our institute. Ten patients with cubitus varus treated by dome osteotomy were evaluated at 24 months. All patients were operated by triceps-splitting approach. Pre- and postoperative carrying angle of elbow, range of motion, and lateral condyle prominence index were compared according to Banerjee criteria. Results: Ten patients with average age of 9.1 years were followed up for 2 years. Mean gap between injury and surgery was 15 months. Postoperative improvement in carrying angle and lateral condylar prominence index was significant. One case developed ulnar neuropraxia, which recovered fully within 2 weeks. Pin tract infection was seen in three cases and skin infections in two cases. Conclusion: Dome osteotomy is a technically demanding surgery. The functional and cosmetic correction is better compared to that for French osteotomy.

Noncommunicable Diseases

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Noncommunicable diseases surveillance in India: Moving toward a more comprehensive approach Jai Prakash Narain, KR Thankappan International Journal of Noncommunicable Diseases 2018 3(4):111-114

Diabetic care delivery with package of essential noncommunicable diseases interventions protocol in rural Nepal: A district hospital-based study Pawan Agrawal, Priyanka Gupta, Bikash Gauchan, Biplav Shrestha International Journal of Noncommunicable Diseases 2018 3(4):115-119 Background: Diabetes ranks fourth among the noncommunicable diseases (NCDs) in terms of proportional mortality in Nepal and is increasingly diagnosed in rural population. We aimed to evaluate the care delivery in diabetes patients in a rural primary care hospital that had implemented the World Health Organization's Package of essential NCDs interventions (PEN) protocol. Subjects and Methods: This was a descriptive study in a rural district hospital. The study was conducted over 5 months and was undertaken as a part of the quality improvement project in the hospital. Data were extracted from the electronic medical record of the hospital after approval from hospital administration. Results: The total diabetic patient visits during the study period were 682 of 30,758 total outpatient visits (2%). There were 240 unique diabetic patients. The age ranged from 25 to 82 years with the median age of 52. Glycated hemoglobin was done in 15 of 59 new cases and in 33 of 181 follow-up cases. Urine protein was assessed in 65 of 240 patients. Comorbidities and complications were documented in 96 of 240 patients (40%), hypertension being the most common. Fifty-six patients (23%) had obtained control as per the target levels with different modalities of treatment, 69 (29%) had partial control, 85 (35%) struggled to reach targets, and 30 (13%) failed to appear in follow-up visits. Conclusion: The study described our adherence to the PEN protocol and identified several areas of improvement in our diabetes care delivery such as continuous medical education activities and monitoring of care delivery with similar study in future after implementation of proposed interventions.

Health professionals' perspectives on factors needed to implement nutrition strategy: A questionnaire validation study Reem Saleh Al Gurg, Mohammed Alameddine, Amar Hassan Khamis International Journal of Noncommunicable Diseases 2018 3(4):120-125 Background: Noncommunicable diseases (NCDs) increasingly recognized as a serious, worldwide public health concern. According to the WHO, NCDs are currently responsible for two-thirds of global deaths annually. Nutritional food and unhealthy diet are contributing to an immense portion of NCDs. Exploring the role of nutrition in healthcare delivery with a particular focus on the United Arab Emirates (UAE) context is also aligned with the UAE Government's Vision 2021. Aim: To develop a reliable and valid questionnaire that helps to assess the agreement about factors needed to implement a nutrition strategy in the UAE. Materials and Methods: One hundred and sixty-one health professionals were invited to respond to a questionnaire assessing agreement with factors needed to implement a nutrition strategy. The questionnaire consisted of 11 factors, each containing four items that made a total of 44 items assessed on a 7-point Likert scale (1 strongly disagree to 7 strongly agree). The questionnaire was evaluated using factor analysis, and Cronbach's alpha was used to test the internal consistency of the responses of participants. Ethical approval was given by the Chair of Humanities and Health Sciences Research Ethics Panel (UAE). Results: The questionnaire was validated by an expert panel. A factor analysis was carried out through responses of the health professional and revealed that the 11 factors are included in the questionnaire; only one item from the factor of resources and enablement was excluded: the exclusion of the item “hospital uses the lifespan approach in nutrition interventions” due to singularity and insufficient load of the variance extracted. Conclusion: The study concluded that the questionnaire was valid and reliable on its form of 43 items divided into 11 factors to assess the agreement toward factors needed to implement a nutrition strategy in the UAE.

Effectiveness of "percutaneous coronary intervention care program" on selected variables among patients undergoing percutaneous coronary intervention Poonam Sharma, Sandhya Ghai, Manoj Kumar Rohit, Monika Dutta International Journal of Noncommunicable Diseases 2018 3(4):126-133 Objective: The study was conducted to assess the effectiveness of “percutaneous coronary intervention (PCI) care program” among patients undergoing PCI. Subjects and Methods: A quasi-experimental design was adopted, and purposive sampling technique was used to enroll the patients in the experimental and control groups. Different tools were used to collect the data, which include numerical pain and comfort rating scale, Barthel Index for activities of daily living, assessment for the presence of vascular complications, modified CADEQ-SV questionnaire, State-Trait Anxiety Inventory scale, self-structured satisfaction scale, and PCI manual. Results: There was a significant decrease observed in state anxiety (P < 0.001), pain level at 12 h (P = 0.03), discomfort within 12 h (P < 0.001) and 24 h (P = 0.002), improving knowledge regarding coronary artery disease (CAD) (P < 0.001), and activities of daily living as well as significant increase in satisfaction level (P < 0.001) among patients undergoing PCI in the experimental group than the control group. Conclusion: The study concluded that this program was effective in reducing anxiety, pain, and discomfort and increased satisfaction level, knowledge regarding CAD, and independence in self-care activities for PCI patients.

