Modified vertical osteotomy cut in bilateral sagittal split osteotomy

Bilateral sagittal split osteotomy (BSSO) is the most common orthognathic surgical procedure for the correction of facial deformities. Like any other surgical procedure, it is also associated with a risk of complications. One of these is described in the literature as notching at the lower inferior border of the mandible. Such discontinuity in the contour of the lower border is often a concern for patients. To overcome this complication, we recommend a modified vertical osteotomy cut while performing BSSO.

Functional Outcome and Complications in Management of Proximal Humerus Fractures Operated with Proximal Humerus Locking Plate

Introduction:

Controversies exist in treatment of proximal humerus fractures as treatment options vary greatly from conservative management, closed pinning, stacked intramedullary nails, plating and hemi-arthroplasty. The purpose of this study is to study the fracture patterns of each case and document the functional outcome and complications post-operative in the management of proximal humerus fractures operated with proximal humerus plate.

Material and Methods:

Thirty five patients with closed proximal humerus fractures, above 18 years old, admitted in our tertiary care hospital during the study period were enrolled. Patients underwent open reduction internal fixation with proximal humerus locking plate under general anaesthesia. Post-operative patients were assessed using Constant and DASH scores. Complications were recorded.

Results:

In our study the absolute Constant score of the study population increases at three months and six months and was found to be significant. Mean Constant score for 4-part fractures was 45.6 which were inferior as compared to 2-part and 3-part fractures (43.1 and 44.6, respectively). The mean Constant score at six months was 51.80 +/- 6.71. All three types of proximal humerus fractures showed significant improvement in the mean DASH score over our study period of six months and was found to be significant. Mean DASH score at six months was 27.97+/-12.84. Out of the 35 cases in the study two had complications. One had implant failure (Neer’s type 3, 60-year-old female) and one had varus collapse (Neer’s type 3, 45-year-old male).

Conclusion:

Due to angular stability and effective maintenance of the intraoperative fracture reduction during follow-up period, early post-operative mobilisation is possible which helps the patient to attain better shoulder range of motion and return to activity faster.

Supersaturated LFCS type III self-emulsifying delivery systems of sorafenib tosylate with improved biopharmaceutical performance: QbD-enabled development and evaluation

The current studies investigate the application of quality by design-enabled type III self-emulsifying delivery system (Type III-SEDDS) of sorafenib tosylate (SFN) in improving its biopharmaceutical attributes. Initially, lipidic and emulsifying excipients were selected by carrying out solubility and phase titration experiments. After screening studies using Taguchi OA design, Type III-SEDDS were further optimised using D-optimal mixture design. The prepared formulations were assessed for globule size, zeta potential and percent of drug release. Following graphical optimisation, the optimum formulation was earmarked and further supersaturated to form saturated Type III-SEDDS (Sat-Type III-SEDDS) using a combination of HPMC and PVP to improve the stability of the formulation for a prolonged period. In vitro drug release of Type III-SEDDS study indicated approximately 8-fold improvement in dissolution rate over the pure powder drug. Cell uptake studies demonstrated higher uptake of dye-loaded Type III-SEDDS formulations in Caco-2 cells vis-à-vis plain dye. Cytotoxicity assay on Hep G2 cells revealed significant reduction in cell growth with Type III- and Sat-Type III-SEDDS vis-à-vis the pure drug. Furthermore, in situ permeation studies carried out using Wistar rats exhibited nearly 8.3- to 10.2-fold augmentation in permeation and absorption parameters of the drug from the Type III- and Sat-Type III-SEDDS, respectively, vis-à-vis the pure drug. Pharmacokinetic studies indicated nearly 3.98- and 3.62-fold improvement in AUC_0-72, and 8.01- and 5.42-fold in C_max, along with 0.25-fold decrease in T_max of the drug from Type III- and Sat-Type III-SEDDS, respectively, in comparison with the SFN suspension. Furthermore, high degree of level A linear correlation was established between fractions of drug dissolved (in vitro) and of drug absorbed (in vivo) at the corresponding time points for Sat-Type III-SEDDS and pure drug, whereas the Type III-SEDDS exhibited a nonlinear relationship. Stability studies indicated the robustness of Sat-Type III-SEDDS, when stored at 25 °C for 3 months. Overall, the manuscript documents the successful systematic development of SFN-loaded Sat-Type III-SEDDS with distinctly improved biopharmaceutical performance. Graphical abstract.

