An Unusual Phenomenon of Spontaneously Reversing Nystagmus in Peripheral Vertigo-A Case Report and Literature Review.

Direction-changing nystagmus on positional testing is classically ascribed to a central pathology. We herein report a case of a patient with Benign Paroxysmal Positional Vertigo (BPPV) who demonstrated the unusual phenomenon of spontaneously reversing nystagmus, and discuss the theorised mechanisms with a novel illustration. In left lateral position, our patient's Videonystagmography (VNG) demonstrated an initially fast-phase geotropic nystagmus (leftward-beating, SPV 29°/s) which then paused for 8 s, then spontaneously reversed direction into a slow-phase ageotropic nystagmus (rightward-beating, SPV 7°/s). The rest of the neurootological examination and audiometry were normal. An MRI Brain scan also revealed no intracranial pathology. In subsequent reviews the vertigo resolved after repositioning manoeuvres for Left Horizontal Canal BPPV. With review of existing literature, this case may have exhibited coexistent left canalolithiasis and cupulolithiasis, resulting in simultaneous ampullopetal then ampullofugal forces in a single head position. Other posited theories include that of Endolymphatic Reflux and short-term central adaptation of the Vestibulo-Ocular Reflex. This case highlights a diagnostic challenge the otolaryngologists and neurologists may face with an atypical spontaneously reversing nystagmus in BPPV. However it remains a priority to rule out central pathologies first, and calls for specialists to take care in diagnosing horizontal canal BPPV by observing for a period of latency and spontaneous reversal of nystagmus first, so as to perform the appropriate repositioning manoeuvres. Laryngoscope, 2024.

Context-aware deep network for coronary artery stenosis classification in coronary CT angiography.

Automatic coronary artery stenosis grading plays an important role in the diagnosis of coronary artery disease. Due to the difficulty of learning the informative features from varying grades of stenosis, it is still a challenging task to identify coronary artery stenosis from coronary CT angiography (CCTA). In this paper, we propose a context-aware deep network (CADN) for coronary artery stenosis classification. The proposed method integrates 3D CNN with Transformer to improve the feature representation of coronary artery stenosis in CCTA. We evaluate the proposed method on a multicenter dataset (APOLLO study with NCT05509010). Experimental results show that our proposed method can achieve the accuracy of 0.84, 0.83, and 0.86 for stenosis diagnosis on the lesion, artery, and patient levels, respectively.

COVID-19 and its effects on neurological functions.

Ever since the first reported case series on SARS-CoV-2-induced neurological manifestation in Wuhan, China in April 2020, various studies reporting similar as well as diverse symptoms of COVID-19 infection relating to the nervous system were published. Since then, scientists started to uncover the mechanism as well as pathophysiological impacts it has on the current understanding of the disease. SARS-CoV-2 binds to the ACE2 receptor which is present in certain parts of the body which are responsible for regulating blood pressure and inflammation in a healthy system. Presence of the receptor in the nasal and oral cavity, brain, and blood allows entry of the virus into the body and cause neurological complications. The peripheral and central nervous system could also be invaded directly in the neurogenic or hematogenous pathways, or indirectly through overstimulation of the immune system by cytokines which may lead to autoimmune diseases. Other neurological implications such as hypoxia, anosmia, dysgeusia, meningitis, encephalitis, and seizures are important symptoms presented clinically in COVID-19 patients with or without the common symptoms of the disease. Further, patients with higher severity of the SARS-CoV-2 infection are also at risk of retaining some neurological complications in the long-run. Treatment of such severe hyperinflammatory conditions will also be discussed, as well as the risks they may pose to the progression of the disease. For this review, articles pertaining information on the neurological manifestation of SARS-CoV-2 infection were gathered from PubMed and Google Scholar using the search keywords "SARS-CoV-2", "COVID-19", and "neurological dysfunction". The findings of the search were filtered, and relevant information were included.

Hybrid Treatment via MHz Acoustic Waves and Plasma to Enhance Seed Germination in Mung Bean.