Segmentation of jet area to quantity the severity of mitral regurgitation by color Doppler echocardiography N Chidambaram, GN Balaji, TS Subashini International Journal of Noncommunicable Diseases 2018 3(4):134-138 Mitral regurgitation (MR) is a disorder of mitral valve and it is one of the most common causes of cardiovascular morbidity and mortality. Mitral valve allows blood to flow from left atrium, to the left ventricle and Mitral Valve regurgitation results in poor apposition of the valvular leaflets, so that the heart's mitral valve doesn't close tightly, allowing blood to flow backward into the left atrium. Transthoracic Echocardiography (TTE) with Doppler is the widely used non-invasive technology for the detection and evaluation of severity of valvular regurgitation. Proximal isovelocity surface area (PISA) method has been widely accepted by clinicians as a means for grading MR severity. In this paper an alternate method to PISA to automatically quantify mitral valve regurgitation severity is proposed. This work attempts to automatically segment the jet region in color Doppler images using K-Means clustering. Further to quantify mitral regurgitation, jet area parameters and shape features are extracted from the segmented jet region which are then modeled using classifiers such as Support Vector machine (SVM) and Back Propagation Neural Network (BPNN). Quantifying MR with PISA calls for considerable expertise as a number of components must be taken into account to fully assess the severity of mitral regurgitation, however the results of the proposed method indicate that it could be used as an alternate method to automatically assess the severity of mitral regurgitation.

Decoding increasing prevalence of noncommunicable diseases Alok K S Thakur International Journal of Noncommunicable Diseases 2018 3(4):139-144 Background: In recent times, noncommunicable diseases (NCDs) have attained epidemic status in India and several other countries. Globally, each year, NCDs cause premature deaths of nearly 40 million people younger than 60 years accounting for 70% of all deaths; 80% of these premature deaths are reportedly in the low- and middle-income countries. Many studies have reported increasing prevalence of NCDs such as type 2 diabetes, coronary and pulmonary diseases, and cancer. Incidentally, all these studies besides discussing environmental pollution have grossly ignored dietary profiling of affected populace despite the fact that several studies have established a direct correlation between food quality and good health. Objective: Besides pollutants, an attempt is made to analyze mathematically effects of dietary changes over the last four decades on constantly increasing prevalence of NCDs at cellular level. A relationship seems to exist between increasing prevalence of NCD and large-scale consumption of synthetic salt. Conclusions: Elimination of essential trace elements and micro- and macro-minerals in regular diet through synthetic salt fortified with iodine alone appears to cause more harm than benefits associated with iodization of salt than pollutants. Regular intake of essential trace elements is necessary for normal functioning of many fundamental functions of the body such as Na-K pump, electron–proton transport, biochemistry, and thermodynamics. An attempt has been made to study effects of salt constituents used in food at the most fundamental cellular level by means of disturbances in body electrolyte through heat and ion transport mechanism that is fundamental to various underlying processes in human body. Interestingly, almost all the families who switched over to unprocessed rock salt from synthetic iodized salt reported improvement in general health and reported reduction in medical visits.

Anaesthesia

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Erector spinae plane block: New block with great expectations Can Aksu, Yavuz Gürkan Saudi Journal of Anaesthesia 2019 13(1):1-2

Physiological and operative severity score for the enumeration of mortality and morbidity, frailty, and perioperative quality of life in the elderly Maria João M. Lima, Daniela F M Cristelo, Joana B Mourão Saudi Journal of Anaesthesia 2019 13(1):3-8 Background: Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a validated instrument used to predict morbidity. The aim of our study was to evaluate the performance of the POSSUM score system on predicting perioperative frailty and quality of life (QOL) in elderly surgical patients. Patients and Methods: An observational prospective study was conducted during 3 months. POSSUM was used to determine operative morbidity risk. Patients with a POSSUM score ≥26 were considered as having a high POSSUM (PHP). WHODAS 2.0, EuroQOL-5 dimensions (EQ-5D), Charlson score, and the Clinical Frailty Scale were used to assess the QOL and frailty. Chi-square, Fisher's exact, or Mann–Whitney tests were used for comparisons. Results: Two hundred and thirty-five patients were included. Median age was 69 years; 58% were ASA I/II and 42% ASA III/IV. Frailty was present in 53 patients (23%). Median POSSUM score was 26. Patients PHP were older (median age 71 vs. 68, P = 0.008), more frequently ASA III/IV (P = 0.001), had higher median Charlson scores (7 vs. 5, P = 0.006) and were more frail (49% vs. 26%, P < 0.001). PHP presented more problems in EQ-5D dimensions preoperatively (mobility: 59% vs 41%, P = 0.008; care: 41% vs. 25%, P = 0.013; activity: 52% vs. 32%, P = 0.002; pain: 59% vs. 45%, P = 0.041) but not anxiety (P = 0.137). Three months after surgery, PHP patients presented more problems in mobility: 63% vs. 38%, P < 0.001; care: 48% vs. 31%, P = 0.009; activity: 58% vs. 44%, P = 0.036; pain 59% vs. 37%, P = 0.001 and anxiety: 54% vs. 50%, P = 0.025. Conclusions: Patients PHP were frailer and had worse perioperative QOL.

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate Asha Tyagi, Gaurav Verma, Ankit Luthra, Shubham Lahan, Shukla Das, Gargi Rai, Ashok Kumar Sethi Saudi Journal of Anaesthesia 2019 13(1):9-15 Background: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. Materials and Methods: Adults scheduled for orthopedic surgery under general anesthesia with >200–300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. Results: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. Conclusion: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.