Absence of Meckel Cave: A Rare Cause of Trigeminal Neuralgia

Trigeminal neuralgia is a debilitating condition with numerous etiologies. In this retrospective case series, we report a cohort of patients with a rarely described entity, absence of Meckel cave, and propose this as a rare cause of trigeminal neuralgia. A search of the electronic medical record was performed between 2000 and 2020 to identify MR imaging reports with terms including "Meckel's cave" and "hypoplasia," "atresia," "collapse," or "asymmetry." Images were reviewed by 2 blinded, board-certified neuroradiologists. Seven cases of the absence of Meckel cave were identified. Seven patients (100%) had ipsilateral trigeminal neuralgia and ipsilateral trigeminal nerve atrophy, suggesting an association between absence of Meckel cave and trigeminal neuralgia. Absence of Meckel cave is a rare entity of unknown etiology, with few existing reports that suggest the possibility of an association with trigeminal neuralgia. Its recognition may have important implications in patient management. Future studies and longitudinal data are needed to assess treatment outcomes and added risks from surgical intervention in these patients.

Systematically designed chitosan-coated solid lipid nanoparticles of ferulic acid for effective management of Alzheimer's disease: A preclinical evidence

Ferulic acid (FA) is a ubiquitous natural plant bioactive with distinctive promise in neurodegenerative disorders. However, its therapeutic efficacy gets compromised owing to its poor aqueous solubility, inadequate permeability across lipophilic barriers, and extensive first-pass metabolism. The current studies, therefore, were undertaken to systematically develop chitosan-coated solid lipid nanoparticles (SLNs) using QbD paradigms for improved efficacy of FA in the management of Alzheimer's disease (AD). SLNs of FA were formulated employing Compritol as lipid and polysorbate 80 as surfactant and optimised using a 3² Central Composite Design (CCD). The optimized formulation, surface-coated with chitosan using ionic gelation, exhibited particle size of 185 nm, entrapment efficiency of 51.2 % and zeta potential of 12.4 mV. FTIR and DSC studies verified the compatibility of FA with formulation excipients, PXRD construed significant loss of drug crystallinity, while FESEM depicted existence of uniform spherical nanoparticles with little aggregation. Notable improvement in ex vivo mucoadhesion and permeation studies using goat nasal mucosa, coupled with extension in in vitro drug release, was obtained with SLNs. Substantial improvement with SLNs in cognitive ability through the reduction in escape latency time during behavioural studies, together with significant improvement in various biochemical parameters and body weight gain was observed in AD-induced rats. Histopathological images of different rat organs showed no perceptible change(s) in tissue morphology. Overall, these preclinical findings successfully demonstrate improved anti-AD efficacy, superior nasal mucoadhesion and permeation, extended drug release, improved patient compliance potential, safety and robustness of the developed lipidic nanoconstructs of FA through intranasal route.

A proposed "Radiological Evaluation Score for Bone Tumors" (REST): An objective system for assessment of a radiograph in patients with suspected bone tumor

BACKGROUND

Although radiographs have been widely used in the evaluation of patients with suspected bone tumors, the lack of an objective radiological assessment method leads to a challenge in reaching correct diagnosis. The study aimed to propose a Radiological Evaluation Score for Bone Tumors (REST) which includes eight radiological factors [characteristics, content, cortical breach, distinctiveness, distribution, periosteal reaction, fracture, and soft tissue swelling] to form a single score along with its validation by multidisciplinary observers.

METHODS

We reviewed the radiographs of 100 patients with a primary bone tumor which were selected at random from the database between January 2017 and January 2019 of a tertiary cancer center. Four reviewers (two orthopedic oncologists and two surgical oncologists) independently assessed the radiographs, based on the reporting system of REST. We constituted two groups according to the probable diagnosis of bone tumor (suspected benign tumor and suspected malignant tumor).

