Surgical tracheostomy (ST) is the oldest life-saving procedure in records, usually done by otolaryngologists and occasionally by general surgeons, thoracic surgeons, and neurosurgeons. It has been an important surgical skill for any given otolaryngology training program. On the contrary, retromolar, submental, submandibular endotracheal intubations, and their modifications are carried out by oral surgeons, maxillofacial surgeons, skull base surgeons, and plastic surgeons and are considered alternative to ST. Despite none are done in an emergency situation, it is suggested to be less invasive, simple, safe, with less surgical time, nearly unknown complications, has unsightly scar and cheaper in comparison to ST. It is thought that these techniques provide free surgical access in cases where oral and nasal intubations are often not suitable and require intermittent intraoperative dental occlusion to check alignment of fractured fragments. In the current report, PubMed has been reviewed for the reasons, indications, complications, techniques, and modifications of the above mentioned ST alternatives. The article critically discusses the surgical part of these innovative procedures and concludes that ST, in spite of its risks, remains the procedure of choice for surgical airway access when long-term intubation is not anticipated, especially in emergencies and difficult airways. A regular workshop of this highly in demand surgical skill is suggested.

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Green dentistry is a high-tech approach that reduces the environmental impact of dental practices and encompasses a service model for dentistry that supports and maintains wellness. It is based on waste reduction, energy conservation, and pollution prevention. Increasing consumption of diminishing natural resources, air and water pollution, ever-growing landfills, and the effects of global warming, makes saving our environment imperative. The aim of this article was to provide a series of "green" recommendations that dentists around the world can implement to become leading stewards of the environment. By conserving water, using digital imaging and recycling the many recyclable items that pass through the office of a green dentist, a great impact is made. So, going green is the need of the hour.

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Background: Analysis performed in the laboratory is subjected to variance; hence, every clinical laboratory must have adequate procedures to assure quality of the medical results reported. The definition of a total testing process incorporates the three classical phases of performance in laboratory testing: (1) pre analytical, (2) analytical, and (3) post analytical. Each phase when carried out properly plays an important role in preventing laboratory errors. Aim of the Work: The present study aimed at evaluating the performance of the Clinical Chemistry Unit of Alexandria Main University Hospital regarding urinalysis, through identification of the problems related to the total testing process. Materials and Methods: The study was conducted on 514 consecutive urine specimens that were received at the clinical chemistry laboratory of Alexandria Main University Hospital, during 3 months period from March to June, 2013. Inspection sheets were based upon the integration of the CLSI approved guidelines for urinalysis collection, transportation and preservation, inspection checklist of the CAP, and the review of the literature for similar studies. Results: Regarding the 514 studied request forms for urine analysis, they were found missing some data essential for interpretation of patient test results as recording time of specimen collection and time the specimen received by the lab (11.85%), followed by 462 missing requests and preliminary diagnosis or relevant clinical information (380 requests), which accounted for11.02 and 9.06% errors respectively. The request form was missing other important data as patients' identification, in 29 requests (0.69%), sex in 239 requests (5.7%), age in 208 requests (4.96%), date of specimen collection in 178 (4.24%), tests requested in 30 (0.72%), and authorized physicians' signature in 185 (4.41%). As regards request forms being authorized by a physicians' name or signature, our study showed that almost one third (185) of the request forms of the studied samples, lacked any indication for ordering physician, which accounts for 4.41% of the TTP errors. Also a comparative study was done between the pre analytical errors in the authorized request form and the unauthorized forms, which revealed that there was a high statistical significance difference (P < 0.0001) between the two forms, with errors being much lower in the authorized request forms. In this study the analytical phase showed the least number of errors, 23 errors done in 1970 activities for 514 specimens studied and 0.55% TTP errors. The high frequency in the analytical phase was for error of analysis 0.31% (13 specimens), followed by 6 specimens lost (0.14%), and 4 specimens mixed up (0.10%) out of 514 specimens study sample. Post analytical phase ranks the second in the error frequency in the present study, 487 errors in 1461 activities done for 514 specimens, which account for 11.61% of the TTP errors. As regards studying the post analytical phase, there was no results loss, but also there was no result verification procedure nor age and sex reference ranges in the results report.