The quality of life and satisfaction rate of patients with upper limb hyperhidrosis before and after bilateral endoscopic thoracic sympathectomy Waseem M Hajjar, Sami A Al-Nassar, Heba M Al-Sharif, Dana M Al-Olayet, Wejdan S Al-Otiebi, Alanoud A Al-Huqayl, Adnan W Hajjar Saudi Journal of Anaesthesia 2019 13(1):16-22 Background: Hyperhidrosis is a functional disorder identified by excessive sweating. Its incidence is approximately 1% in any population. Bilateral endoscopic thoracic sympathectomy (BETS) intervention is the definitive treatment of choice for palmar and axillary hyperhidrosis. Aims and Objectives: The purpose of this study is to evaluate and compare the quality of life (QOL) and satisfaction rate of patients with upper limb hyperhidrosis before and after BETS surgery and the influence of compensatory hyperhidrosis (CH) on patients' QOL after surgery. Settings and Design: This study is a cross-sectional study designed to generate longitudinal data. Subjects and Methods: This study is a cross-sectional study designed to generate longitudinal data pre- and postbilateral BETS prospectively. This study was conducted in the surgery department of University Hospital in Riyadh, Saudi Arabia. Hundred patients with upper limb hyperhidrosis who underwent BETS from 2014 to 2017 were included. A modified and validated QOL questionnaire for hyperhidrosis was completed by the patients themselves in order to compare the QOL for patients both before and after BETS. Patients' satisfaction and the occurrence of CH were obtained postoperatively. Statistical Analysis Used: Data were analyzed using the SPSS® statistical package for social studies, version 22.0 (SPSS 22; IBM Corp., New York, NY, USA) for Windows®. Results: A total of 100 patients completed the questionnaire; 94% of patients had a positive QOL outcome after the surgery. The mean decrease in QOL scores was −42.0 points toward better QOL. The site of sweating had a significant effect on the patients' QOL before and after the surgery (P value < 0.001). Moreover, 76% of patients reported a high satisfaction rate. Conclusion: Primary hyperhidrosis can negatively impair patients' QOL in different domains. BETS showed to be an effective option for improving the QOL of patients and it provided both short- and long-term effectiveness in treating upper limb hyperhidrosis. CH did not interfere with the rate of patient satisfaction or their QOL postoperatively.

Bedside ultrasonography for the confirmation of gastric tube placement in the neonate Yunus Oktay Atalay, Ahmet Veysel Polat, Elif Ozyazici Ozkan, Leman Tomak, Canan Aygun, Joseph Drew Tobias Saudi Journal of Anaesthesia 2019 13(1):23-27 Background: Naso/Orogastric tube (NOGT) misplacement can lead to significant complications. Therefore, the assessment of tube position is essential to ensure patient safety. Although radiography is considered the gold standard for determining NOGT location, new methods may be helpful in reducing repetitive radiation exposure, especially for neonates. In this study, we sought to investigate if bedside ultrasonography (BUSG) can be used to verify NOGT placement in neonatal intensive care patients. Materials and Methods: Infants requiring NOGT placement were enrolled. After insertion of the NOGT, the location was first identified using BUSG and then confirmed using abdominal radiography for comparison. Results: The study cohort included 51 infants with an average gestational age of 34 ± 4.9 weeks. BUSG determined the NOGT location correctly with a sensitivity of 92.2%. The location of the NOGT could not be determined by BUSG in four neonates (7.8%). In one infant, the NOGT was positioned in the esophagus, as determined both by BUSG and radiography. Conclusion: BUSG is a promising diagnostic tool for determining NOGT location in neonates, thereby eliminating the need for abdominal radiography.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study Eman Ramadan Salama, Doaa El Amrousy Saudi Journal of Anaesthesia 2019 13(1):28-34 Background and Objective: Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia. Materials and Methods: Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded. Results: TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5–28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8–32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45–100 and median = 82.4, range 10–100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt. Conclusion: In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

Comparative evaluation of two approaches of infraclavicular brachial plexus block for upper-limb surgeries Chandni Sinha, Neeraj Kumar, Amarjeet Kumar, Ajeet Kumar, Anup Kumar Saudi Journal of Anaesthesia 2019 13(1):35-39 Background: Infraclavicular approach is a common technique of brachial plexus block. The main difficulty of ultrasound guided technique is in needle visualization due to deep location of the cords. Hebbard et al described a retroclavicular approach wherein the needle was inserted posteriorly to the clavicle. Materials and Methods: In this prospective randomized controlled study, we have compared the classical technique with the retroclavicular approach in terms of needle visibility, block success rate, number of needle passes, block performance time, procedure-related pain, complications, patient and operator comfort and satisfaction. Results: The rate of block success was similar in both the groups. The needle tip and shaft visibility was more in the retroclavicular group (P < 0.05). The number of needle passes was also less in the retroclavicular group. Time for the block procedure was less in retroclavicular group when compared to the classical coracoid group. The patients reported less pain in retroclavicular group (P < 0.05). Discussion: Retroclavicular approach is a feasible option of infraclavicular brachial plexus block in Indian Subpopulation in terms of needle visibility and block success rate.

Respiratory mechanics with volume-controlled auto-flow ventilation mode in cardiac surgery* Murat Arslan, Elvan Öçmen, Seden Duru, Belkis Şaşmaz, Şule Özbılgın, Hasan Hepağuşlar Saudi Journal of Anaesthesia 2019 13(1):40-45 Aim: We aimed to investigate the changes in respiratory mechanics in adult patients undergoing open heart surgery (OHS) while using volume-controlled auto-flow (VCAF) ventilation mode. Materials and Methods: After obtaining ethics committee's approval and informed consent, 30 patients (17 males and 13 females; mean age: 57.3 ± 17.0 years; mean weight; 74.9 ± 13.6 kg) scheduled for OHS were enrolled. Mechanical ventilation was carried out using VCAF mode (VT: 5–8 mL/kg, I/E: 1/2, 10 ± 2 fr/min). Values of dynamic compliance (Cdyn) and resistance (R) were obtained at six time points (TPs). Normally distributed variables were analyzed with repeated measure of analysis of variance and Bonferroni tests. For abnormally distributed variables, Friedman variance analysis and Wilcoxon signed-rank tests were used. Values were expressed as mean ± standard deviation. P value <0.05 was considered significant. Results: Cdyn (mL/mbar) and R (mbar/L/s) values were as follows – (1) before sternotomy (S): 49.9 ± 17.1 and 7.8 ± 3.6; (2) after S: 56.7 ± 18.3 and 7.1 ± 3.7; (3) after S and after sternal retractor placement: 48.7 ± 16.1 and 8.3 ± 4.4; (4) after weaning from cardiopulmonary bypass and following decannulation while retractor was in place: 49.6 ± 16.5 and 8.1 ± 4.0; (5) after retractor removal: 56.5 ± 19.6 and 7.4 ± 3.7; and (6) after sternal closure: 43.1 ± 14.2 and 9.6 ± 9.1, respectively. Significant differences were observed in Cdynand R between; first and second TPs, second and third TPs, fourth and fifth TPs, and fifth and sixth TPs. Also, significant difference in Cdynwas found between first and sixth TPs, but it was not found in R. Conclusion: Cdyndecreases, but R remains the same in cardiac surgical patients when mechanical ventilation is performed with VCAF ventilation mode. Additionally, Cdynis negatively affected by the presence of sternal retractor and the sternal closure in OHS.

