Repigmentation of gray hair: A case report with a brief review of literature

A case of gray hair nearly 99% was seen to be converted to more than 99% of the pigmented hair, after using full sleeves shirts for 2 years, with 1‑year follow‑up, with the same results, and on screening the literature, we find it first such case in the world literature of almost complete repigmentation of both the forearms after using full sleeves shirts for 2 years and a follow-up of 1 year.

Comparative Analytical Study of Madana Shalatu (Unripen Fruit of Randia Dumetorum Lam) and Phalapippali (Processed Fruits of Randia Dumetorum Lam) - A Study of Abhava Pratinidhi Dravya

Vamana is the Agrya karma for Kaphaja vikaras. Madanaphala - Randia dumetorum Lam is the drug of choice for Vamana karma because of its property – Anapayitwat (without untoward effect). Specific collection method, season and processing is required to get Phalapippali to possess above quality. Madana shalatu– Unripen fruits of Madanaphala is an Abhavapratinidhi dravya mentioned in Sushrutha Samhita and Ashtanga Hrudaya which does not require this processing- Samskara. So, in the present study comparative qualitative and quantitative physicochemical and phytochemical analysis of the Madana Shalatu, Pakwa Madanaphala Ripen fruit of Madanaphala and Madanaphala Pippali– Processed fruits of Madanaphala has been carried out. Aim: 1. Pharmacognostic, Physicochemical and Phytochemical analysis of Madana Shalatu, Pakwa Madanaphala, Madanaphala Pippali. 2. Comparative qualitative and quantitative phytochemical analysis of Madana Shalatu, Pakwa Madanaphala, Madanaphala Pippali. Method: 1. Pharmacognostic study – Macroscopic study and Microscopic study. 2. Preliminary physico chemical analysis. 3. Qualitative phyto chemical evaluation of aqueous and alcoholic extracts of the test drugs. 4. Quantitative analysis– UV Spectrophotometry. Result: Microscopic study, qualitative phyto chemical evaluation of all test drugs did not showed much differences. In total saponin estimation by UV Spectrophotometry of methanol and Water extract of ripen processed fruits of Randia, Ripen fruits of Randia and Unripen fruits of Randia is found to contain 73.71, 83.23, 71.35 and 72.62, 92.44, 75.25µg DE/mL of Saponin content respectively. Conclusion: Quantity of Saponin which is the main active principle in Randia Dumetorum responsible for Vamana Karma was similar in the Madana Shalatu and in Phala Pippali, whereas it was highest in Pakwa Madanaphala, thus it may be used like Phala Pippali without any laborious process of Samskara. Further Toxicity studies and clinical trials are required to prove its safety and efficacy in humans.

Obstructive Sleep Apnea and Sleep Quality in Women with Polycystic Ovary Syndrome: A Cross-sectional Study

Background: Polycystic ovary syndrome (PCOS) is a common disorder in women of reproductive age. Although PCOS patients have a high prevalence of obstructive sleep apnea (OSA), there is limited data on sleep quality and abnormalities in sleep architecture among this patient population. We conducted a study to assess the frequency of OSA and poor sleep quality in women with PCOS and to assess any association between these sleep disorders and metabolic abnormalities. Materials and methods: An observational study of adults with PCOS (by revised Rotterdam criteria) from May 2015 to June 2017 was conducted. Patients with thyroid disorders, pre-existing depression, current pregnancy, and recent drug use (benzodiazepines, antidiabetics, antiepileptics, steroids, and androgens) were excluded. The evaluations included the following: overnight polysomnography (PSG), lipid profile, testosterone, fasting insulin, fasting glucose levels, free androgen index (FAI), and homeostatic model assessment for insulin resistance (HOMA-IR); sleep quality [Pittsburgh Sleep Quality Index (PSQI), Jenkins Sleep Scale (JSS)], daytime sleepiness and possible depression were assessed by standard questionnaires. Descriptive statistics, t-test/Mann朩hitney test, Chi-squared test/Fischer's test were used as appropriate; p <0.05 was considered statistically significant. Results: A total of 65 patients, mean age 24.3 � 4.0 years; mean body mass index (BMI) 26.4 � 5.3 kg/m2 were included. Frequencies of sleep disorders were evaluated as follows: Obstructive sleep apnea 10.9% (7/64) [95% confidence interval (CI): 5.4�.9%], poor sleep quality 35.0% (21/60) (95% CI: 24.2�.6%) by JSS, 54.2% (32/59) (95% CI: 41.6�.3%) by PSQI. The PSG indicators of sleep quality were abnormal in arousal index, 96.8% (62); %wake time, 62.5% (40); sleep latency, 40.6% (26); and sleep efficiency, 12.5% (8). Anthropometric indicators of obesity were higher in OSA vs non-OSA patients (p <0.05). The OSA patients had lower total sleep time and %N2 stage, and higher desaturation index than non-OSA patients. When patients with good and poor sleep quality were compared, poor sleepers (by JSS and PSQI) had higher depression scores; poor sleepers by JSS had a lower waist杊ip ratio (p <0.05). Daytime sleepiness scores were similar in OSA and non-OSA patients, and in good and poor sleepers. Conclusion: Sleep disorders, particularly poor sleep quality, are frequent in women with PCOS. Patients should be screened for these disorders using specific questionnaires. Further research into the metabolic consequences of these sleep disorders is mandated.