We investigate a hybrid treatment-consisting of an atmospheric pressure plasma pretreatment, followed by an MHz surface acoustic waves (SAWs) treatment with either de-ionized (DI) water or plasma activated water (PAW)-on mung beans to accelerate the germination process, as mung bean sprout is one of the important food staples. For the early growth rate (after 320 min), we observe that the hybrid treatment with PAW can lead to approximately 217% higher moisture content for the treated beans when compared with that without hybrid treatment. Additionally, the hybrid-treated beans germinate in around 120 min, while the untreated beans germinate only in around 420 min, that is, 3.5-fold faster for treated beans. This can be attributed to the dominant effect of SAW that accelerates stage 1 water absorption process and the effect of direct plasma and PAW that promote stage 2 metabolism process, leading to the enhancement in stage 3 germination process in early growth rate. For the post growth rate (after 24 h), we observe that the hybrid treatment with DI water can lead to an approximately 44.20% in higher moisture and 71.17% in radicle length when compared with untreated beans. Interestingly, the hybrid treatment with PAW, on the other hand, is observed to have an adverse effect on germination after 24 h, that is, approximately 14.51% lower in moisture content and 43.49% lower in radicle length for the hybrid-treated beans with PAW when compared with that with DI water.

COVID-19 and its effects on neurological functions

@#Ever since the first reported case series on SARS-CoV-2-induced neurological manifestation in Wuhan, China in April 2020, various studies reporting similar as well as diverse symptoms of COVID-19 infection relating to the nervous system were published. Since then, scientists started to uncover the mechanism as well as pathophysiological impacts it has on the current understanding of the disease. SARS-CoV-2 binds to the ACE2 receptor which is present in certain parts of the body which are responsible for regulating blood pressure and inflammation in a healthy system. Presence of the receptor in the nasal and oral cavity, brain, and blood allows entry of the virus into the body and cause neurological complications. The peripheral and central nervous system could also be invaded directly in the neurogenic or hematogenous pathways, or indirectly through overstimulation of the immune system by cytokines which may lead to autoimmune diseases. Other neurological implications such as hypoxia, anosmia, dysgeusia, meningitis, encephalitis, and seizures are important symptoms presented clinically in COVID-19 patients with or without the common symptoms of the disease. Further, patients with higher severity of the SARS-CoV-2 infection are also at risk of retaining some neurological complications in the long-run. Treatment of such severe hyperinflammatory conditions will also be discussed, as well as the risks they may pose to the progression of the disease. For this review, articles pertaining information on the neurological manifestation of SARS-CoV-2 infection were gathered from PubMed and Google Scholar using the search keywords “SARS-CoV-2”, “COVID-19”, and “neurological dysfunction”. The findings of the search were filtered, and relevant information were included.

Super-Resolution Microscopy and FIB-SEM Imaging Reveal Parental Centriole-Derived, Hybrid Cilium in Mammalian Multiciliated Cells.

Motile cilia are cellular beating machines that play a critical role in mucociliary clearance, cerebrospinal fluid movement, and fertility. In the airways, hundreds of motile cilia present on the surface of a multiciliated epithelia cell beat coordinately to protect the epithelium from bacteria, viruses, and harmful particulates. During multiciliated cell differentiation, motile cilia are templated from basal bodies, each extending a basal foot-an appendage linking motile cilia together to ensure coordinated beating. Here, we demonstrate that among the many motile cilia of a multiciliated cell, a hybrid cilium with structural features of both primary and motile cilia is harbored. The hybrid cilium is conserved in mammalian multiciliated cells, originates from parental centrioles, and its cellular position is biased and dependent on ciliary beating. Furthermore, we show that the hybrid cilium emerges independently of other motile cilia and functions in regulating basal body alignment.

Lamb to Rayleigh Wave Conversion on Superstrates as a Means to Facilitate Disposable Acoustomicrofluidic Applications.

Rayleigh surface acoustic waves (SAWs) have been demonstrated as a powerful and effective means for driving a wide range of microfluidic actuation processes. Traditionally, SAWs have been generated on piezoelectric substrates, although the cost of the material and the electrode deposition process makes them less amenable as low-cost and disposable components. As such, a "razor-and-blades" model that couples the acoustic energy of the SAW on the piezoelectric substrate through a fluid coupling layer and into a low-cost and, hence, disposable silicon superstrate on which various microfluidic processes can be conducted has been proposed. Nevertheless, it was shown that only bulk vibration in the form of Lamb waves can be excited in the superstrate, which is considerably less efficient and flexible in terms of microfluidic functionality compared to its surface counterpart, that is, the SAW. Here, we reveal an extremely simple way that quite unexpectedly and rather nonintuitively allows SAWs to be generated on the superstrate-by coating the superstrate with a thin gold layer. In addition to verifying the existence of the SAW on the coated superstrate, we carry out finite-difference time domain numerical simulations that not only confirm the experimental observations but also facilitate an understanding of the surprising difference that the coating makes. Finally, we elucidate the various power-dependent particle concentration phenomena that can be carried out in a sessile droplet atop the superstrate and show the possibility for simply carrying out rapid and effective microcentrifugation-a process that is considerably more difficult with Lamb wave excitation on the superstrate.

