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This topic aims to discuss key aspects of anesthetic and airway management for head and neck surgery. Airway management is a central part of patient care and management in Head and Neck Surgery. Common challenges in Head and Neck surgery are shared airway, distorted airway anatomy due to existing pathology; risk of airway obstruction, disconnection or loss of airway intra-operatively; risk of soiling of the airway due to bleeding and surgical debris; and the potential for airway compromise post-operatively. The option for airway management technique is influenced by patient’s factors, anesthetic needs, and surgical requirements. Intubation technique necessitating either a small or large cuffed tracheal tube with a throat pack provides the highest level of airway protection Non-intubation or open airway techniques involve mask ventilation, apneic techniques, and insufflation techniques, or the use of a laryngeal mask airway. Lastly, jet ventilation techniques may be conducted via a supraglottic, subglottic or transtracheal routes. It is essential to have clear airway management plans including rescue airway strategies that should be communicated with the surgeons and patients at the earliest opportunity.

Pulmonary aspiration in the perioperative period is one of the well-known complications under anesthesia and procedural sedation. A full stomach condition either due to non-adherence to fasting guidelines or due to various other factors that delay gastric emptying are the most common causes. Following aspiration, a patient may develop a wide spectrum of clinical sequelae. The key factors in preventing aspiration include proper pre-operative assessment, appropriate premedication and operating room preparations. Rapid sequence induction and intubation is the recommended technique for securing the airway in cases of full stomach. Management of aspiration depends on the nature of the aspirate. Pre-operative fasting guidelines have been established by various medical societies which may be modified in special circumstances of high risk of aspiration. Prediction of difficult airway in certain cases of full stomach necessitates clinical expertise in airway management.

Several studies have been conducted by antioxidant properties of the Beta-carotenes in relation to their ability like prevention to coronary diseases. Similarly, 3 out of 4 randomized studies have shown that higher intakes or higher blood concentrations of β-carotenes are associated with the reduced risk of the Predictive Heart Disease (PHD). As vitamin A functions as an epithelial membrane regulator and provides immunity. In spite beta-carotene is the precursor of the vitamin A in the body, which also shows proportional relation to the body vitamin A concentration. However, beta-carotene is mostly addressing through its antioxidant properties. Similarly, a direct relation to the PHD by the pupil response effected by the pro-vitamin A have not been studied.

Although medical services in aviation have evolved over years based on our understanding of physiology, advancement in monitoring technology but airway management was only recently studied with a focus on space environment. The barometric pressure of ambient air declines as altitude increases, while the volume of air in a confined space will increase according to Boyle law, and therefore oxygen concentration remains at a constant 21%. Altitude sensitive equipment includes endotracheal and tracheostomy cuffs, pneumatic anti shock garments, air splints, colostomy bags, Foley catheters, orogastric and nasogastric tubes, ventilators, invasive monitors, and intra-aortic balloon pumps. The microgravity reduces the body compensation capacity for hemorrhage, while the redistribution of the blood can affect intubation by causing facial edema. Another change is the decreased gastric emptying during aviation. Acute respiratory failure, hypoxemia or inadequate ventilation and protection of the airway in a patient with impaired consciousness are common indications for advanced airway management in aviation. Airway management requires adequate training to maintain excellent medical care during aviation. Tracheal intubation using laryngoscopy would be difficult in microgravity, since the force exerted by the laryngoscope causes the head and neck move out of the field of vision by lever effect exerted on the head and generated through the laryngoscope blade by hand generating a lack of stability, resulting in the difficulty to insert the tracheal tube. While on the ground with the help of gravity, an adequate positioning of the patient is facilitated to achieve alignment of the laryngeal, pharyngeal and oral axes, which is known as sniffing position that allows visualization of the vocal cords and supraglottic structures allowing the introduction of an endotracheal tube.

