Ethnobotanical and ecological study of Punica granatum in Dir district, Khyber Pakhtunkhwa, Pakistan

Punica granatum L. (wild) belongs to family Punicaceae, a woody plant, predominantly found on calcareous and alkaline soils. The species is extensively utilized as food and firewood and for the extraction of various chemicals due to its therapeutic properties. To understand the ethno-botanical and ecological status of the species on a regional scale, a questionnaire survey was conducted in the Dir (L) area using close and open-ended questionnaires. Data collected from 124 respondents were analysed quantitatively using statistical analysis to calculate indices like Relative Frequency of Citation (RFC), Use value (UV) and multivariate analysis. GPS data used for the presence data of the plants were used to develop GIS thematic maps. Geo-referenced data on P. granatum was collected from the study area, using GPS. Results suggest that the plant is mostly used as a remedy for dry cough, as an astringent, people used powder form of fruit peelings. It was documented in the present investigation that P. granatum is mainly eradicated due to its extensive use as firewood. The study also evaluated on the major aspect of how the P. granatum can be conserved naturally. It was found out that the plant is conserved in areas inaccessible to humans. The status of the vegetation community around this plant was also explored, it is found out that specific shrub and tree communities were major flora growing in proximity to P. granatum. The finding of this survey has concluded that wild P. granatum is an endangered species due to its extensive and uncontrollable use for firewood, curing diseases and its economic potential. These findings could be exploited to take necessary steps for the conservation of this species. 

Tissue Engineering in Achilles Tendon Reconstruction: A Systematic Review of Preclincal Studies

BACKGROUND

Tissue engineering is now being used in Achilles tendon (AT) repair in animal models. There are many preclinical studies that have used different types of stem cells for AT repair. However, there are no systematic reviews that evaluate all these studies to see which type of stem cell provides the most improvement for AT repair in animal models. Sahni V et al.,(1) divided the multiple stem cell types into three broad categories; Tendon derived stem cells (TDSCs), mesenchymal stem cells (MSCs) and embryonic stem cells (ESCs). These three categories have been used in this systematic review to group the different stem cell types together and to also see which category of stem cells provide superior enhancement of AT repair.

METHOD

All studies that have focused on using different types of stem cells in animal models for AT repair and have also included an outcome measure to identify any improvement made with stem cells have been included in this systematic review. Online published articles from 1946 to January 2016 were searched using Ovid MEDLINE (R) and PubMed databases.

RESULTS

Of the 181 articles found and assessed for eligibility, 15 articles met predefined selection criteria and were included in this systematic review. Stem cells can either augment current methods of surgical repair or can provide an alternative route for tendon regeneration because of their unique ability of improving histological characteristics and biomechanical properties.

CONCLUSION

This systematic review shows that stem cells can provide an improvement in AT repair in animal models. Histological analysis of the tendon tissue as well as biomechanical tests such as ultimate failure load have been used to show this improvement in AT repair. Nevertheless, we do not know which type of stem cell, from the three broad categories, provides a superior enhancement of AT regeneration in animal models. Our results underscore a need for a head-to-head comparison of the different types of stem cells used in AT repair with or without current methods of surgical repair.

Stress fractures of the foot and ankle

Stress fractures occur as a result of microscopic injuries sustained when bone is subjected to repeated submaximal stresses. Overtime, with repeated cycles of loading, accumulation of such injuries can lead to macro-structural failure and frank fracture. There are numerous stress fractures about the foot and ankle of which a trauma and orthopaedic surgeon should be aware. These include: metatarsal, tibia, calcaneus, navicular, fibula, talus, medial malleolus, sesamoid, cuneiform and cuboid. Awareness of these fractures is important as the diagnosis is frequently missed and appropriate treatment delayed. Late identification can be associated with protracted pain and disability, and may predispose to non-union and therefore necessitate operative intervention. This article outlines the epidemiology and risk factors, aetiology, presentation and management of the range of stress fractures in the foot and ankle.

Combined Intracapsular And Extracapsular Neck Of Femur Fractures Case Series, Literature Review And Management Recommendations

Concomitant ipsilateral intracapsular and extracapsular fractures of the femoral neck are rare injuries with only 14 cases described in the literature as single case reports. We present three cases that were successfully and uniquely treated by uncemented hip arthroplasties. Two patients underwent complex primary uncemented total hip replacements, and one patient underwent an uncemented bipolar fluted stem hemiarthroplasty. The level of bearing constraint varied between implants. After describing our cases we review the literature and make recommendations on the management of these injuries. We believe that these are significant injuries and best functional results can be achieved with an early diagnosis and patient-specific approach that can include a total hip replacement in appropriate cases.

Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis

BACKGROUND

No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS).

AIM

To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates.

METHODS

Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014-April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR.

RESULTS

Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001).

CONCLUSION

This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.