Outcome prediction with physiological and operative severity score for the enumeration of mortality and morbidity score system in elderly patients submitted to elective surgery Diana F Torres Lima, Daniela Cristelo, Pedro Reis, Fernando Abelha, Joana Mourão Saudi Journal of Anaesthesia 2019 13(1):46-51 Context: Elderly patients have a higher risk of complications and 30-day mortality than younger patients. Population is aging and this is an emergent preoccupation. Aims: The aim of this study was to evaluate the performance of Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) system on 30-day mortality in elderly patients submitted to elective surgery. Additionally, the correlation of WHODAS 2.0 and Clinical Frailty Score (CFS) with mortality was evaluated. Settings and Design: An observational prospective study was conducted between May and July 2017. Methods and Material: Patients submitted to elective orthopedic, gynecologic, urologic, vascular, plastic, and general surgery were included. Exclusion criteria were as follows: age <60 years old; inability to give informed consent; emergency/urgency surgery, inability to understand Portuguese; patients admitted in the ICU after surgery. POSSUM was used to estimate postoperative mortality risk. WHODAS 2.0 and CFS were used to assess quality of life and health status. Mortality was evaluated during hospital stay and 30 days after surgery. area under the receiver operating characteristic (AUROC) was analyzed to test the discrimination of P-POSSUM, WHODAS 2.0 and CFS scale. Statistical Analysis Used: Statistical analysis was done using the SPSS Software (version 24.0). Results: POSSUM-predicted mortality was 3.0% with a standardized mortality ratio = 0.87; 95% CI 0.62–0.93; and a good calibration (H–L: P = 0.646); however, the AUROC was poor (0.563). We identified an association between mortality and a higher CFS grade (P = 0.000 and AUROC = 0.859) and a higher WHODAS 2.0 score (P = 0.000 and AUROC = 0.808). Conclusions: WHODAS and CFS appear to be a better assessment tolls for predicting postoperative mortality with a good discrimination comparing with P-POSSUM system.

Comparative study of mid-thoracic spinal versus epidural anesthesia for open nephrectomy in patients with obstructive/restrictive lung disease: A randomized controlled study Nazmy Edward Seif, Ahmed Mohamed ELbadawy Saudi Journal of Anaesthesia 2019 13(1):52-59 Background: The aim of this randomized controlled study is to compare the safety and efficacy of thoracic spinal versus thoracic epidural anesthesia for open nephrectomy in patients with obstructive/restrictive lung disease. Methods: Sixty patients with mild to moderate chronic obstructive/restrictive lung disease undergoing open nephrectomy were randomized into two groups, 30 patients each. The thoracic spinal group (TSA) group received ultrasound guided mid-thoracic spinal anesthesia, and the thoracic epidural group (TEA) group received thoracic epidural anesthesia. All blocks were performed at the T7-T8. Hemodynamics, visual analogue scale score, sensory and motor block profile as well as any adverse events, and patient satisfaction were all reported. Results: Both blocks were successfully performed and were effective for surgery in all patients, with the exception of only one patient in TSA group who needed to receive general anesthesia even after IV midazolam because of extreme anxiety and was excluded from the study analysis. The sensory block ranges were quiet close, with T2-T5 for the TSA group and T3-T6 for the TEA group as the upper level and L3-L5 as the same lower level. The values for the onset time and the duration of sensory and motor blocks were lower in TSA group. There were no statistically significant differences existed in intraoperative VAS, and hemodynamics between the two groups. Postoperative adverse effects were negligible and insignificant, with no case reporting any neurological sequel. Conclusion: Ultrasound guided thoracic spinal anesthesia can be performed safely and effectively for open nephrectomy in patients with obstructive/restrictive lung disease with the potential for an early ambulation and great patient satisfaction.

Forensic Science and Medicine

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Deaths due to electrocution: An evaluation of death scene investigations and autopsy findings Brittani K Massey, Mohammed A Sait, William L. A. Johnson, Mary Ripple, David R Fowler, Ling Li Journal of Forensic Science and Medicine 2018 4(4):179-183 The purpose of the study was to delineate the epidemiological characteristics of electrocution deaths in Maryland, identify any potential risks, and address preventive measures. A retrospective review of all the deaths due to electrocution was conducted at the Office of the Chief Medical Examiner in the State of Maryland from 2005 to 2015. During the 11-year period, a total of 55 electrocution deaths were identified from the autopsy cases at the statewide medical examiner system. More males died of electrocution than females with its ratio of (M: F) = 9:1. Of the 55 cases, 67.3% were White, 18.2% were African-American, 12.7% were Hispanic, and 1.8% were other races. The age of the victims ranged from 4 to 83 years with mean age of 40 years. >96% deaths due to accidents and 3.4% were suicide. The majority of deaths (70.9%) were caused by high-voltage circuits. Approximately 64% of fatalities were work-related accidents. The study indicated that electrocution deaths frequently affected young male workers who were in contact with a high-voltage currents while on the job. The detailed death scene investigation and autopsy findings are presented. The potential hazards of electricity must continue to be addressed in public safety campaigns to prevent such deaths. Strategies should ensure safe work environments for any contact with electric currents.