RESULTS

The mean score in the suspected benign tumor group was 1.1 (range 0-3, 95% CI 0.8-1.3) and in malignant tumor group was 6.1 (range 2-8, 95% CI 5.8-6.4). A receiver operator characteristic (ROC) curve for REST was with a cutoff of 3.5, with the most diagnostic value area under curve (AUC) of 0.99. The sensitivity was 98% and specificity was 100% with a positive predictive value of 100% and a negative predictive value of 98%. The inter-observer correlation coefficient was 0.985 (p value < 0.05), and Fleiss kappa value for the prediction of the benign or malignant lesion was 0.97 (p value < 0.05). The characteristics and content of tumor, cortical erosion, distinctiveness, distribution, periosteal reaction, and soft tissue mass had a significant correlation with the aggressiveness of bone lesion p value < 0.05.

CONCLUSIONS

The Radiological Evaluation Score for Bone Tumors (REST) is a structured reporting and objective method for the assessment of radiographs in patients with suspected bone tumors. This method is a reliable and helpful tool for clinicians in their outdoor patient department to differentiate a radiograph of a suspected benign tumor from a malignant bone tumor.

935 Stridor in Multiple System Atrophy: An Otolaryngologist Perspective

Background

Bilateral vocal cord paralysis is a rare emergency presentation for Parkinson's disease (PD) but an acknowledged complication of an atypical rarer form of PD called Multi system atrophy ( MSA). MSA is a neurodegenerative disorder comprising of autononic failure, cerebellar ataxia and parkinsonism. An early occurence of stridor can indicate a shorten survival and quality of life remains uncertain. Airway definitive management of this patient group can pose a dilemma for the Otolaryngologist who may be asked to provide a specialist opinion.

Case: We present a case of a 73 year old female who developed mild stridor, hours after an emergency right sided hemiarthroplasty. On day 23 of her admission, there was a sudden airway deteoriation. The otolaryngology and anasthetic emergency team stablised her conservatively with an option of non invasive ventilation. Bilateral vocal cord palsy was observed on nasendoscopy On day 27, she was eventually diagnosed with MSA and showed partial response to a trial of madopar. Both options of a tracheostomy and laser cordotomy were avoided. She was safely discharged with follow up.

Conclusions

There remains gaps in the literature towards an unaminous consensus on stridor management in MSA patients. However, raising awareness of this patient groups will strenghten decision making processes.

Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall

BACKGROUND

Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort.

METHODS

Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres.

RESULTS

The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort.

CONCLUSION

A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

P18: CONVENTIONAL DUPUYTREN'S DIATHESIS FACTORS ARE NOT ASSOCIATED WITH POOR OUTCOME FOLLOWING SURGERY: A SYSTEMATIC REVIEW

Introduction

Dupuytren's diathesis describes an aggressive disease course with tendency for recurrence or extension following intervention. Conventional factors associated with Dupuytren's diathesis are ethnicity, family history, bilateral and ectopic disease. Disease recurrence is not the only cause of poor outcome following intervention. This systematic review aimed to identify all factors that have been investigated for a potential association with the development, progression, recurrence and outcome of treatment in Dupuytren's diathesis.

Method

A systematic review of MEDLINE, EMBASE and CINAHL using a PRISMA-compliant methodology up to February 2019 was conducted. Abstract screening and data extraction were performed in duplicate. Included prognostic cohort studies were quality assessed using the Quality in Prognosis Study tool.

Result

The search revealed 2,661 records from which 11 full text articles reported both conventional diathesis factors and outcomes (in addition to recurrence) following intervention for Dupuytren's in 938 patients. Collectively 67% underwent fasciectomy and seven outcomes were reported: three patient reported outcome measures (DASH, quick-DASH and EQ-5D), three functional measures (grip strength, joint angle correction and range of motion) and treatment complications. Two studies used multiple univariate statistical techniques and found no significant association between diathesis factors and disease outcome.