Acoustically Driven Micromixing: Effect of Transducer Geometry.

The ability to drive efficient micromixing on a microfluidic platform is crucial for a wide range of lab-on-a-chip applications. Here, we investigate the ability of acoustic waves generated on different geometric surfaces (concave and convex) to enhance the micromixing efficiency in droplet acoustomicrofluidic systems, and, concomitantly, to reduce the power consumption in these devices for a given performance requirement. Quite counterintuitively, we observe that although the acoustic streaming velocity, which scaled inversely with the droplet size, tended to be generally lower (by approximately 45%) when the flow is generated by transducers with convex surfaces compared to those with concave surfaces, the mixing efficiency is disproportionately higher: compared to pure diffusional mixing in the absence of the acoustic forcing, the mixing efficiency due to the acoustically driven convection increased by up to 25% and 43% on these respective surfaces. As such, the mixing enhancement cannot simply be attributed to an increase in the convective flow arising from the acoustic forcing. Rather, we observe the mixing enhancement to be due to the stronger chaotic advection arising in the transducer with the convex surface due to its diverging acoustic field into the droplet.

Acoustially-mediated microfluidic nanofiltration through graphene films.

We exploit the possibility of enhancing the molecular transport of liquids through graphene films using amplitude modulated surface acoustic waves (SAWs) to demonstrate effective and efficient nanoparticle filtration. The use of the SAW, which is an extremely efficient means for driving microfluidic transport, overcomes the need for the large mechanical pumps required to circumvent the large pressure drops encountered in conventional membranes for nanoparticle filtration. 100% filtration efficiency was obtained for micron-dimension particulates, decreasing to only 95% for the filtration of particles of tens of nanometers in dimension, which is comparable to that achieved with other methods. To circumvent clogging of the film, which is typical with all membrane filters, a backwash operation to flush the nanoparticles is incorporated simply by reversing the SAW-induced flow such that 98% recovery of the initial filtration rate is recovered. Given these efficiencies, together with the low cost and compact size of the chipscale SAW devices, we envisage the possibility of scaling out the process by operating a large number of devices in parallel to achieve typical industrial-scale throughputs with potential benefits in terms of substantially lower capital, operating and maintenance costs.

Amplitude modulation schemes for enhancing acoustically-driven microcentrifugation and micromixing.

The ability to drive microcentrifugation for efficient micromixing and particle concentration and separation on a microfluidic platform is critical for a wide range of lab-on-a-chip applications. In this work, we investigate the use of amplitude modulation to enhance the efficiency of the microcentrifugal recirculation flows in surface acoustic wave microfluidic systems, thus concomitantly reducing the power consumption in these devices for a given performance requirement-a crucial step in the development of miniaturized, integrated circuits for true portable functionality. In particular, we show that it is possible to obtain an increase of up to 60% in the acoustic streaming velocity in a microdroplet with kHz order modulation frequencies due to the intensification in Eckart streaming; the streaming velocity is increasing as the modulation index is increased. Additionally, we show that it is possible to exploit this streaming enhancement to effect improvements in the speed of particle concentration by up to 70% and the efficiency of micromixing by 50%, together with a modest decrease in the droplet temperature.

Graphene-mediated microfluidic transport and nebulization via high frequency Rayleigh wave substrate excitation.

The deposition of a thin graphene film atop a chip scale piezoelectric substrate on which surface acoustic waves are excited is observed to enhance its performance for fluid transport and manipulation considerably, which can be exploited to achieve further efficiency gains in these devices. Such gains can then enable complete integration and miniaturization for true portability for a variety of microfluidic applications across drug delivery, biosensing and point-of-care diagnostics, among others, where field-use, point-of-collection or point-of-care functionality is desired. In addition to a first demonstration of vibration-induced molecular transport in graphene films, we show that the coupling of the surface acoustic wave gives rise to antisymmetric Lamb waves in the film which enhance molecular diffusion and hence the flow through the interstitial layers that make up the film. Above a critical input power, the strong substrate vibration displacement can also force the molecules out of the graphene film to form a thin fluid layer, which subsequently destabilizes and breaks up to form a mist of micron dimension aerosol droplets. We provide physical insight into this coupling through a simple numerical model, verified through experiments, and show several-fold improvement in the rate of fluid transport through the film, and up to 55% enhancement in the rate of fluid atomization from the film using this simple method.