IntroductionMicronutrient deficiencies, commonly referred to as ‘hidden hunger’, affect more than two billion people worldwide, with zinc and iron-deficiency frequently reported. The aim of this study is to examine the impact of consuming zinc biofortified flour (Zincol-2016) on biochemical and functional measures of status in adolescent girls and children living in a low-resource setting in Pakistan.Methods and analysisWe are conducting a pragmatic, cluster-randomised, double-blind, controlled trial. A total of 482 households have been recruited from two catchment areas approximately 30–40 km distance from Peshawar. Household inclusion criteria are the presence of both an adolescent girl, aged 10–16 years, and a child aged 1–5 years. The study duration is 12 months, divided into two 6-month phases. During phase 1, all households will be provided with locally procured flour from standard varieties of wheat. During phase 2, clusters will be paired, and randomised to either the control or intervention arm of the study. The intervention arm will be provided with zinc biofortified wheat flour, with a target zinc concentration of 40 mg/kg. The control arm will be provided with locally procured wheat flour from standard varieties with an expected zinc concentration of 20 mg/kg. The primary outcome measure is plasma zinc concentration. Secondary outcomes include anthropometric measurements, biomarkers of iron and zinc status, and the presence and duration of respiratory tract infections and diarrhoea.Ethics and disseminationEthical approval was granted from the University of Central Lancashire STEMH Ethics Committee (reference number: STEMH 1014) and Khyber Medical University Ethics Committee (DIR/KMU-EB/BZ/000683). The final study methods will be published in peer-reviewed journals, alongside the study outcomes. In addition, findings will be disseminated to the scientific community via conference presentations and abstracts and communicated to the study participants through the village elders at an appropriate community forum.Trial registration numberISRCTN17107812; Pre-results.

To compare the projectional surface anatomy of healthy individuals in an adult population with those with a thyroid mass, using computed tomography (CT). Sixteen slice CT images of 101 individuals were analyzed using a 32-bit Radiant DICOM viewer to establish the relationships among major anatomical landmarks in the neck and their vertebral levels. The structures investigated included: hard palate (HP), hyoid bone (HB) including body and lesser horns, soft palate (SP), thyroid gland (TG) (both superior and inferior poles), thyroid gland anteroposterior (APD) and superoinferior (SID) diameters, thyroid isthmus (TI) superoinferior dimension, epiglottis, vertebral arteries (right and left), and both right and left parotid glands (superior and inferior extents). The vertebral levels noted most frequently were: body of hyoid bone (C4, 42.71%); lesser horns of hyoid bone (C3, 36.46%); thyroid gland superior pole (C6, 31.25%); and thyroid gland inferior pole (T2, 30.2%). TG-ID, TG-APD, and TG-SID were not significantly different between males and females in the healthy group; however, there was a significant gender difference in thyroid gland inferior diameter in the pathology group [males 2.16(±1.16) vs. females 3.37(±1.30), P = 0.01, paired sample t-test]. Further studies are needed to determine whether neck pathology in those with a thyroid mass affects the dimensions of the thyroid gland. Moreover, the surface anatomy of the neck should be revisited using modern imaging techniques to address inconsistencies in anatomy and clinical reference texts. Clin. Anat. 30:781-787, 2017. © 2017Wiley Periodicals, Inc.

To compare key thoracic anatomical surface landmarks between healthy and patient adult populations using Computed Tomography (CT). Sixteen slice CT images of 250 age and gender matched healthy individuals and 99 patients with lung parenchymal disease were analyzed to determine the relationship of 17 thoracic structures and their vertebral levels using a 32-bit Radiant DICOM viewer. The structures studied were: aortic hiatus, azygos vein, brachiocephalic artery, gastroesophageal junction (GEJ), left and right common carotid arteries, left and right subclavian arteries, pulmonary trunk bifurcation, superior vena cava junction with the right atrium, carina, cardiac apex, manubriosternal junction, xiphisternal joint, inferior vena cava (IVC) crossing the diaphragm, aortic arch and junction of brachiocephalic veins. The surface anatomy of all structures varied among individuals with no significant effect of age. Binary logistic regression analysis showed a significant association between individual health status and vertebral level for brachiocephalic artery (P = 0.049), GEJ (P = 0.020), right common carotid (P = 0.009) and subclavian arteries (P = 0.009), pulmonary trunk bifurcation (P = 0.049), carina (P = 0.004), and IVC crossing the diaphragm (P = 0.025). These observations differ from those reported in a healthy white Caucasian population and from the vertebral levels of the IVC, esophagus, and aorta crossing the diaphragm in an Iranian population. The differences observed in this study provide insight into the effect of lung pathology on specific thoracic structures and their vertebral levels. Further studies are needed to determine whether these are general changes or pathology-specific. Clin. Anat. 30:227-236, 2017. © 2017 Wiley Periodicals, Inc.