Conclusion

This systematic review challenges conventional notions of Diathesis factors and provides a comprehensive appraisal of factors associated with poor outcome following intervention for Dupuytren's disease.

Take-home message

Conventional factors associated with recurrence in Dupuytren's disease are not associated with poor outcome following intervention.

A99 OPTIMIZING COLONOSCOPY PROCEDURES AND REDUCING PATIENT ANXIETY THROUGH RECENTLY DEVELOPED ONLINE INFORMATION RESOURCES

Background

Invasive medical procedures such as colonoscopies are known to cause psychological distress and anxiety. Patient anxiety leads to reduce patient compliance for colonoscopy and increased adverse effects. Patient education prior to colonoscopy has previously been shown to have positive effects on outcomes and experience. Based on patient and provider input, we have developed easy to read written materials and easy to follow video materials, which other patients have rated highly. These, along with other materials, are embedded on Mycolonoscopy.ca. Mycolonoscopy.ca is a website that provides online information access for patients regarding preparation and peri-procedural expectations. Information about accessing the website is provided with appointment materials (which includes information about split-dose versus one day bowel preparation, giving patients the option between the two) mailed to all patients undergoing outpatient colonoscopy in Winnipeg.

Aims

(1) To evaluate the current use of mycolonoscopy.ca among patients undergoing colonoscopy (2) To determine whether there is an association between visitation to the website and patient outcomes such as reduction in procedural anxiety, bowel preparation tolerance/compliance, and bowel preparation score.

Methods

A paper-based survey was given out to patients at their colonoscopy appointments. Univariate and multivariate logistic regression analyses was performed to determine the factors associated with website visitation and association with procedural anxiety, bowel preparation compliance and bowel preparation scores.

Results

A total of 593 participants were given the surveys, of which 506 were completed. 17.4% of participants had visited the website prior to their colonoscopy. Visitors to mycolonoscopy.ca and those that had heard of the website were more likely to consume a split-dose bowel preparation (63.9% and 68.2% respectively) compared with non-visitors (52.5%) (p=0.0062). Individuals who consumed split-dose bowel preparation had a median Boston bowel preparation score of 9, compared with a score of 7 for individuals who used other forms of preparation (p&lt;0.0001). 31.3% of website visitors were very or extremely worried about their colonoscopy compared with 17.9% of non-visitors. 76.6% of individuals agreed or strongly agreed that visiting the website helped them prepare for their colonoscopy and 69.7% who visited the website agreed or strongly agreed that it helped to reduce their stress/anxiety for the procedure as well.

Conclusions

Our study suggests that use of an informative online platform such as mycolonoscopy.ca can help to improve patient education prior to colonoscopy, reduce anxiety and stress surrounding the procedure, and improve bowel preparation compliance and bowel cleansing score.

Funding Agencies

CAG

A136 LIVING ON THE EDGE: EUS-DIRECTED TRANSGASTRIC ERCP (EDGE) IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS ANATOMY

Background

Roux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EUS-directed transgastric ERCP (EDGE), is an entirely endoscopic approach which involves accessing the excluded stomach to facilitate conventional ERCP.

Objectives

To describe the results of EDGE procedures performed in two centres in British Columbia.

Aims

To describe the results of EDGE procedures performed in two centres in British Columbia.

Methods

Data were collected from five patient cases who had undergone an EDGE procedure at Victoria General Hospital (4) or Vancouver General Hospital (1) in British Columbia from 2019 to 2020. All patients had a history of RYGB bariatric surgery. In each of the procedures, a 20 mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS-guidance to allow access from the gastric remnant or proximal jejunum to the excluded stomach. Subsequently, during a separate procedure 4 to 28 days later, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was removed 0 to 38 days later and replaced with a double pigtail stent to facilitate controlled closure of the gastro-jejunal or gastro-gastric fistula.

Results

Of the five cases included in the case series, 4 patients underwent EDGE for treatment of choledocholithiasis and one patient underwent the procedure for gallstone pancreatitis. The technical success rate of the EDGE procedure in the five cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all of the cases. There were no adverse events related to the EDGE procedure in these five cases.

Conclusions

The results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery.

Funding Agencies

None