Determination of methadone and eight new psychoactive substances in hair samples by gas chromatography/mass spectrometry Luca Anzillotti, Luca Calò, Marianna Giacalone, Antonio Banchini, Rossana Cecchi Journal of Forensic Science and Medicine 2018 4(4):184-191 Many new psychoactive substances (NPSs) with different chemical structures have emerged in the illicit drug market in the last decade. The present work was aimed at the development of a simple method in gas chromatography/mass spectrometry (MS) for the determination of NPS of different classes, the use of cannabinoids, and, at the same time, the evaluation of methadone therapy in hair matrix, within our routine analysis control for methadone treatment or from autopsy cases. The determination of synthetic cannabinoids and methadone therapy used an extraction method based on incubation in concentrated sodium hydroxide (NaOH) solution, providing a dissolution of the keratin matrix. The described method was applied on 15 authentic specimens from our cases: five showed the presence of methadone and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP). The described method can be useful not only in the forensic investigation of NPS-related addiction histories but also in epidemiological and retrospective studies on the spread of NPS among specific safety-sensitive social workers. The GC instrument was an Agilent 7820A (Agilent Technologies, Santa Clara, CA, USA), and the detection system was an Agilent 5977B single quadrupole MS operating in selective ion monitoring mode. Validation parameters such as limit of detections (LODs), limit of quantifications (LOQs), repeatability, accuracy, and linearity were satisfactory for its application on real specimens. LODs, LOQs, R%CV, standard deviation, and the mean concentration for the analyzed compounds are reported in Table 1b. Accuracy and repeatability were acceptable for all the analytes at their respective LOQs. Recovery experiments varied from 58.3% to 103.0%, thus allowing the application on authentic specimens. The described method can be useful not only in the forensic investigation of NPS-related addiction histories but also in epidemiological and retrospective studies on the spread of NPS among specific safety-sensitive social workers, such as drivers.

Fast fourier transform: A Niche, but critical strategy in optimizing impression evidence Brian Dalrymple Journal of Forensic Science and Medicine 2018 4(4):192-196 The evolution from film to digital as the recording medium for forensic imaging has extended the reach of forensic photographers, both in original capture and postphotography processing. Images of fingermarks and footwear impressions are routinely obstructed by substrates displaying intrusive color and pattern. Such backgrounds are frequently sufficiently intrusive as to prevent the analysis and comparison of the images to known exemplars. Digital techniques such as Fast Fourier Transform (FFT) in postphotography processing can optimize the signal-to-noise ratio to a greater degree than was ever possible when film was the recording standard. Occasionally, unwanted backgrounds can be removed or diminished in Photoshop with techniques such as background subtraction and channel blending. These strategies, however, are dependent on either physical removal of the evidence impression to obtain a second image of the obstructive pattern or on differences in color between the impression and the offending substrate. FFT is unique in its ability to optimize the image signal to noise ratio by suppressing the obstructive background, in that it is not reliant on color, and is not applied in the spatial domain.

Is magnetic flux a valuable tool for the analysis of electrophotographic-printed documents? Williams David Mazzella, Bing Li Journal of Forensic Science and Medicine 2018 4(4):197-202 The goal of this preliminary study was to evaluate the potential application of magnetic flux for document screening. In this investigation, we examined the homogeneity of magnetic flux over the entire page of sample documents and provided recommendations on the measurements procedure.

Research on subjective bias cognition effect in handwriting identification Bing Li, Tiantian Ma Journal of Forensic Science and Medicine 2018 4(4):203-212 This article starts from the point of view that handwriting examination is dependent on empiricism and by analyzing the core steps of handwriting identification explains that it might be influenced by subjective bias. In practice, examiners cannot avoid biases in decision-making; instead, we must accept the existence of subjective bias in handwriting identification and then discuss its impact; for instance, feature selection in the process of comprehensive evaluation, which involves a comparison of the number and quality of similarities and differences between a questioned sample and the references. While we conclude that comprehensive evaluation is the most important step in the identification process, industries in China do not stipulate explicit and transparent criteria for it, making it hard to numerically quantify the characteristics of handwriting identification. In this article, forensic examiners' opinions on handwriting identification were obtained through a survey. One finding was that most handwriting examiners believe that handwriting identification is subject to subjective bias. In addition, they believe that the subjective cognition of handwriting identification can somehow help actively produce the correct opinion; before the examination, most handwriting examiners think that they should understand the context and so on. Finally, through the questionnaire, which contained variations such as the same case with different background information, different cases with the same background information, and the same case with or without context, it was concluded that handwriting identification does have certain subjectivity. However, which kind of factors influence this subjectivity is not presently clear. Furthermore, it is difficult to control uncertainties when forming an opinion on identification. An alternative way is to perform scrutiny after the formulation of handwriting opinions; for example, internal and external reviews such as appearing in court.

Modernization of medicine in the ottoman empire and its effects on forensic sciences Ferat Buran, Erdem Özkara Journal of Forensic Science and Medicine 2018 4(4):213-220 Modernization in medicine began in the Ottoman Empire in the 19th century. Until that time, medical education had been provided through the traditional master–apprentice practices and its methods had relied on custom or religion. The most important of these reforms was in 1827, when the first medical schools in surgical and clinical branches were opened in İstanbul. The lack of contemporary understanding in medical education until that time had caused an underdevelopment in forensic sciences as it had in various other fields. Following the reform movements, the contents of the forensic medicine curriculum, mainly influenced by the French medical schooling, touched upon all areas of forensic sciences such as pathology, toxicology, organic chemistry, neuropsychiatry, gynecology, handwriting analysis and criminalistics. It was noteworthy to see such rapid development in scientific modernization considering the fact that, before the reform movements, the religion had a repressive effect and it was forbidden to even perform laboratory tests or examinations on corpses. In the modern Turkish Republic, founded in 1923 after World War I, scientific reforms gained momentum and began competing with the modern world. Such that, after a letter sent to the Turkish Government by Albert Einstein in 1933, the contemporary Turkish universities embraced the scientists who escaped from the Nazi regime.

On trends of the role transition from expert assistant to expert witness Baosheng Zhang, Shuai Dong, Ping Yang Journal of Forensic Science and Medicine 2018 4(4):221-228 In the context of Chinese evidence law, the role of the expert assistant is to “offer opinion on the forensic expertise or specialized issues.” This role is multiple-facet, somewhat similar to a lawyer's role, and to some extent similar to that of a forensic expert or a witness. For this simple reason, the views on the legal status of opinions of the expert assistant also vary from “cross-examination method,” “forensic expertise” to “witness testimony.” This confusion regarding the role of the expert assistant often results in difficulties in deciding whether to admit the expert assistant opinion as evidence at trial. The regulation that the expert assistant opinion “can be taken as evidence for determining facts of a case after cross-examination” stipulated in Paragraph 2 of Article 15 of the Supreme People's Court Interpretation of the Law in the Conduct of Environmental Civil Public Interest Litigations promulgated in 2015 could be seen as trends of a transition in the role of the expert assistant towards that of the expert witness. This article attempts to analyze reasons, significance, and prospects of such a transition, and give suggestions to improve the application of examination rules for the expert witness and admissibility rules for scientific evidence.