In silico interaction of Berberine with some immunomodulatory targets: A docking analysis

Plant, mineral, and animal products have been utilized as medications from the beginning of time to cure a variety of ailments. Use of medicinal herbs to modulate immune function has a rich history. Natural products serve as the foundation for contemporary pharmaceutical ingredients. Immunomodulation alters an individual's immune system by interfering with its normal processes. Immunomodulators derived from natural sources have been extensively studied in order to modify the immune system and prevent illness. Berberine is an alkaloid has been identified for its anti-inflammatory properties. In animal studies, Berberine was found to demonstrate analgesic properties. The current work is aimed to explore the in silico interactions of Berberine with various chemokines and inflammatory pathways. Berberine was docked with TNF-?, IL-1?, IL-6, and NOs in this investigation. Docking study demonstrated notable interactions with these targets. The present research provides insight into the development of new compounds for immunomodulation and the management of inflammatory illnesses. More research on Berberine and related flavonoids is necessary to assess its safety. As a result, Berberine can be regarded as a candidate for the advancement of an immunomodulatory agent.

Quantitative Evaluation of the Diffusion Tensor Imaging Matrix Parameters and the Subsequent Correlation with the Clinical Assessment of Disease Severity in Cervical Spondylotic Myelopathy

Methods@#DTI images were processed to produce FA and ADC values of the acquired axial slices with the regions of interest placed within the stenotic and non-stenotic segments. The final quantitative radiological derivations were matched with the clinical scoring system. @*Results@#Total 52 people (24 men and 28 women), mean age 53.16 years with different symptoms of myelopathy, graded as mild (n=11), moderate (n=25), and severe (n=16) as per the mJOA scoring system, underwent MRI of the cervical spine with DTI. In the most stenotic segments, the mean FA value was significantly lower (0.5009±0.087 vs. 0.655.7±0.104, p<0.001), and the mean ADC value was significantly higher (1.196.5±0.311 vs. 0.9370±0.284, p<0.001) than that in the non-stenotic segments. The overall sensitivity in identifying DTI metrics abnormalities was more with FA (87.5%) and ADC (75.0%) than with T2 weighted images (25%). @*Conclusions@#In addition to the routine MRI sequences, DTI metrics (FA value better than ADC) can detect myelopathy even in patients with a mild grade mJOA score before irreversible changes become apparent on routine T2 weighted imaging and thus enhance the clinical success of decompression surgery.