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Context: Saudi Arabia remains one of the countries where Filipino nurses sought opportunities. However, this country has a different culture where Filipino nurses are not accustomed yet, therefore patient care can be compromised. Aims: The aim of the following study is to present the practical competency of Filipino nurses working in the hospitals of Taif city, Kingdom of Saudi Arabia. It dealt with the strength of self-efficacy perception of the nurses on the practical constructs and the variations among the strength of self-efficacy perception of the nurses on the practical constructs. Settings and Design: A descriptive - evaluative study using transcultural self-efficacy tool to determine differences in the level of cognitive competency among Filipino nurses with their demographic profile. Subjects and Methods: Filipino nurses (n = 307) participated in the study. They were working in five hospitals (namely King Abdulaziz Specialist Hospital, King Faisal Hospital, Children's Hospital, Chest Hospital and Mental Health Hospital) in Taif city, Kingdom of Saudi Arabia. Statistical Analysis: Data were analyzed using analysis of variance for comparison between the various groups to specific factors. Results: The strength of self-efficacy perceptions of the nurses within the practical constructs were religious practices and beliefs, religious background and identity, aging, educational background and interest and level of English comprehension. Nonetheless, the majority of the mean score were above the mean score of seven. Conclusion: Nurses were confident in identifying the specific cultural factors that could influence their client behaviors in accepting or rejecting care interventions, and although they shows confidence in some practical construct scale, they still need to have formal education and trainings regarding transcultural nursing, Arabic language and Saudi Arabia's cultural beliefs and practices to enhance their competencies in caring for a patient with diverse cultures.

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Introduction: Management of periodontitis-related oral malodor may include simple measures such as scaling and root planning (SRP) and oral hygiene instructions. Aim: A prospective cross-sectional study was conducted to evaluate the effect of non-surgical management of periodontitis on controlling halitosis (oral malodor) measured by Halimeter. Methodology: Clinical data were recorded from 60 participants who were attended the out-patient periodontics clinic at the College of Dentistry of King Khalid University, Abha city, Saudi Arabia. The participants were grouped as periodontitis (case), non-surgically treated periodontitis and healthy (control). Volatile sulfur compounds were measured in parts per billion (ppb) as a caliber for halitosis for each group using a Halimeter ^® . Data were statistically analyzed utilizing the Chi-square distribution test (P < 0.05). Results: In the average, case group showed strong halitosis 230.00 ± 54.29 ppb that was reduced to weak halitosis 124.25 ± 26.43 ppb following non-surgical (SRP) management of chronic periodontitis, with the deeper pockets, increased halitosis was measured as mean halitosis of periodontitis and treated cases 188.90 ± 14.22 ppb and 114.70 ± 20.75 ppb, 240.25 ± 58.08 ppb and 128.25 ± 39.31 ppb and 294.33 ± 19.64 ppb and 137.50 ± 23.36 ppb, respectively, in 5-6, 6.1-7 and 7.1-8 mm groups respectively. Conclusion: Based on study results, halitosis is directly related to periodontitis and periodontal pocket depth among the adults, which can be successfully controlled by SRP.

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Primary pleomorphic liposarcoma of the chest wall or mediastinum is rare. Most of the reported cases of the chest wall liposarcomas were low-grade well-differentiated liposarcoma and/or developed from a subcutaneous lipoma. We report a very unique and unusual case of primary pleomorphic liposarcoma of anterior chest wall entrapping the anterior wall of the thoracic cage with extension into the anterior mediastinum in a 46-year-old male patient.