Knowledge of variations in MF location, size and shape is important when anesthetizing nerves of the mandibular region in dental procedures. The location, shape and position of the MF were determined in 119 human mandibles of unknown age and sex from different KP medical institutions. Parameters determined were: MF length and width; accessory mental foramen (AMF) width; MF and AMF to midline (MF-ML) (AMF-ML), upper (MF-UM) (AMF-UM) and lower mandibular margins (MF-LM) (AMF-LM) and posterior border of the mandibular ramus (MF-PRM) (AMF-PRM). AMF position in relation to the MF was also noted. MF were mainly oval and situated below the second premolar. MF mean length and width were: 2.4 ± 0.89 (right) and 2.4 ± 0.727 mm (left), and 3.0 ± 0.80 (right) and 2.9 ± 0.94 mm (left) respectively. MF-ML, MF-UM, MF-LM and MF-PRM distances on the right and left sides were: 29.1 ± 2.19 mm and 28.1 ± 2.12 mm; 11.0 ± 3.99 mm and 11.2 ± 3.98 mm; 13.1 ± 1.83 mm and 12.8 ± 1.74 mm; and 69.3 ± 5.52 mm and 68.7 ± 5.02 mm, respectively. Double mental foramen (DMF) were observed on both sides (10.9 % right, 12.6 % left) with length and width 0.7 ± 0.42 mm and 0.9 ± 0.34 mm (right) and 0.8 ± 0.32 mm and 1.0 ± 0.47 mm (left): they were mainly oval (5.8 % right, 7.56 % left). DMF-MF distance was 8.9 ± 4.58 mm on the right and 6.6 ± 4.11 mm on the left. An oval accessory mental foramen was observed in one mandible. There was no difference between right and left MF; however differences in the parameters measured were observed in relation to other populations indicating the need to be aware of such differences when undertaking surgical procedures around the MF.

Introduction Dietary zinc (Zn) deficiency is a global problem, particularly in low-income and middle-income countries where access to rich, animal-source foods of Zn is limited due to poverty. In Pakistan, Zn deficiency affects over 40% of the adult female population, resulting in suboptimal immune status and increased likelihood of complications during pregnancy. Methods and analysis We are conducting a double-blind, randomised controlled feeding study with cross-over design in a low-resource setting in Pakistan. Households were provided with flour milled from genetically and agronomically biofortified grain (Zincol-2016/NR-421) or control grain (Galaxy-2013). Fifty households were recruited. Each household included a woman aged 16–49 years who is neither pregnant nor breastfeeding, and not currently consuming nutritional supplements. These women were the primary study participants. All households were provided with control flour for an initial 2-week baseline period, followed by an 8-week intervention period where 25 households receive biofortified flour (group A) and 25 households receive control flour (group B). After this 8-week period, groups A and B crossed over, receiving control and biofortified flour respectively for 8 weeks. Tissue (blood, hair and nails) have been collected from the women at five time points: baseline, middle and end of period 1, and middle and end of period 2. Ethics and dissemination Ethical approval was granted from the lead university (reference no. STEMH 697 FR) and the collaborating institution in Pakistan. The final study methods (including any modifications) will be published in peer-reviewed journals, alongside the study outcomes on completion of the data analysis. In addition, findings will be disseminated to the scientific community via conference presentations and abstracts and communicated to the study participants through the village elders at an appropriate community forum. Registration details The trial has been registered with the ISRCTN registry, study ID ISRCTN83678069.