A comparative prospective open label randomized controlled 8 week study in patients of depression treated with vilazodone and sertraline

Background: Depression is a mood disorder treated with various antidepressant such as SSRIs due to lesser toxicity and improved safety profile.Methods: This was an eight week randomised active controlled parallel group study. 54 patients were allocated in two group. Group A received vilazodone while group B received sertraline. Assessment done at baseline, 2, 4 and 8 weeks on the basis of clinical efficacy, sexual dysfunction, side effects and weight gain using Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Arizona Sexual Experience Scale (ASEX) and UKU Side Effect Rating Scale.Results: HAM-D score of group A was 18.78±1.78 and 7.67±1.66 while in group B was 19.04±2.12 and 8.15±1.77 at baseline and 8 weeks respectively. HAM-A score of group A was 15.44±1.50 and 6.63±1.39 while in group B was 15.26±1.83 and 7.07±1.14 at baseline and 8 weeks. ASEX total score of group A was 15.63±1.28 and 14.63±1.33 while group B was 15.52±1.37 and 16.41±1.12 at baseline and 8 weeks. ASEX desire score of group A was 9.63±0.93 and 8.67±0.88 while of group B was 9.59±0.93 and 10.07±0.92 at baseline and 8 weeks. UKU side effect rating at 2 and 8 weeks of group A was 0.22±0.42, 1.04±0.76 while in group B was 0.37±0.49, 1.89±0.85.Conclusions: Vilazodone and Sertraline are equally efficacious in treatment of depression and associated anxiety. When side effect profile were compared Vilazodone is found superior to Sertraline

Escitalopram add-on in stable Schizophrenia with subsyndromal depression

Background: Significant proportion of the patients of schizophrenia suffer from subsyndromal symptomatic depressive symptoms (SSD) which not only add to the burden of disease but also to the already pre-existing challenges of living with this serious mental illness. Many psychiatrists prescribe antidepressants to patients with schizophrenia who have subsyndromal symptomatic depressive symptoms but data regarding SSD in schizophrenia is meagre. Aim was to study the effect of addition of Escitalopram on psychopathology, cognition and functioning in patients with stable schizophrenia having subsyndromal depressive symptoms and to compare these parameters with patients treated with antipsychotics alone.Methods: The study was a prospective, 8-week randomized double-blind placebo-controlled trial. Seventy four patients who fulfilled the diagnostic criteria of Schizophrenia on the basis of the ICD10-DCR, adjudged to be stable clinically and not requiring any increase in dose of antipsychotic medication over the last eight weeks were recruited into the study. The patients randomly received either Antipsychotics with add-on Escitalopram (10 mg/day) or Antipsychotics with placebo for 8 weeks. The patients were assessed using the HAM-D, CDRS, PANSS, SCoRS, SOFAS and CGI scores at the end of 8 weeks. Patients were also assessed for adverse events at baseline, week 4 and week 8.Results: A total of sixty-six patients who completed the study were analyzed. The HAM-D, CDRS and PANSS score showed significantly better cognition and functioning in the patients of add-on Escitalopram group when compared with the placebo group. There was no significant difference between the two groups in terms of observed side effects.Conclusions: Escitalopram addition to the standard anti-psychotic treatment of schizophrenia, in patients having subsyndromal depressive symptoms, results in better cognition and improved functioning.

Diagnostic Evaluation of Non-Interpretable Results Associated with rpoB Gene in Genotype MTBDRplus Ver 2.0 / 결핵및호흡기질환

Background@#Line probe assay (LPA) is standard diagnostic tool to detect multidrug resistant tuberculosis. Noninterpretable (NI) results in LPA (complete missing or light wild-type 3 and 8 bands with no mutation band in rpoB gene region) poses a diagnostic challenge. @*Methods@#Sputum samples obtained between October 2016 and July 2017 at the Intermediate Reference Laboratory, All India Institute of Medical Sciences Hospital, New Delhi, India were screened. Smear-positive and smear-negative culturepositive specimens were subjected to LPA Genotype MTBDRplus Ver 2.0. Smear-negative with culture-negative and culture contamination were excluded. LPA NI samples were subjected to phenotypic drug susceptibility testing (pDST) using MGIT-960 and sequencing. @*Results@#A total of 1,614 sputum specimens were screened and 1,340 were included for the study (smear-positive [n=1,188] and smear-negative culture-positive [n=152]). LPA demonstrated 1,306 (97.5%) valid results with TUB (Mycobacterium tuberculosis) band, 24 (1.8%) NI, three (0.2%) valid results without TUB band, and seven (0.5%) invalid results. Among the NI results, 22 isolates (91.7%) were found to be rifampicin (RIF) resistant and two (8.3%) were RIF sensitive in the pDST. Sequencing revealed that rpoB mutations were noted in all 22 cases with RIF resistance, whereas the remaining two cases had wild-type strains. Of the 22 cases with rpoB mutations, the most frequent mutation was S531W (n=10, 45.5%), followed by S531F (n=6, 27.2%), L530P (n=2, 9.1%), A532V (n=2, 9.1%), and L533P (n=2, 9.1%). @*Conclusion@#The present study showed that the results of the Genotype MTBDRplus assay were NI in a small proportion of isolates. pDST and rpoB sequencing were useful in elucidating the cause and clinical meaning of the NI results.