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Objective: The clinical acceptance of restorative material normally depends on its biological safety. This in vivo study considered the clinical and histological gingival response to methacrylate and silorane-based composites. Materials and Methods: Sixty patients with sub-gingival tooth defects were treated in two groups (n = 30) with Tetric N-Ceram and Filtek P90 composite restoratives with minimal finishing procedures. An additional 10 patients with pre-existing gingival inflammation and no cervical tooth defects served as control. The gingiva in contact was assessed clinically and histologically at 2, 4 and 8 week intervals. Results: A significant time-dependent gingival response was noted in both test groups (t-test, P < 0.05). Inflammatory cell infiltrates, cellular degeneration, epithelial hyperplasia, keratinization, and erosion were found in selected gingival biopsies. Conclusion: The results confirmed that minimally finished subgingival composite restorations contribute to significant histopathological changes to the contacting gingival tissues. However, the silorane-based composite elicited less severe gingival inflammatory symptoms in comparison to the methacrylate-based resin system.

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Background: In India, adverse drug reactions (ADRs) occur frequently with combination antiretroviral therapy (cART) leading to switching or discontinuing cART intentionally. Objective: The study was conducted to characterize the effects of cART regimen and the development of ADRs in human immunodeficiency virus positive patients (HIV) in a tertiary care teaching hospital. Materials and Methods: A prospective observational study was conducted from August 2009 to May 2012 to characterize the pattern of ADRs to cART at Kasturba Hospital, Manipal in South India. Collection of the data was done by a clinical pharmacist during daily ward rounds to identify the suspected ADRs associated with the use of cART for various parameters which included patient demographics, cART with its adverse reaction characteristics. Assessment was also done for preventability, predictability and seriousness of ADRs, system organ classes affected and causality of the suspected ADRs using the World Health Organization (WHO) Probability Scale. Results: Among 450 patients enrolled, 230 suspected ADRs to cART were reported. By Pearson Chi-square test, higher occurrence of ADRs (P < 0.001) was noted in females, age 41-60 years, CD4 ⁺ T-cell counts 350-500 cells/μl, 5 years use of cART. ADRs were highest with zidovudine + lamivudine + nevirapine (42.3%) and tenofovir + emtricitabine + efavirenz (14.2%). On bivariate analysis, (P < 0.001) were identified in 1) Anemia with zidovudine use, 2) Pancytopenia with zidovudine, lamivudine use 3) Hepatotoxicity with nevirapine, efavirenz use, 4) Peripheral neuropathy with stavudine use, 5) Renal failure with tenofovir use and 6) Maculopapular rash with emtricitabine, tenofovir, efavirenz use. The system organ class most affected with ADRs to cART was red blood cell disorders (30.9%) followed by skin and appendages disorders (16.5%). Conclusion: With increasing reports of ADRs in India, clinicians need to select a safe cART regimen with underlying illness, medicines and drug intolerances.

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Antimicrobial resistance of methicillin-resistant Staphylococcus aureus (MRSA) continues to be a problem for clinicians worldwide. It poses a serious therapeutic problem, leading to prolonged hospital stay and increased health-care costs. Current therapeutic options for MRSA are limited few expensive drugs. This study is a systematic review of published studies on MRSA and evaluates their antibiotic resistance pattern, and major finding as related to the objective of the study. Antimicrobial resistance of MRSA is based on CSLI guidelines-either disc diffusion or MIC methods. MRSA detection is either by classical methods for determining MICs (disc diffusion, Etest, or broth dilution), or screening techniques with solid culture medium containing oxacillin/cefoxitin and methods that detect the mecA gene or its protein product (PBP20 protein); S. aureus isolation should be based on standard bacteriological procedures: Tube/slide coagulase test or specific test like Pastorex or StaphID. A total of 33 studies were identified investigating the antimicrobial resistance of MRSA; of which 19 were included in the review. The majority of studies reported high levels of MRSA resistance against different antimicrobials. However, low levels of vancomycin resistance have been reported. Therefore, the knowledge of antimicrobial resistance of MRSA becomes necessary in the selection of appropriate empirical treatment of these infections. In addition, by employing a variety of prevention strategies, marked progress can be achieved in the control of drug-resistant pathogens, which can translate into more effective antimicrobial therapy.