Septicemic melioidosis: A forensic autopsy case report Atif Shamsudin, Heo Chong Chin, Ahmad Hafizam Hasmi, Hapizah Mohd Nawawi Journal of Forensic Science and Medicine 2018 4(4):229-232 We report a 27-year-old male from Kuwait who died due to melioidosis, and the diagnosis was achieved after the deceased underwent postmortem examination at the Forensic Department, Kuala Lumpur Hospital. While the disease is endemic in Southeast Asia and Northern Australia, human melioidosis infection has yet been reported in Kuwait. He was initially diagnosed as acute gastroenteritis at a private clinic before being found dead at a hotel in Kuala Lumpur. The autopsy revealed positive findings of Burkholderia pseudomallei in the deceased's brain, lung, liver, and spleen as well as in the blood and cerebrospinal fluid culture. The deceased's death highlights the importance of early accurate diagnosis, the common manifestations, and the need of effective antibiotic treatment of septicemic melioidosis in high prevalent areas.

Forensic investigation of atypical asphysia Zhe Cao, Zhiyuan An, Xiaoning Hou, Dong Zhao Journal of Forensic Science and Medicine 2018 4(4):233-237 Smothering, choking, confined spaces, traumatic asphyxia, positional asphyxia, and other kinds of atypical mechanical asphyxia are not rare in forensic practice. However, these are not commonly well demonstrated in forensic monographs worldwide. The authors researched related works and literatures and summarized these with a view to contribute to the existing teaching resources and provide help to forensic practitioners who are involved in scene investigation and identification of such deaths.

Nursing

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Effect of selected play activities on preoperative anxiety level and fear among children undergoing abdominal surgeries Asmaa Abd El-Maksoud El-Moazen, Soheir Abd-Rabou Mohamed, Marwa Abdel Kereem Egyptian Nursing Journal 2018 15(3):205-216 Backgroun Hospitalization and surgery are stressful events children face especially during the early years. Through play activities, children can reduce the level of preoperative anxiety and fear. Aim The aim of the current study was to evaluate the effect of selected play activities on preoperative anxiety level and fear among children undergoing abdominal surgeries. Sample A convenient sample of 50 school-age children undergoing abdominal surgeries participated in the current study. Design One-group pre–post-test time series quasi-experimental research design was used to achieve the aim of the current study. Setting The current study was conducted at the General Pediatric Surgical unit at Cairo University Specialized Pediatric Hospital. Tools Data were collected through the following tools: structured interview questionnaire, State-Trait Anxiety Inventory for Children (STAIC), and the Glasses Fear Scale (GFS). Results The results revealed that preoperative anxiety scores on STAIC and preoperative fear scores on GFS were lower among the studied children after using the selected play activities than before. A highly statistically significant difference was detected between total mean score of STAIC and GFS in the pretest and after the first, second, and third play sessions and at 30 min before surgery. Conclusion The current study concluded that the selected play activities were effective in reducing the level of anxiety and fear among children undergoing abdominal surgeries. Recommendations It was recommended that establishing preoperative play activities for children undergoing abdominal surgeries is essential for preparation of the child for surgery.

Effect of nursing intervention on improving intellectual education teachers' performance toward students with epilepsy Samia F Mahmoud Egyptian Nursing Journal 2018 15(3):217-227 Background Epilepsy is a major health problem that oftenoccursseen among intellectual schools. Students with seizures annoy their teachers. The aim of this study was to evaluate the effect of nursing intervention on improving intellectual education teachers’ performance toward students with epilepsy atSharkia Governorate. A quasi-experimental design was used in this study. A purposive sample composed of 163 teachers from 13 intellectual schools working at least two years. Three tools were used: Tool (I): Teacher’s knowledge about epileptic student, self-administered questionnaire. Tool (II): Teacher’s practice observation checklist. Tool (III): Teacher’s attitudes toward students with epilepsy scale. Results Most of the studied teachers were married. In addition, statistically significant improvements were detected in the teachers’ knowledge, practices, and attitudes, from pre-sessions to immediately after and 3 months of post sessions where the total mean score of their knowledge increased from9.61±3.30in pre-sessions, to 19.35±1.73 immediately post sessions and 18.67±2.61, at 3 months of post sessions. The total mean score of their practices increased from 3.31±5.081 pre-sessions to 26.72±5.46 immediately post sessions and 24.83±6.71, at 3 months of post sessions. The total mean score of their attitudes increased from 13.62±2.25 in pre-sessions, to 16.38±1.83 immediately post sessions.Therefore, it is recommended that in-service training courses to be conducted periodically among all intellectual schools teachers’.

The effect of oral versus intravenous fluid therapy on maternal and neonatal outcomes for women with oligohydramnios Hala Abd El-fttah Ali, Sabah Ramadan Hussein Ahmed Egyptian Nursing Journal 2018 15(3):228-235 Background Oligohydramnios may increase the perinatal morbidity and mortality rate and is associated with adverse fetal outcomes. Aim The aim of this study was to assess the effect of oral versus intravenous fluid therapy on maternal and neonatal outcomes for women with oligohydramnios. Study design This was a quasi-experimental study model. Setting Th study was conducted at a high-risk pregnancy department at a specific private hospital in El-Mansoura City, Egypt. Participants and methods A purposive sample of 45 pregnant women with oligohydramnios was included in the study, and the women were divided equally into three groups, with 15 women per each group: the first group was administered intravenous (i.v.) isotonic solution, second group was administered i.v. hypotonic solution, and the third group was administered oral water. Data were collected during the period of 6 months from the first of December 2016 to the end of August 2017. Tools Four tools were used to conduct this study: maternal characteristics questionnaire, sonographic report for measuring amniotic fluid index (AFI) in oligohydramnios women before and after hydration, fluid chart, and maternal and neonatal assessment sheet. Results The AFI was significantly increased from 0.35±0.07 to 1.7±0.5 in the i.v. isotonic group whereas the AFI was significantly increased from 0.37±0.08 to 1.9±0.9 in the i.v. hypotonic group. Moreover, the AFI was more markedly increased from 0.37±0.07 to 2.7±0.8 in the oral water group. The maternal and neonatal outcomes did not differ significantly among the groups but were more markedly increased in the oral water group. Conclusion Oral hydration is as effective as intravenous hydration in significantly increasing the AFI in the third trimester oligohydramnios. The AFI was more markedly increased in the oral water. Maternal and neonatal outcomes did not differ significantly among the groups. Recommendations Oral hydration is recommended for pregnant women with oligohydramnios till delivery.

