The "11 O'clock Heel First" technique for microvascular end-to-side anastomosis

BACKGROUND

The heel of a microvascular end-to-side anastomosis is a common site for technical imperfections. We describe a simple technique to overcome this challenge. The aim of the technique is to insert all the sutures in an inside-to-outside manner at the heel area on the donor side of the anastomosis. This technique has first been tested in a laboratory setting and then was further elaborated in a clinical setting.

MATERIALS AND METHODS

One hundred and twenty adult albino Wistar rats of both genders were randomized into the following two groups: (A) Control, 48 rats, representing approximately 40% of the total sample, underwent the usual two anchoring stitch technique; (B) Study group, 72 rats, representing approximately 60% of the total sample, underwent the technique described. Patency was confirmed both clinically and by the use of fluorescein angiography. Rat weight, diameter of both the donor and recipient vessels, type of anastomosis (arterio-arterial or arterio-venous) and angiographic findings were used as variables. A P value of less than 0.05 was considered significant.

RESULTS

The proposed technique had increased patency rates as compared to the standard technique, which was statistically significant (P = 0.021). However, there was no difference between the patency rates of arterio-arterial and arterio-venous atastomoses.

CONCLUSION

The proposed technique is useful for perfecting the heel area of a microvascular end-to-side anastomosis in both laboratory and clinical settings.

Verrucous carcinoma: A clinicopathological study

Objective

The purpose of this study is to identify a co-relation between clinical and histopathological features of verrucous carcinoma.

Materials and Methods

This study was conducted based on Knowledge Attitude and Practice (KAP) questionnaire comprising of 3 sets of questions covering clinical and histopathological aspects of the oral verrucous carcinoma. The target subjects were specialists in the field of Oral Medicine and Radiology, Oral and Maxillofacial Surgery and Oral Pathology.

Results and Conclusion

Verrucous carcinoma is a low grade variant of squamous cell carcinoma and the clinical features of both are very similar. The treatment of both differs widely; we fail to diagnose it correctly. This study correlates the clinic-pathologic features of oral verrucous carcinoma by means of statistically analyzing the varied clinical features and pathological impressions. This is helpful in eliminating the diagnostic dilemma and thus channelizing the data to present a clear treatment planning.

Correction of Toe-Walking Gait in Children with Spastic Cerebral Palsy by using Electrical Stimulation Therapy

Toe-walking is a very common gait abnormality seen in children with Cerebral Palsy (CP). The present study aims to improvise the toe-walking gait by applying Electrical Stimulation (ES) therapy of the Tricep Surae (TS) muscles. The study was carried out on sixteen children with spastic CP with unilateral toe-walking gait problem, divided into the intervention group that received both ES therapy along with conventional physiotherapy treatment and the control group that received only conventional physiotherapy treatment. Both groups were treated for 60 (30 + 30) minutes per day, for 5 days a week, up to 12 weeks. The gait data were analyzed for spatiotemporal and parameters influencing the walking capacity. The results showed that those children who received the intervention had a significant increase in gait speed by 17.67 % (p = 0.019) and decrease in stride length by 10.25 % (p = 0.037), resulting in improvement of body balance. There was a significant percentage increase in initial contact (heel strike) of 85.71 % (p = 0.000) and flat foot position (loading response) of 49.2 % (p = 0.005), confirming reduction in toe-walking. There was also an increase in the swing power by 39.8 % (p = 0.028) and ground impact by 19.5 % (p = 0.003) suggesting a change in foot contact pattern. The results indicate that ES therapy on TS muscle along with conventional physiotherapy may correct the toe-walking gait in children with spastic hemiplegic CP.

Role of surgery for small petrous apex meningiomas causing refractory trigeminal neuropathy in the minimally invasive era

BACKGROUND

Radiosurgery seems to be a very appealing option for patients having a small petrous apex meningioma and presenting with trigeminal neuralgia, presumably because of the lower risk and cost involved. The aim of this study was to analyze the results of our surgical series of petrous apex meningioma presenting with trigeminal neuralgia, and to determine the efficacy of neurosurgical treatment with regard to pain control. The procedure-related complication and morbidity rates were also evaluated.

MATERIALS AND METHODS

This is a retrospective study of 17 patients with a small (<3 cm) petrous apex meningioma. The included patients were refractory to medical treatment for trigeminal neuralgia and were deemed as surgical candidates. Postoperatively, the patients were assessed for pain relief according to the Barrow Neurological Institute (BNI) scale. A P value of less than 0.05 was considered significant. Magnetic resonance imaging was also performed after 6 weeks to assess the radicality of resection.

RESULTS

In a median follow-up of approximately 2 years, the study showed that 14 of the 17 (82.4%) patients had complete pain relief, with very low morbidity and no mortality, and 100% tumor control. According to the Barrow Neurological Institute (BNI) scale for the assessment of postoperative pain relief, 52.9, 23.5, 5.9, 11.8, and 5.9% of patients had grades I, II, IIIa, IIIb, and IV in terms of their pain relief, respectively.