Objective: Progressive hemorrhagic shock (HS) causes splanchnic vasoconstriction and hypo-perfusion together with profound depletions of cellular cytosolic energy phosphates (ATP). Cellular energy failure and the splanchnic hypo-perfusion are critical to the pathogenesis of shock decompensation and the subsequent death from cardiocirculatory arrest. We recently demonstrated post-resuscitation survival benefit for cellular cytosolic ATP replenishment but not for vasopressors use in a rat model of refractory HS. The aim of this study was to determine the effects of progressive HS on the splanchnic microvasculature, and to compare the effects of adjuvant resuscitations with either norepinephrine, vasopressin or lipid vesicles encapsulating ATP (ATPv) on this microvasculature. Methods: 40-male Sprague-Dawley rats were randomized into 4 groups of 10 each: HS/conventionalresuscitation (CR), HS/CR+Norepinephrine, HS/CR+Vasopressin, and HS/CR+ATPv. HS=initial removal of 30% of the calculated blood volume plus subsequent transection of the spleen for uncontrolled haemorrhage until a predefined intervention set-point was achieved; CR=shed blood returned+double the shed blood volume as lactated Ringer’s solution. Four-level intestinal microvascular A1 through A4 arterioles (100–8 μm diameter) in the terminalileum were continuously monitored with intravital-microscopy, and their diameters were measured at baseline, during shock, after completion of resuscitation, and during a 2 h post-resuscitation observation period. In addition, we recorded measurements of the mean arterial pressure, shock index, blood-gas profiles, and complete metabolic panels. Results: Progressive HS caused bimodal arteriole responses with progressive vasoconstriction from baseline of first-order A1 and second-order A2 (-22.1 ± 1.9%), a progressive vasodilation of the third-order A3 and fourth-order A4 arterioles (+22.2 ± 2.8%). Resuscitation initially restored A1 and A2 diameters to near baseline. This was followed by post-resuscitation A1 and A2 vasoconstriction in all groups, except the ATPv group (-8.1 ± 3.4%). The hemorrhage-induced vasodilation of the A3 and A4 arterioles was maintained during the post-resuscitation observation period in the CR (+55.3 ± 6.4%) and the ATPv groups (+39.5 ± 5.2%), but remarkably attenuated in the norepinephrine (+9.6 ± 5.8%) and vasopressin (+9.4 ± 8.8) groups. Conclusions: Severe hemorrhagic shock causes specific splanchnic microvascular bimodal response that is dependent on arteriolar level. First-order A1 and second-order A2 arterioles exhibit progressive vasoconstriction, whereas, third-order A3 and fourth-order A4 arterioles show progressive vasodilation. Temporary administration of either norepinephrine or vasopressin along with conventional resuscitation exerted deleterious effects at all splanchnic microvascular levels by virtue of their peripheral vascular actions. The cellular cytosolic ATP replenishment maintained a better microvascular profile when compared with the two vasopressors.

Zinc is an important constituent of diet that regulates gut epithelial wall and modify gut microbiome in humans as well as animals. Zinc deficiency may affect 39% children in Pakistan, according to the recent National Nutritional Survey 2011. Although zinc has been used in the prevention and treatment of diarrhea, the relationship of plasma zinc status with potentially pathogenic bacteria has not been studied. In this review, we have discussed evidence suggesting the impact of zinc on gut microbiota and its interaction with gut epithelium. Furthermore, animal and human studies suggesting the role of zinc in modifying gut microbiota have been presented.

Pakistan has one of the highest prevalence of poisoning in the world. However, limited data exist on the frequency of poisons implicated in homicidal, suicidal, and accidental cases in North-West Pakistan (Khyber Pakhtunkhwa).This retrospective study of 353 cases and biological specimens of poisoning received at the department of Forensic medicine and toxicology, Khyber Medical College Peshawar from 13 districts of Khyber Pakhtunkhwa. Frequency of poisoning was assessed by testing each specimen for 17 different poisons.Of all the specimens, 250 (70.8%) specimens tested positive and the rest didn't show any indication of poisoning (n=103, 29.2%). The most frequent poisons detected were benzodiazepines (total n=75), organophosphates (total n=58), phencyclidine (total n=30) and morphine (total n=23). Gender had a significant association with benzodiazepines (p=0.011), tricyclic antidepressants (p=0.001), and organophosphates (p0.001). Organophosphates were the most common cause of poisoning in females while benzodiazepines were the most common cause of poisoning in males.Poisoning by benzodiazepines, organophosphates and phencyclidine are the most common causes of intoxication in population of Khyber Pakhtunkhwa. Source of poisoning varies with gender for organophosphates, benzodiazepines and tricyclic antidepressants.