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Phyllodes tumor (PT) is uncommon biphasic epithelial tumors with exaggerated stromal cellularity, accounting for 0.3-0.9% of primary breast tumors. Malignant PT (MPT) is a rare and potentially aggressive breast neoplasm. Histologically has fibrosarcomatous type of stroma and rarely heterologous mesenchymal differentiation. MPT with osteoclastic giant cells is even rarer, which can be confused for primary malignant fibrous histiocytoma and metaplastic carcinoma. Herein, authors present a 51 year female who presented with right breast mass, clinically and cytological diagnosed as carcinoma of the breast. Histopathology and added immunohistochemistry enabled in arriving at a final definitive diagnosis of MPT with osteoclast giant cells. The diagnosis of this distinct entity is of importance due to their better prognostic implication.

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Background: Penetrating keratoplasty (PKP) is a safe, effective, and a reasonable treatment for corneal blindness in many countries. The study was conducted with the objective to assess the visual outcome after optical PKP at a secondary-level hospital. Materials and Methods: A total of 30 eyes of 30 patients enrolled prospectively in the hospital for surgery were selected for the study from May 2010 to April 2011. Age, gender, eye, indication of PKP, and best-corrected visual acuity (BCVA) constituting the preoperative data were recorded in a predesigned proforma. Follow-up examinations were done at the time of discharge, second at 1 month, and third on completion of 3 months postoperatively. Results: Common indications for optical PKP were bullous keratopathy either pseudophakic or aphakic; corneal scar following viral keratitis or trauma, corneal dystrophy, and graft failure. At 3 months follow-up, BCVA of ≥6/18 was obtained in six patients (20%), 6/18-6/60 in 43.33% and ≤6/60 in 36.67% patients. Persistent epithelial defects, graft rejection mainly endothelial type late graft rejection, and secondary glaucoma were the most common complications found. Conclusion: The study found the main indication for optical PKP was bullous keratopathy, either pseudophakic or aphakic. The persistent epithelial defect and graft rejection were the main complications in the study. Astigmatism, preexisting abnormalities such as glaucoma, optic atrophy, and graft failure were probable causes of less BCVA.

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Primary or secondary non-Hodgkin's lymphomas of the pleura are well known. Although secondary are more frequent to involve the pleura; primary pleural lymphomas [PPLs] are relatively rare in occurrence. Two types are discussed in literature: Primary effusion lymphoma in patients with human immunodeficiency virus (HIV) infection and pyothorax associated lymphoma. Primary pleural lymphoma can be also seen in immunocompetent patients with no history of pyothorax or HIV infection. Primary T lymphoblastic lymphomas of pleura that too occurring in children are quite rare. One should keep in mind the differential diagnosis of PPL with unusual presentation and rare location in immunocompetent patients not only in adults but also in children. Herewith we discuss two cases of T lymphoblastic lymphoma in immunocompetent children who presented with pleural effusion and extensive thickening of the pleura but were not associated with pyothorax.

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Purpose: To evaluate the outcome of same day topographic-guided photorefractive keratomileusis (PRK) and corneal cross-linkage in patients with subclinical keratoconus. Materials and Methods: A total of 20 patients with subclinical keratoconus were treated with topographic-guided PRK and same day corneal collagen cross-linkage with riboflavin. Inclusion criteria was low grade myopia of up to 3 diopter spherical equivalent, corneal thickness more than 475 microns, maximum keratometry reading K max less than 50 D. Results: Median preoperative spherical equivalent refraction was −2.25 D. At final follow-up visit at 1 year spherical equivalent was statistically significantly reduced to −0.25 D (P < 0.001). Median preoperative uncorrected visual acuity was 0.25 and best corrected visual acuity was 0.60. Median postoperative uncorrected visual acuity was 0.90 and best corrected visual acuity was 1.0. Median steepest K reading preoperatively was 46.25 D and it was 43.62 D at final follow-up visit. Conclusion: Same day topographic-guided PRK and corneal cross-linkage is a safe treatment offering good vision in subclinical cases of keratoconus.

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