CONCLUSIONS

In our population of patients, surgery proved to be successful in providing symptomatic relief, with low morbidity and no mortality, and was comparable with other studies involving the minimally invasive modalities. However, these results warrant further follow-up, with recruitment of more patients, to demonstrate whether or not, surgery should be the primary choice of treatment in this subgroup of patients.

Potent suppression of HIV-1 cell attachment by Kudzu root extract

There is a constant need to improve antiretrovirals against HIV since therapy is limited by cost, side effects and the emergence of drug resistance. Kudzu is a climbing vine from which the root extract (Pueraria lobata), rich in isoflavones and saponins, has long been used in traditional Chinese medicine for a variety of purposes, from weight loss to alcoholism prevention. Here we show that Kudzu root extract significantly inhibits HIV-1 entry into cell lines, primary human CD4⁺T lymphocytes and macrophages, without cell-associated toxicity. Specifically, Kudzu inhibits the initial attachment of the viral particle to the cell surface, a mechanism that depends on the envelope glycoprotein gp120 but is independent from the HIV-1 cell receptor CD4 and co-receptors CXCR4/CCR5. This activity seems selective to lentiviruses since Kudzu inhibits HIV-2 and simian immunodeficiency virus, but does not interfere with Hepatitis C, Influenza, Zika Brazil and adenovirus infection. Importantly, depending on the dose, Kudzu can act synergistically or additively with the current antiretroviral cocktails against HIV-1 and can block   viruses resistant to the fusion inhibitor Enfuvirtide. Together our results highlight Kudzu's root extract value as a supplement to current antiretroviral therapy against HIV.

Physical comorbidity in schizophrenia & its correlates

The presence of common physical comorbidities, their demographic and clinical correlates and impact on functioning was assessed in 100 patients with schizophrenia. The patients had a mean age of 35.12±10.7 yr with mean duration of illness of 8.3±0.58 years. Seventy per cent were detected to have a comorbid physical condition. Common conditions included hypertension (21%), diabetes mellitus (15%) and anaemia (12%). Increasing age, being female, being married, longer duration of illness and longer duration of treatment were associated with higher risk of having a comorbid physical illness. Further studies need to be done with a large sample to confirm these findings.

Type-3 von Willebrand disease in India-Clinical spectrum and molecular profile

INTRODUCTION

Type 3 von Willebrand disease (VWD) is the rare and most severe form of VWD which results from a near-complete deficiency of the von Willebrand factor (VWF). This study evaluates in detail the molecular pathology of type-3 VWD in India. One hundred and two patients from 90 families were evaluated.

PATIENTS AND METHODS

Phenotypic data, including bleeding scores (BS), were documented using structured questionnaires. Diagnosis of type 3 VWD was based on undetectable VWF antigen levels in the plasma. Genomic DNA from these patients was screened for mutations in VWF gene. Structural modeling and expression studies were carried out for missense mutations.

RESULTS

Out of 102 patients, mutations could be identified in 91% (n = 93). Fifty-five different gene variants were identified. Thirty-four (61.8%) were novel. Mutations could be identified in both the alleles in 90 patients, while no causative mutation could be identified in 9 patients; twenty-four (23.5%) patients had mutations clustered in the propeptide region of VWF. Interestingly, five mutations accounted for the defects in 37/93 (39.8%) patients. Structural analysis and in vitro studies on missense mutations imply impaired processes associated with secretion of VWF.

CONCLUSION

This study is one of the largest series to define the molecular basis of type-3 VWD.

Mobilization of the outer cavernous membrane decreases bleeding and improves resection in spheno-clinoidal meningiomas without cavernous sinus extension: A randomized controlled trial

Objective

The aim of this study was to determine whether adding mobilization of the outer cavernous sinus membrane as a part of the approach, in large spheno-clinoidal meningiomas without cavernous sinus extension, would reduce bleeding and increase the extent of resection.

Methods:

This prospective randomized controlled trial was held between February 2016 and April 2017 at Cairo University Hospitals. The study recruited 94 patients with spheno-clinoidal meningiomas without cavernous sinus involvement. Patients were randomly assigned (by a computer based randomization system) into two groups; the treatment group, in which the patients received mobilization of the outer layer of the lateral wall of the cavernous sinus, prior to opening of the dura; and, the control group, in which the patients were operated by a direct opening of the dura without cavernous sinus dissection. The primary outcome of this study was the difference in the amount of blood lost during surgery between both groups of patients. The secondary outcome variables were the estimated blood loss (EBL) calculated according to Mercurelli's formula, the extent of tumor resection and the amount of blood transfused.

Results:

The amount of blood loss and estimated blood loss (EBL) were significantly less in the "with mobilization group" with the P value being 0.00 and 0.013, respectively. Additionally, the amount of residual tumor was compared between both the groups and it showed that the group of patients who have received mobilization of the outer cavernous sinus membrane had a higher rate of radical resection as expressed by a lower volume of residual tumor (P value 0.005).