Angiogenesis is involved in many cardiovascular and cancerous diseases, including atherosclerosis and is controlled by a fine balance between angiogenic and angiostatic mediators. Endostatin is one of the main angiostatic mediators, and inhibits angiogenesis and prevents progression of atherosclerosis. The available literature shows a broad range of concentrations in relatively small samples of healthy controls and is calculated by using different techniques. This study was aimed to determine the basal endostatin concentration in plasma of healthy volunteers, to fully understand its physiological role.Fifty healthy adult volunteers were recruited to the study. Participants were advised not to participate in any physical activity on the day before the blood sampling. The volunteers' physical activity, height, weight, heart rate and blood pressure were recorded. The samples were analysed for plasma endostatin concentration, using ELISA. The participants were divided by gender and ethnic groups to calculate any difference.Endostatin and other variables were normally distributed. Most of the participants had a moderate level of physical activity with no gender related difference (p=0.370). The mean value for plasma endostatin in all samples was 105±12 ng/ml with range of 81-132 ng/ml. For males, it was 107±13 ng/ml, while for females; 102±12 ng/ml. There were no significant gender or ethnicity related differences in endostatin concentration. Moreover, endostatin was not significantly related with any anthropometric and physical variable.This study gives endostatin levels in normal healthy people and show no gender and ethnicity related differences in endostatin levels. Endostatin was not related with any anthropometric and physical variable.

Objective: A refractory haemorrhagic hypovolemic shock (HS) resuscitation is challenging. HS is associated with profound depletions of cellular energy nucleotides that can cause death from a cardio-circulatory arrest. To prevent an imminent cardio-circulatory arrest, vasopressors, commonly norepinephrine is usually temporarily administered to manage a persistent hypotension that is not corrected by aggressive resuscitation efforts. The objective of this study is to determine the post-resuscitation survival time after adjuvant resuscitations of a refractory HS with norepinephrine, vasopressin or direct cytosolic energy (adenosine-5`-triphosphate, ATP) replenishment using lipid vesicles encapsulating ATP (ATPv). Methods: 50 male Sprague-Dawley rats were randomized to 5 groups of 10 each: HS/conventional resuscitation (CR), HS/CR+Norepinephrine, HS/CR+Vasopressin, HS/CR+Vesicles, and HS/CR+ATPv. (HS=initial removal of 30% of the calculated blood volume, a 60 min hypotensive phase, and a subsequent transection of the spleen for uncontrolled haemorrhage until persistent shock index (SI)>5 and mean arterial pressure (MAP)

The aetiology of obesity has been attributed to several factors (environmental, dietary, lifestyle, host, and genetic factors); however none of these fully explain the increase in the prevalence of obesity worldwide. Gut microbiota located at the interface of host and environment in the gut are a new area of research being explored to explain the excess accumulation of energy in obese individuals and may be a potential target for therapeutic manipulation to reduce host energy storage. Several mechanisms have been suggested to explain the role of gut microbiota in the aetiology of obesity such as short chain fatty acid production, stimulation of hormones, chronic low-grade inflammation, lipoprotein and bile acid metabolism, and increased endocannabinoid receptor system tone. However, evidence from animal and human studies clearly indicates controversies in determining the cause or effect relationship between the gut microbiota and obesity. Metagenomics based studies indicate that functionality rather than the composition of gut microbiota may be important. Further mechanistic studies controlling for environmental and epigenetic factors are therefore required to help unravel obesity pathogenesis.