Internet based patient education improves informed consent for elective orthopaedic surgery: a randomized controlled trial.

BACKGROUND: Obtaining informed consent is an essential step in the surgical pathway. Providing adequate patient education to enable informed decision making is a continued challenge of contemporary surgical practice. This study investigates whether the use of a patient information website, to augment patient education and informed consent for elective orthopaedic procedures is an effective measure. METHODS: A randomised controlled trial was conducted comparing the quality of informed consent provided by a standard discussion with the treating surgeon compared to augmentation of this discussion with an online education resource (www.orthoanswer.org). Participants were recruited from orthopaedic outpatient clinics. Patients undergoing five common orthopaedic procedures were eligible to participate in the trial. The primary outcome measure was knowledge about their operation. Satisfaction with their informed consent and anxiety relating to their operation were the secondary outcome measures. RESULTS: There was a statistically significant increase in patient knowledge for the intervention arm as compared to the control arm (p < 0.01). Patients in the intervention arm, had an average score of 69.25% (SD 14.91) correct answers as compared to 47.38% (SD 17.77) in the control arm. Satisfaction was also improved in the intervention arm (p = 0.043). There was no statistically significant difference between the control and intervention arm relating to their anxiety scores (p = 0.195). CONCLUSIONS: The use of a patient education website as an augment to informed consent improves patient knowledge about their planned operation as well as satisfaction with the consent process whilst not increasing their anxiety levels. We recommend that all patients be directed to web based education tools to augment their consent. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614001058662 .

Suppression of the Leidenfrost effect via low frequency vibrations.

The ability to suppress the Leidenfrost effect is of significant importance in applications that require rapid and efficient cooling of surfaces with temperature higher than the Leidenfrost point TSL. The Leidenfrost effect will result in substantial reduction in cooling efficiency and hence there have been a few different approaches to suppress the Leidenfrost effect. The majority of these approaches relies on fabricating micro/nano-structures on heated surfaces, others rely on inducing an electric field between the droplets and the heated surfaces. In this paper, we present an approach that induces low frequency vibrations (f∼10(2) Hz) on a heated surface to suppress the effect. By mapping the different magnitudes of surface acceleration [greek xi with two dots above]sversus different initial surface temperatures Ts of the substrate, three regimes that represent three distinct impact dynamics are analyzed. Regime-I represents gentle film boiling ([greek xi with two dots above]s∼10(2) m s(-2) and Ts∼TSL), which is associated with the formation of thin spreading lamella around the periphery of the impinged droplet; Regime-II ([greek xi with two dots above]s∼10(2) m s(-2) and Ts>TSL) represents film boiling, which is associated with the rebound of the impinged droplet due to the presence of a thick vapor layer; Regime-III ([greek xi with two dots above]s∼10(3) m s(-2) and Ts∼TSL) represents contact boiling, which is associated with the ejection of tiny droplets due to the direct contact between the droplet and the heated surface. The estimated cooling enhancement for Regime-I is between 10% and 95%, Regime-II is between 5% and 15%, and Regime-III is between 95% and 105%. The improvement in cooling enhancement between Regime-I (strong Leidenfrost effect) and Regime-III (suppressed Leidenfrost effect) is more than 80%, demonstrating the effectiveness of using low frequency vibrations to suppress the Leidenfrost effect.

Fire propagation performance of intumescent fire protective coatings using eggshells as a novel biofiller.

This paper aims to synthesize and characterize an effective intumescent fire protective coating that incorporates eggshell powder as a novel biofiller. The performances of thermal stability, char formation, fire propagation, water resistance, and adhesion strength of coatings have been evaluated. A few intumescent flame-retardant coatings based on these three ecofriendly fire retardant additives ammonium polyphosphate phase II, pentaerythritol and melamine mixed together with flame-retardant fillers, and acrylic binder have been prepared and designed for steel. The fire performance of the coatings has conducted employing BS 476: Part 6-Fire propagation test. The foam structures of the intumescent coatings have been observed using field emission scanning electron microscopy. On exposure, the coated specimens' B, C, and D had been certified to be Class 0 due to the fact that their fire propagation indexes were less than 12. Incorporation of ecofriendly eggshell, biofiller into formulation D led to excellent performance in fire stopping (index value, (I) = 4.3) and antioxidation of intumescent coating. The coating is also found to be quite effective in water repellency, uniform foam structure, and adhesion strength.