Sexual functioning in females with depression in remission receiving escitalopram

Background & objectives: Sexual functioning is a strong determinant of quality of life. Sexual dysfunction has been widely reported due to depressive disorder as well as selective serotonin reuptake inhibitors. Thus, treatment with antidepressants can culminate in a double-edged sword, leading to drug discontinuation and symptom relapse. The objective of this study was to assess the sexual functioning of sexually active females with depression, currently in remission, receiving escitalopram and to compare with healthy controls. Methods: Fifty female patients with depression, currently in remission, with self-reported normal pre-morbid sexual function and receiving escitalopram for at least three months, were assessed on female sexual function index (FSFI) questionnaire and compared with healthy controls. Results: Half of the patients (n=25, 50%) in group A were found to have sexual dysfunction (FSFI score <26.55), while, 90 per cent (n=45) had decreased desire, 86 per cent (n=43) had decreased arousal, 54 per cent (n=27) had decreased lubrication, 68 per cent (n=34) had decreased orgasm, 62 per cent (n=31) had decreased satisfaction and 32 per cent (n=16) had pain during sexual activity. Patients receiving escitalopram had significantly higher sexual dysfunction as compared to healthy controls in mean total FSFI score (P < 0.001) and all mean domain scores of FSFI except pain. Interpretation & conclusions: A significant proportion of sexually active females with depression currently in remission, receiving escitalopram, reported dysfunction in all domains of sexual function; thus, routine screening for sexual dysfunction during follow up is advisable for early identification and prompt treatment.

Hepatitis B Seroprotection in Pediatric Nephrotic Syndrome

Objectives: To study the prevalence of Hepatitis B seroprotection in children (>1 y) withnephrotic syndrome vaccinated against Hepatitis B vaccine as per the UniversalImmunization Program schedule (0,6,10,14 wk); to compare the Hepatitis B seroprotectionrates and anti-HBs titers among different phenotypes of nephrotic syndrome; to evaluate theassociation between Hepatitis B seroprotection status and the immunosuppressive agents;and to study the correlation between anti-HBs titres and proteinuria. Methods: Hepatitis Bserology and anti-HBs titers were analyzed in 100 children (age-1-18 y) with different clinicalphenotypes of nephrotic syndrome (cases) and 100 healthy controls. Results: Theproportion of seroprotected children among the cases and controls was 37% (n=37) and 61%(n=61), respectively (P<0.04). The median (IQR) anti- HBs antibodies titers among the caseswas 75 (62.5, 81) mIU/mL and 112 (56, 367) mIU/mL among the controls (P=0.001). Theproportion of seroprotected children among the steroid sensitive nephrotic syndrome, steroid-resistant nephrotic syndrome and controls was 40% (n=28), 30% (n=9) and 61% (n=61),respectively (P<0.01). No differences in the anti-HBs titers between children receivingsteroids versus steroids along with other immunosuppressants were found. Weak negativecorrelation was noted between proteinuria and protective titers (r = -0.155; P=0.039).Conclusion: Children with nephrotic syndrome, in general, and steroid-resistant nephroticsyndrome in particular, show poor seroprotection with Hepatitis B vaccination.