Health guidelines to prevent recurrence of urinary tract infection among diabetic patients Sharbat T Hassanine, Manar F Hamza, Eglal H Abdel-Hakeim Egyptian Nursing Journal 2018 15(3):236-245 Background Urinary tract infection (UTI), the most common bacterial infections, affects humans throughout their life span. The more complicated UTI and the recurrent nature increase the risk of hospitalization by two-folds leading to economic stress on the patient. There is also an associated increase in morbidity and mortality. Aims The aim of the study was to evaluate the effect of health guidelines on prevention and recurrence of UTI among diabetic patients. Sample The sample was a purposive one, which composed of 186 diabetic patients of both sexes. It included control and study groups of 93 patients each, with specific criteria. Design A quasi-experimental design was used to conduct the study. Setting This study was carried out in the urology outpatient clinic at the National Diabetic Institute, affiliated to Cairo University Hospitals. Tools Two tools were used for data collection: (a) an interviewing questionnaire for the diabetic patients concerning sociodemographic characteristics and medical-related data and (b) assessment tool of patient’s knowledge regarding preventive measure and care of UTI. Results The study showed that after the application of health guidelines, and follow-up for 1 year, the recurrence of UTI was seen in less than one-tenth of the study group compared with nearly one-third of the control group. Conclusion The results revealed a significant effect of health guidelines on prevention of recurrence of UTI among diabetic patients. Recommendations The findings of this study lead us to recommend conducting educational programs for the diabetic patient in the outpatient clinic to raise their awareness related to the preventive measures and care of UTI and design a simple illustrated booklet in Arabic language for them.

Effect of educational programs on knowledge and self-management of patients with chronic obstructive pulmonary disease Reda A.S Ibrahim, Mona M Abd El-Maksoud Egyptian Nursing Journal 2018 15(3):246-257 Background Patient education has a vital role in caring for patients with chronic obstructive pulmonary disease (COPD), and a corner stone of self-management in chronic illnesses. Aim of the study This study aimed to evaluate the effect of educational programs on the knowledge and self-management of patients with COPD. Methods This study was carried out on 40 COPD patients at outpatient follow-up Medical Clinics at Tanta University Hospital. The researchers interviewed them using an interview schedule to assess the sociodemographic characteristics, patients’ medical history, physical examination, and knowledge regarding COPD and an observational checklist to assess self-care practice of the patient. Results The results have shown significant differences in relation to decrease in the signs of cough, sputum, and shortness of breath immediately and after 2 months of implementing the self-care management program, but there were no significant differences in relation to other signs of the disease. The majority of patients (95%) had poor knowledge, and all of them had unsatisfied practice regarding self-management skills for COPD before implementation. Immediately postimplementation of the educational program, the study showed highly statistically significant improvement in total score of knowledge, where the majority of them had a fair knowledge and good practice regarding COPD; these scores decreased in post-test 2. Conclusion This study concluded that the education of patients regarding knowledge for COPD and healthcare practice is very effective in improving their self-management skills, but they need reinforcement follow-up. Therefore, this study recommended that the healthcare personnel should provide health education for COPD patients on self-care to their improve knowledge which helps prevent complications and maintain their life.

Impact of quality of working life on the psychological well-being and marital adjustment among female nurses Safaa Mohamed Metwaly, Mona Mohamed Abd El-Maksoud Egyptian Nursing Journal 2018 15(3):258-267 Background Nurses are one of the most diverse and largest workforces in the health-care system. Their work usually affects different concerns of their life. The aim of the present study was to investigate the impact of quality of working life (QoWL) on the psychological well-being (PWB) and marital adjustment among female nurses. Research design A descriptive-analytical study design was used to carry out this study. Setting This study was conducted at all maternal and child health centers in Zagazig City. Patients and methods A purposive sample composed of 208 female nurses who were working in the previously mentioned settings were recruited. Tools of data collection: four tools were used for data collection. They were the sociodemographic data sheet, the QoWL scale, Ryff’s PWB scales, and ENRICH marital satisfaction scale. Results The study results revealed that more than two-thirds of female nurses had a low QoWL and all of them had stress at their work. Majority of the studied nurses showed low level of PWB and marital adjustment. Also, there was positive correlation between QoWL, psychosocial well-being, and marital adjustment among female nurses with high statistical significance. Conclusion It was concluded that most of the studied samples had a low level of QoWL, PWB, and marital adjustment and there was statistically significant positive correlation between these variables. Recommendations This study recommended that further researches are needed to identify the predicted factors of low QoWL and factors that affect PWB and marital adjustment.