Conclusion:

In large spheno-clinoidal meningiomas without cavernous sinus involvement, routine mobilization of the outer cavernous sinus membrane reduces bleeding. This helps in a better visualization of cranial nerves in a relatively avascular field as it enables the performance of neurovascular dissection in an earlier phase of surgery. It also enables a more radical resection.

Combined coagulation factor VIII and factor IX deficiency (CDF8F9) in a patient from Lithuania

Haemophilia A (FVIII deficiency) and haemophilia B (FIX deficiency) are X-linked inherited bleeding disorders. It is a very rare event to identify both haemophilias in the same patient. So far, only two families with such combination are reported in the literature worldwide supported by genetic background. Patients and methods: Evaluation of clinical data, determination of FVIII and FIX levels and genetic analysis of F8 and F9 genes by direct sequencing. Results: We report on a patient having severe haemophilia B (FIX:C <1 IU dl-1) and mild haemophilia A (FVIII:C 18 IU dl-1 ). FIX deficiency was known since childhood, whereas mild haemophilia A was confirmed at the age of 42 due to unexpected bleeding complications after dental extraction despite adequate substitution with plasma derived FIX concentrate. F9 gene analysis showed a point mutation in exon 2 (c.223C>T, p.R75X), whereas F8 gene analysis revealed a point mutation in exon 4 (c.545A>C, p.D182A). The mother of the patient was heterozygous for F8 mutation, but not for F9 mutation suggesting a de novo F9 mutation. Accidentally, further family from Germany with mild Haemophilia A was identified to have the same F8 mutation. F8 Haplo-type analysis revealed that the p.D182A mutation most likely represents a founder mutation with common ancestors of the German and the Lithuanian family. Conclusions: Our results confirm the rare event of Haemophilia A and haemophilia B in the same patient originating from two distinct genetic defects in F8 and F9 genes.

A novel fibrinogen γ chain frameshift deletion (c.637delT) in a patient with hypodysfibrinogenemia associated with thrombosis

Inherited fibrinogen (FG) disorders are rare and result in quantitative or/and qualitative FG deficiency. While the majority of patients with clinically relevant FG deficiencies demonstrate a bleeding phenotype, a subset of patients are at increased risk of thrombosis.

We report a 54-years old man presenting with a thrombophilic phenotype characterized by two episodes of unprovoked venous thrombosis and a deep vein thrombosis several weeks after myocardial infarction. Recently, he developed A. carotis communis thrombosis and died. Coagulation tests were done using standard procedures. FG genes were screened using direct sequencing. Effect on fibrin clot structure was analyzed by scanning electron microscopy (SEM) and FG chain polymerization was analysed using SDS-PAGE.

While thrombophilia testing was negative, we found a decreased concentration of clottable FG (126-148 mg/dl) compared to FG antigen (182-194 mg/dl of normal). The thrombin time was slightly prolonged, while aPTT and reptilase time were within the normal range. A novel deletion in FGG gene (c.637delT) resulting in a frameshift and the premature termination of the γ chain at amino acid position p.228 was identified. SDS-PAGE showed a time-shift in γ-γ and α-α cross linking. SEM showed no statistically significant differences between the patient´s and a healthy control´s fibrin clot structure.

In addition to the reduction of FG concentration expected by the nature of the mutation also a functional defect (hypodysfibrinogenemia) was found. Moreover this mutation seems to increase the risk of thrombosis warranting long term anticoagulation possibly in a combination with antiplatelet drugs.

A prospective study examining the influence of cardiac rehabilitation on the sedentary time of highly sedentary, physically inactive patients

OBJECTIVES

Prolonged sedentary time is recognized as a distinct health risk, and mortality risks are expected to be greatest for individuals with low exercise levels. It is unknown whether participation in exercise-based cardiac rehabilitation (CR) programs influences sedentary behaviour particularly among those patients expected to be at greatest mortality risk. This study examined the influence of CR participation on sedentary behaviour and identified the proportion and characteristics (socio-demographic and clinical) of patients who do not meet exercise recommendations and have prolonged sedentary times.

METHODS

A prospective study was conducted among patients of an exercise-based CR program and assessments performed at baseline and 3 months. Physical activity and sedentary behaviour information were collected by self-report, and convergent validity was examined on an accelerometer-wearing subsample.

RESULTS

Of 468 CR patients approached, 130 participants were recruited with an average sedentary time of 8hours/day. Sedentary behaviour remained consistent at follow-up (relative change= -2.4%, P=0.07) notwithstanding a greater proportion meeting exercise recommendations (relative change= 57.4%). 19.2% of participants were classified to have prolonged sedentary time and not meet exercise recommendations at baseline. No significant differences were found between the characteristics of high-risk individuals and lower risk subgroups. Findings were consistent among the accelerometer-derived subgroup and the overall sample despite poor to moderate convergent validity.

CONCLUSIONS

These results suggest that the exercise-focus of CR may not reduce sedentary behaviours. Future studies are needed to determine whether sedentary behaviour-specific reduction strategies are more effective than traditional exercise-based strategies and lead to meaningful improvements in clinical outcomes.