Correlation between corneal and scleral thickness in glaucoma.

PURPOSE: To assess the correlation between central corneal thickness (CCT) and anterior scleral thickness (ST) in patients of primary open-angle glaucoma (POAG), normal tension glaucoma (NTG), and ocular hypertension (OHT). PATIENTS AND METHODS: Consecutive patients with OHT, POAG, NTG, and normal individuals were recruited. CCT was measured by ultrasonic pachymetry, whereas ST was measured using ultrasonic biomicroscopy at the temporal quadrant, 2 mm posterior to the scleral spur. Investigators were masked to the diagnosis and CCT/ ultrasonic biomicroscopy data. Correlation between mean CCT and ST was analyzed. RESULTS: One hundred and twenty-four subjects (31 with OHT, 31 with POAG, 31 with NTG, and 31 normal individuals) were enrolled. The CCT (OHT 548.06+/-30.45 microm; POAG 519.39+/-42.95 microm; NTG 505.81+/-27.23 microm; controls 529.90+/-43.40 microm) was found to be thicker in patients with OHT than POAG (P=0.004) or NTG (P<0.01). There was also a difference in CCT between NTG and control eyes (P=0.012). The ST (OHT 755.03+/-69.58 microm; POAG 738.45+/-66.83 microm; NTG 708.74+/-71.58 microm; controls 724.45+/-73.27 microm) was thicker in the OHT group than in NTG patients (P=0.012). No significant difference in ST was found among other groups. Among subgroups, the correlation between CCT and ST was found only among the patients with NTG (r=0.440, P=0.013). However, no correlation was seen between CCT and ST in patients with OHT, POAG, and controls. CONCLUSIONS: There is a correlation between CCT and ST among the NTG group but no correlation was seen among OHT, POAG, and controls.

Two types of detergent-insoluble, glycosphingolipid/cholesterol-rich membrane domains from isolated myelin.

Two different types of low-density detergent-insoluble glycosphingolipid-enriched membrane domain (DIG) fractions were isolated from myelin by extraction with Triton X-100 (TX-100) in 50 mM sodium phosphate buffer at room temperature (20 degrees C) (procedure 1), in contrast to a single low-density fraction obtained by extraction with TX-100 in Tris buffer containing 150 mM NaCl and 5 mM EDTA at 4 degrees C (procedure 2). Procedure 1 has been used in the past by others for myelin extraction to preserve the cytoskeleton and/or radial component of oligodendrocytes and myelin, whereas procedure 2 is now more commonly used to isolate myelin DIG fractions. The two DIG fractions obtained by procedure 1 gave opaque bands, B1 and B2, at somewhat lower and higher sucrose density respectively than myelin itself. The single DIG fraction obtained by procedure 2 gave a single opaque band at a similar sucrose density to B1. Both B1 and B2 had characteristics of lipid rafts, i.e. high galactosylceramide and cholesterol content and enrichment in GPI-linked 120-kDa neural cell adhesion molecule (NCAM)120, as found by others for the single low-density DIG fraction obtained by procedure 2. However, B2 had most of the myelin GM1 and more of the sulfatide than B1, and they differed significantly in their protein composition. B2 contained 41% of the actin, 100% of the tubulin, and most of the flotillin-1 and caveolin in myelin, whereas B1 contained more NCAM120 and other proteins than B2. The single low-density DIG fraction obtained by procedure 2 contained only low amounts of actin and tubulin. B1 and B2 also had size-isoform selectivity for some proteins, suggesting specific interactions and different functions of the two membrane domains. We propose that B1 may come from non-caveolar raft domains whereas B2 may derive from caveolin-containing raft domains associated with cytoskeletal proteins. Some kinases present were active on myelin basic protein suggesting that the DIGs may come from signaling domains.

Knowledge and beliefs on corneal donation in Singapore adults.