Relationship between burden, psychological well-being, and social support among caregivers of mentally ill patients Shadia Fathy Mahmoud Mohammed, Rehab Fathy Abdel Hady Ghaith Egyptian Nursing Journal 2018 15(3):268-280 Background Family caregivers of patients with chronic mental illness experience psychological stresses. Such stresses affect the psychological well-being of relatives, who have moderately high levels of burden and frequently get inadequate support from mental health professionals. Aim The aim of this study is to examine the relationship between burden, psychological well-being, and social support among caregivers of mentally ill patients. Research design A descriptive correlational design was used in this study. Setting This study was conducted at the psychiatric outpatient clinic in Azzazi Psychiatric Mental Health Hospital at Abu Hammad in Sharkia Governorate. Patients A purposive sample of 150 mentally ill patients’ caregivers, who accompany their patients to the psychiatric outpatient clinics, was recruited. Tools of data collection Four tools were utilized for data collection: sociodemographic data sheets, family burden scale, psychological well-being scale, and multidimensional scale of perceived social support. Results More than half of the caregivers aged from 40 to 60 years. Most of the patients were diagnosed as having schizophrenia. More than two-fifths of the caregivers were parents and had high level of burden. Nearly two-thirds had moderate level of psychological well-being, and approximately half of the caregivers had moderate level of social support. Conclusion There were negative statistically significant correlations among family burden, psychological well-being, and social support. However, a positive statistically significant correlation was detected between social support and psychological well-being. Recommendations It is recommended that training programs should be designed for caregivers to enhance psychological well-being and social support and decrease the level of burden among caregivers of mentally ill patients.

Effect of educational sessions about dengue fever on nurse's knowledge and attitude at Zagazig Fever Hospital Gamalat Moustafa Abd El-Ghany, Samia Farouk Mahmoud Egyptian Nursing Journal 2018 15(3):281-291 Background Dengue fever (DF) is emerging as a serious global health problem. Nurses serve as the frontline health care workers who assist in the diagnosis and treatment of dengue and other febrile illnesses. Aim The aim of this article is to assess the effect of educational sessions about DF on nurse’s knowledge and attitude at Zagazig Fever Hospital. Patients and methods A quasi-experimental design was used in carrying out the study during the period from November 2017 to January 2018. The study was conducted in Zagazig Fever Hospital, Sharkia Governorate. The sample included 71 nurses (39 diploma nurses and 32 bachelor nurses), working at the outpatient and the emergency clinic according to the inclusion criteria. Two tools were used. Tool 1 was a questionnaire that consisted of two parts: part A was used to collect data relating to demographic characteristics of the nurses, whereas part B involved nurse’s knowledge about DF using a self-administered questionnaire. Tool 2 was a self-administered questionnaire that was designed to assess nurses’ attitude toward DF. Results The comparison of pretest and post-test scores of nurses’ knowledge and attitudes revealed highly statistically significant improvement (P<0.001), which justified the research hypotheses of educational sessions’ implementation. The total score of their knowledge increased from 9.9% in pre-implementation session to 87.3% 1 month after the implementation, and the total score of their attitudes increased from 60.6% before the sessions, to 91.5% 1 month after the sessions. Conclusion The post-test score was higher than the pretest score for both knowledge and attitudes of nurses regarding DF. Recommendations Primary prevention of infectious diseases like DF should be given priority, and education about it should be provided in fever hospitals, through in-service health educational training session to be provided to all nurses in the fever hospitals, especially the newly appointed ones before they start their work.

Effect of menopausal symptoms on psychological problems among middle-aged women Shadia Fathy Mahmoud Mohammed, Nabila Salem Mohammed Egyptian Nursing Journal 2018 15(3):292-301 Background Menopause characterizes the end of the female reproductive period. Psychological problems such as anxiety and depression are reported among women in the menopausal period. Aim The aim was to find out the effect of menopausal symptoms on psychological problems such as anxiety and depression among middle-aged women. Participants and methods A descriptive cross-sectional design was used. This study was conducted at eight colleges from Zagazig University. A convenience sample composed of 200 menopausal women was recruited. Four tools were used for collection of data: interview questionnaire, menopause rating scale, Beck depression inventory scale, and Taylor manifest anxiety scale. Results More than three-quarters of the studied women were aged 50 years and older, with the mean age being 53.6±6.3 years. Nearly half of them had severe menopausal symptoms. More than one-third had mild depression and more than half of them had severe anxiety. Conclusion Nearly half of the studied women had severe menopausal symptoms. More than one-third had mild depression and more than half of them had severe anxiety. There were positive statistically significant correlations among total menopausal symptom, anxiety, and depression scores. Moreover, there were statistically significant relations between total menopausal symptom score and both educational level and duration of menopause. Recommendations The present study emphasizes that depression and anxiety are commonly prevalent among the middle-aged women; therefore, women should be screened in the menopause transition period, especially for clinically significant depression and anxiety, as some changes in women lifestyle like diet and exercises can improve good mood. Moreover, training programs should be designed for middle-aged women to decrease psychological problems associated with menopause, and delivery of mental health services in this group is essential.

The impact of psychiatric nurses' psychological capital on their burnout and coping style Safaa Mohamed Metwaly, Hanem Ahmed, Abd Elkhalek Ahmed Egyptian Nursing Journal 2018 15(3):302-313 Background Nurses with a high level of psychological capital have the essential motivational and cognitive properties that can be used in any given work situation to protect them from work-related stress and burnout. Aim This study aims to examine the impact of psychiatric nurses’ psychological capital on their burnout and coping style. Participants and methods A descriptive correlational design was utilized in this study. This study was conducted at three psychiatric hospitals: El Azazi Hospital for mental illness, Banha Hospital for mental illness, and at the Psychiatric Department at Zagazig University Hospital. A simple, random sample composed of 139 nurses who are working at a previous mentioned setting was recruited for this study. Five tools were utilized in this study for data collection, sociodemographic data sheet, burnout scale, psychological capital questionnaire, brief coping inventory, and emotional approach coping scale. Results The present study revealed that the level of burnout was moderate among the studied nurses, more than half of them had low level of psychological capital, about half of them had low level of problems − focused coping and near half of them had a high level of emotion-focused coping. Conclusion On the basis of the finding of this study, it can be concluded that the burnout is a psychological problem among psychiatric nurses. Unfortunately, about one-half of the studied psychiatric nurses has moderate level of burnout and has low level of psychological capital. Also, about half of them utilize the emotion-focused coping style more frequently than problem-focused coping. When nurses have a high level of psychological capital, their level of burnout decreased. Recommendation Intervention programs for nurses should be carried out to enhance their level of psychological capital (self-efficacy, hope, optimism, and resilience), improve their coping ability, and reduce their level of burnout are recommended.