Trash to treasure Retcam

Digital fundus imaging is being used in diagnosis, documentation, and sharing of many retinal diseases and hence forms an essential part of ophthalmology. The use of smartphones for the same has been ever increasing. There is a need for simpler devices to couple the 20D lens and smartphone so as to take fundus photographs which can help in fundus documentation. This article describes a simple inexpensive technique of preparing a smartphone fundus photography device (Trash To Treasure (T3) Retcam) from the used materials in the clinics within minutes. This article will also review the optical principles of the T3 Retcam and describe the step–by–step method to record good-quality retinal image/videos. This inexpensive device is made by recycling and modifying the plastic hand sanitizer bottle in the clinics/hospitals which can be used for documenting, diagnosing, screening, and academic purposes.

Current status of treatment of latent tuberculosis infection in India

In view of the high burden of latency of tuberculosis (TB) in India, tackling latent TB in the right way is a menace. All latent TB’s infection (LTBI) are treated in countries having low burden such as the United States. However, this approach cannot be implemented in high burden countries like India until concrete evidence or consensus by experts on this subject is made. There are very specific risk groups where these patients are to be treated as far as current evidence-based medicine is concerned. Hence, the need to develop a document was felt, through which the treatment of LTBI becomes homogeneous by each and every physician who is practicing and treating TB. The last attempt to review the topic was made in 2015, after which there have been many changes and update in this subject.

A Clinical Prospective Study of Hypocalcaemia Following Thyroid Surgery.

Background: Hypocalcaemia is one of the acute and most feared complication following thyroidectomy. Depending upon the extent of parathyroid damage, post-operative hypocalcaemia may be temporary or permanent requiring lifelong calcium supplements. Aims and objectives: This study aims to prospectively study and analyse the demographics and possible causes of hypocalcaemia post thyroidectomy.Methods: This is a prospective study of 150 patients undergoing thyroidectomy surgery from January 2015 to December 2015 in Victoria hospital, Bangalore medical college and research institute, Bangalore. Patients demographics, intra operative and pathological aspects were correlated to our hypocalcaemic findings.Results: Out of 150 patients, 18 patients developed temporary hypocalcaemia (12%), none of them developed permanent hypocalcaemia. Mean age of patients developing hypocalcaemia was 45.16 years. 15 (83.33%) of them were females and 3 (16.66%) were male. Hypocalcaemia was found in 9% in multinodular goitre (9 out of 99 patients), 20% in papillary carcinoma (3 out of 15 patients) and 40 % in follicular neoplasm (6 out of 15 patients). Near total thyroidectomy was the procedure in 105(70%) patients, 3 from them (2.86%) developed hypocalcaemia and the other 15 out of 45 cases (30%) were after total thyroidectomy. Mean duration of surgery was 101 mins. Average no of parathyroid glands identified was 2. Conclusion: Risk factor for development of hypocalcaemia is multifactorial. The recommended surgical strategy is meticulous dissection and preservation of at least one parathyroid gland and their blood supply to prevent permanent hypocalcaemia.

Anesthetic implications of subxiphoid coronary artery bypass surgery.

Background: Minimal invasive surgeries are carried out to benefit the patient with less pain, blood loss, mechanical ventilation and hospital stay; a smaller scar is not the aim. Minimal invasive cardiac surgeries are carried out via small sternotomy, small thoracotomy and via robotic arms. Subxiphoid route is a novel method and avoids sternotomy. Aim: This case series is an attempt to understand the anesthetic modifications required. Secondly, whether it is feasible to carry out subxiphoid coronary artery bypass surgery. Methods: Elective patients scheduled to undergo subxiphoid coronary artery bypass surgery were chosen. The surgeries were conducted under general anesthesia with left lung isolation via either endobronchial tube or bronchial blocker. Results: We conducted ten (seven males and 3 females) coronary artery bypass graft surgeries via subxiphoid technique. The mean EuroSCORE was 1.7 and the mean ejection fraction was 53.6. Eight patients underwent surgery via endobronchial tube, while, in the remaining two lung isolation was obtained using bronchial blocker. Mean blood loss intraoperatively was 300 ± 42 ml and postoperatively 2000 ± 95 ml. The pain score on the postoperative day ‘0’ was 4.3 ± 0.6 and 2.3 ± 0.7 on the day of discharge. Length of stay in the hospital was 4.8 ± 0.9 days. There were no complications, blood transfusions, conversion to cardiopulmonary bypass. The modifications in the anesthetic and surgical techniques are, use of left lung isolation using either endobronchial tube or bronchial blocker, increased duration for conduit harvesting, grafting, requirement of transesophageal echocardiography monitoring in addition to hemodynamic monitoring. Other minor requirements are transcutaneous pacing and defibrillator pads, a wedge under the chest to ‘lift’ up the chest, sparing right femoral artery and vein (to serve as vascular access) for an unlikely event of conversion to cardiopulmonary bypass. Any anesthesiologist wishing to start this technique must be aware of these modifications. Conclusions: Subxiphoid route is safe to carry out coronary artery bypass graft surgery using the minimal invasive cardiac surgery. It is reproducible and has undeniable benefits. We plan to conduct such surgeries in awake patients under thoracic epidural anesthesia thus making it even less invasive and amenable for fast tracking.