AIM: To assess the knowledge and willingness of Singapore adults towards corneal donation. METHODS: The study population consists of a cluster random sample of the population living in Bedok North (an area in the eastern part of Singapore). The study population comprised residents aged 21-65 years living in 675 randomly sampled housing units. The participation rate was 65.9% (544/825). All participants were interviewed face to face with a questionnaire formulated according to the modified Horton and Horton model. Knowledge, values, attitudes, and spiritual beliefs of participants were assessed to evaluate their willingness to donate their corneas. RESULTS: 67.0% of participants were willing to donate their corneas. Ethnicity (Chinese) and religion (Christians, Hindus, or those with no religion) were associated with increased willingness to donate corneas. Greater knowledge and increased altruistic values were also associated with increased willingness to donate corneas. CONCLUSION: A proportion of participants were willing to donate their corneas. Awareness of corneal donation is high but specific knowledge should be further increased among adults.

Influence of mismatching of HLA cross-reactive groups on cadaveric kidney transplantation.

Finding fully HLA-matched recipients for a given donor is not practical due to the allelic diversity of the loci. Cross-reactive group (CREG) matching has been considered a feasible alternative to HLA matching. However, the true efficacy of CREG matching in cadaveric kidney transplantation is controversial. Using conventional HLA and CREG classifications proposed by Rodey and McKenna, we counted the number of mismatches for 319 patients who received cadaver kidney transplants between 1992 and 2003 at Asan Medical Center in Korea. When we compared transplants with four or fewer HLA-A, -B, and -DR antigen mismatches with those with five or more, we observed a significant difference in 5-year survival rate (88.5% versus 78.6%; P = .0189). Transplants with no or one HLA-DR mismatch had a significantly better 5-year survival rate than those with two HLA-DR mismatches (87.9% versus 80.0%; P = .0469). Among transplants with one or two HLA-DR mismatches, transplants with zero or one CREG mismatch showed better 5-year graft survival rate than those with two or more CREG mismatches (89.4% versus 79.8%; P = .0415) only in McKenna's CREG classification. These results suggest that the impact of CREG mismatches on graft survival may depend on CREG classification and on the distribution of HLA-DR mismatches.

Antenatal use of a novel vaginal birth training device by term primiparous women in Singapore.

INTRODUCTION: To study the use, safety and effectiveness of a novel antenatal vaginal birth training device (EPI-NO) in primiparous women. METHODS: Antenatal use of the EPI-NO vaginal birth trainer was prospectively studied in 31 primiparous booked patients who were delivered by obstetricians from July to December 2002 at the KK Women's and Children's Hospital. This was studied in relation to episiotomy rate, perineal trauma and analgesic requirements during the postpartum period. A patient questionnaire form was used to assess their perception of pain and how well they coped with its use. For comparison, perineal trauma was also studied retrospectively in 60 consecutive obstetrician-booked primiparous term patients who had normal vaginal delivery (NVD) and who did not use EPI-NO during the same study period. RESULTS: The mean length of usage was for 2.1 weeks (standard deviation [sd] 1.2 weeks). The mean frequency of use was 5.3 episodes per week (sd 2.1, range 1 to 7). There was no laceration and vaginal infection arising from its usage. There was a case of minimal bleeding post-usage. There were 20 (64.5 percent) NVDs, four (12.9 percent) forceps deliveries, five vacuum deliveries (16.1 percent) and two (6.5 percent) Caesarean sections. Of the 29 vaginal delivery cases, 19 (65.5 percent) had episiotomy, eight (27.6 percent) had lacerations, and two (6.9 percent) did not sustain laceration. The reasons for episiotomy in the 19 cases were nine cases of pending tearing of vagina/perineum, nine cases of instrumental vaginal deliveries, and one to shorten second stage. There was no third degree tear. 21 (67.7 percent) out of 30 required a painkiller. The majority of patients (17; 54.8 percent) appeared to be comfortable with the use of EPI-NO. All coped well with vaginal examination after using EPI-NO perineal training. Comparing among term primiparous NVD cases with (n value equals 20) and without (n value equals 60) EPI-NO, the perineal trauma rate (90.0 percent vs 96.6 percent, p value equals 0.24) was slightly but not significantly lower in the EPI-NO group. The episiotomy rate was significantly lower (50.0 percent vs 93.3 percent, p value is less than 0.0001) and the extent of perineal trauma in the patient appeared to be less severe in cases using EPI-NO. CONCLUSION: EPI-NO appeared to be safe and acceptable to the majority of users. Although birth training with EPI-NO significantly decreases the rate of episiotomies in term primiparous patients, and the degree of perineal tissue injury appeared to be less in the EPI-NO group especially among those with lacerations, the overall perineal trauma rate was slightly but not significantly lower, in view of the higher spontaneous laceration rate in the EPI-NO group.