Ahmed Hasanin

OBJECTIVE: Hydrocephalus is the most common brain disorder in children and is more common in low- and middle-income countries. Research output on hydrocephalus remains sparse and of lower quality in low- and middle-income countries compared with high-income countries. Most studies addressing hydrocephalus epidemiology are retrospective registry studies entailing their inherent limitations and biases. This study aimed to investigate child-related, parental, and socioeconomic risk factors of congenital hydrocephalus (CH) in a lower-middle-income country.

METHODS: An investigator-administered questionnaire was used to query parents of patients with CH and controls who visited the authors' institution from 2017 until 2021. Patients with secondary hydrocephalus and children older than 2 years of age at diagnosis were excluded. Uni- and multivariable logistic regression was performed to identify the factors affecting CH development.

RESULTS: Seven hundred forty-one respondents (312 cases and 429 controls) were included in this study. The authors showed that maternal diseases during pregnancy (OR 3.12, 95% CI 1.96-5.03), a lack of periconceptional folic acid intake (OR 1.92, 95% CI 1.32-2.81), being a housewife (OR 2.66, 95% CI 1.51-4.87), paternal illiteracy (OR 1.65, 95% CI 1.02-2.69), parental consanguinity (OR 3.67, 95% CI 2.40-5.69), a history of other CNS conditions in the family (OR 2.93, 95% CI 1.24-7.34), conceiving a child via assisted fertilization techniques (OR 3.93, 95% CI 1.57-10.52), and the presence of other congenital anomalies (OR 2.57, 95% CI 1.38-4.87) were associated with an independent higher odds of a child having CH. Conversely, maternal hypertension (OR 0.22, 95% CI 0.09-0.48), older maternal age at delivery (OR 0.93, 95% CI 0.89-0.97), and having more abortions (OR 0.80, 95% CI 0.67-0.95) were negatively correlated with CH.

CONCLUSIONS: Multiple parental, socioeconomic, and child-related factors were associated with higher odds for developing CH. These results can be utilized to guide parental counseling and management, and direct social education and prevention programs.

BACKGROUND: Studies of the accuracy of different airway tests are lacking in elderly. We evaluated and compared the accuracy of thyromental height in predicting difficult intubation in relation to the other traditional airway tests in elderly.

METHODS: We included 120 patients aged ≥ 65 years scheduled for general anesthesia with tracheal intubation. Thyromental height, modified Mallampati test, thyromental distance and sternomental distance were evaluated. Cormack-Lehane grade > 2 was considered difficult laryngoscopy. Difficult tracheal intubation was considered if successful intubation required more than 2 attempts. The accuracy of different tests in predicting difficult intubation and difficult laryngoscopy were evaluated through area under receiver operating characteristic (AUROC) curves. Univariate and multivariate analyses were conducted to identify risk factors for difficult intubation and difficult laryngoscopy.

RESULTS: Our cohort had a mean age of 71(7) years. We encountered difficult laryngoscopy in 15/120 (12%) patients, difficult intubation in 20/120 (17%) patients, and failed laryngoscopy requiring alternative methods for securing the airway in 3/120 (3%) patients. For predicting difficult intubation, thyromental height and modified Mallampati test showed the highest accuracy AUROC (95% confidence interval): 0.9 (0.83-0.95), cut-off value ≤ 5.9 cm, and AUROC (95% confidence interval): 0.89 (0.82-0.94), cut-off value > 2, respectively. Low thyromental height and high modified Mallampati test were the only independent risk factors for difficult laryngoscopy and difficult intubation.

CONCLUSION: In elderly scheduled for elective procedure, both thyromental height and modified Mallampati tests showed good accuracy in predicting difficult intubation and difficult laryngoscopy, whilst thyromental distance and sternomental distance were poor predictors.

BACKGROUND: Deliberate hypotension is used to provide a bloodless field during functional endoscopic sinus surgery; however, the impact of controlled hypotension during anesthesia on peripheral tissue perfusion has not been extensively evaluated. The aim of this study was to compare the impact of nitroglycerin- versus labetalol-induced hypotension on peripheral perfusion.

METHODS: The present randomized, double-blinded, controlled trial included adult patients undergoing endoscopic sinus surgery. Patients were allocated to one of two groups according to the drug received for induction of deliberate hypotension: nitroglycerin (n = 20) or labetalol (n = 20). Mean arterial pressure was maintained at 55-65 mmHg in both groups. Both study groups were compared according to pulse oximeter-derived peripheral perfusion index (primary outcome), serum lactate level, mean arterial pressure, heart rate, surgical field score, and intraoperative blood loss.

RESULTS: Forty patients were included in the final analysis. The nitroglycerin group exhibited a higher peripheral perfusion index at nearly all records (p < 0.0001) and lower postoperative serum lactate levels (1.3 ± 0.2 mmol/L vs. 1.7 ± 0.4 mmol/L; p = 0.001) than the labetalol group. The peripheral perfusion index was higher in the nitroglycerin group than at baseline at most intraoperative readings. The median surgical field score was modestly lower in the labetalol group than in the nitroglycerin group in the first 20 min (2 [interquartile range (IQR) 2-2.5] versus 1.5 [IQR 1-2]; p = 0.001). Both groups demonstrated comparable and acceptable surgical field scores in all subsequent readings.

CONCLUSION: Nitroglycerin-induced deliberate hypotension was accompanied by higher peripheral perfusion index and lower serum lactate levels than labetalol-induced deliberate hypotension during sinus endoscopic surgery.

TRIAL REGISTRATION: The study was registered at clinicaltrials registry system with trial number: NCT03809065. Registered at 19 January 2019. This study adheres to CONSORT guidelines.