News from here and there.

The Prime Minister launched, in New Delhi on 9 March 2015, an indigenously developed and manufactured rotavirus vaccine ROTAVAC® for the private sector. The vaccine has been introduced in India’s Universal Immunization Programme (UIP) in July 2014. A public–private partnership model has been used to develop this vaccine. It involved the work of 300 scientists and collaboration between the Ministry of Science and Technology, Government of India; government institutions of the USA, such as the National Institute of Allergy and Infectious Diseases (NIAID); and various government institutions and non-governmental organizations in India. Other institutions involved included the Stanford University School of Medicine, Research Council of Norway and the Department of International Development, UK. The project was supported by the Bill and Melinda Gates Foundation. The Gates Foundation and Bharat Biotech, an Indian biotechnology company, were involved in product development and testing of the new vaccine. Selected in 1997–98 by the India– US Vaccine Action Programme, Bharat Biotech developed an innovative low-cost manufacturing process. It invested around US$ 20 million to develop new manufacturing facilities and supporting infrastructure in its genome valley plant, located at Hyderabad. The facility has an installed manufacturing capacity of 300 million doses per year. The vaccine originated from an attenuated rotavirus strain that was isolated from a child at the All India Institute of Medical Sciences (AIIMS), New Delhi, in 1985–86. Phase 3 clinical trial data showed excellent safety and efficacy with reduction of severe rotavirus diarrhoea in 56% of participants in the first year of life, with protection continuing into the second year. This compares favourably with the efficacy of currently available rotavirus vaccines in low-resource countries. ROTAVAC® has been priced at about US$ 1 per dose, which at current prices will be the cheapest rotavirus vaccine. The threedose vaccine will help in reducing annually in India approximately 1 000 000 hospitalizations and nearly 80 000 deaths of children under the age of 5 years. Rotavirus is the most common cause of severe diarrhoeal disease in children worldwide and accounts for approximately one-third of the nearly 600 000 global child deaths due to diarrhoea. Ninety-five per cent of these deaths occur in developing countries. Most children below the age of 5 years are at risk of infection regardless of hygienic practices or access to clean drinking water. In young children, the disease is characterized by diarrhoea, vomiting, fever and severe dehydration. In fatal cases, death is due to severe dehydration. The disease cannot be treated by antibiotics or other drugs. Vaccination is the only way to prevent the infection. The WHO recommends that rotavirus vaccines be included in every country’s immunization programme. The Prime Minister lauded this initiative as an example of India’s capabilities for high-end research and development; local manufacture of sophisticated pharmaceutical products; and, effective public–private partnership models for finding affordable solutions to societal challenges. He highlighted the vaccine as a

Encephalcoele- A Cause of Recurrent Meningitis.

There are many causes of recurrent meningitis of which anatomical defects such as cephalocele are common. We report a case of a 45 year-old woman who presented with recurrent meningitis and was found to have an underlying naso-ethmoid encephalocele .

Consensus & Evidence-based INOSA Guidelines 2014 (First edition).

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive Sleep Apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or comorbidities or >15 such episodes without any sleep related symptoms or comorbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography (PSG) is the “gold standard” for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioural measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.