A Systemic Review of Adult Mesenchymal Stem Cell Sources and their Multilineage Differentiation Potential Relevant to Musculoskeletal Tissue Repair and Regeneration

BACKGROUND

Adult mesenchymal stem cells (MSCs) were first isolated from bone marrow by Friedenstein in 1976. These cells were clonogenic, non-haematopoietic, and able to replicate extensively in vitro. The fields of regenerative medicine and tissue engineering have grown dramatically since their inception. In the decades since, MSCs have been identified from mesoderm-, endoderm- and ectoderm-derived tissues. In light of our ageing population, the need for effective cell-based therapies for tissue repair and regeneration is ever-expanding.

OBJECTIVES

The purpose of this systematic review was to summarise evidence from the most recent studies outlining different sources of adult MSCs and their suitability in musculoskeletal applications.

METHODS

Online published articles were searched for using the PubMed/MEDLINE and Ovid databases, and relevant articles fulfilling the pre-defined eligibility criteria were analysed.

RESULTS

To date, MSCs have been isolated from a number of adult tissues, including trabecular bone, adipose tissue, bone marrow, synovium, dermis, periodontal ligament, dental pulp, bursa and the umbilical cord. Bone marrow MSCs are currently considered the gold standard, with which newly discovered sources are compared on the basis of their renewal capabilities and multipotency. Furthermore, MSCs have been successful in the regeneration of osteonecrosis, osteoarthritis, bony defects, fracture remodeling and so on.

CONCLUSION

Unfortunately, significant hurdles remain and will need to be overcome before tissue engineering using MSCs becomes routine in clinical practice. Thus, further research and understanding are required into the safe and effective sourcing and application of mesenchymal stem cells in musculoskeletal applications.

Coronal Knee Alignment 40 Years after Total Meniscectomy in Adolescents: A Prospective Cohort Study

Introduction:

Meniscectomies result in altered knee biomechanics and increase contact forces on the operated knee joint.

Methods:

We assessed coronal knee alignment in relation to radiological osteoarthritis grading, clinical range of movement and patient reported outcome measures 40 years after total open meniscectomies in adolescence. Thirty eight knees (30 patients) that underwent total open meniscectomy were assessed on standardised weight-bearing anteroposterior radiographs for deviation from ‘physiological valgus angle’ in either direction (magnitude of malalignment). These values were analysed as per site of meniscectomy for correlations with radiographic scoring systems, range of motion and patient reported outcome measures.

Results:

Tibiofemoral angle was significantly more varus, and the magnitude of malalignment was significantly higher for the medial meniscectomy patients. The range of flexion was lower for those patients who underwent medial and lateral meniscectomies of the same knee. The patients who underwent meniscectomies of both knees had worse scores for IKDC and KOOS quality of life. Tibiofemoral angle, magnitude of malalignment and range of flexion strongly correlated with Ahlback, and Kellgren and Laurence scores, but patient reported that outcome measures did not correlate.

Conclusion:

Meniscectomy induced malalignment corresponds to the site of meniscectomy and the radiographic degree of osteoarthritis. While malalignment and reduced range of movement correlate well with worsening radiographic signs of arthritis, patient reported outcome measures do not correlate.

Limb reconstruction after traumatic bone loss

A variety of options exist to reconstruct limbs following traumatic bone loss. The management of these injuries is challenging and often requires prolonged and potentially painful treatment. The Ilizarov technique of bone transport using circular external fixators is widely used for limb reconstruction of large bone defects. Other techniques include vascularised fibular grafting, the use of induced pseudosynovial membranes combined with cancellous autologous bone grafts and the use of autologous, allogeneic or synthetic bone grafts on their own for smaller defects. Future directions include further research on bone tissue engineering using stem cell therapy and growth factors such as bone morphogenetic proteins. The purpose of this Continuing Medical Education article is to describe the key limb reconstructive techniques that may be employed to treat traumatic bone loss. In particular, this article is intended to serve as a revision tool for those preparing for postgraduate examinations.

Cell Surface Markers on Adipose-Derived Stem Cells: A Systematic Review

BACKGROUND

Since the discovery and isolation of a mesenchymal stem cell population from within the stromal vascular fraction (SVF) of adipose tissue, there has been a concerted effort to discover the characteristics of these cells. Particular attention has been paid to their morphology, selfrenewal capacity, multi-lineage differentiation capabilities and, as is of greatest interest in this instance, their cell surface profile.

OBJECTIVES

The purpose of this study is to analyze and summarize the available literature that pertains to the cell surface characterization of adipose-derived stem cells (ASCs). The identification of a common set of positive and negative cell surface markers would allow for a much more consistent and reliable method of identifying this stem cell population both in vitro and in vivo.

SEARCH METHODS

The keywords "adipose-derived stem cells; stromal cells; surface markers" were searched in the following electronic databases: Medline, PubMed, ZETOC, Web of Knowledge, AMED, EMBASE, Ovid in process & other non-indexed citations and PsychINFO.

RESULTS

The most commonly reported positive markers were found to be CD90, CD44, CD29, CD105, CD13, CD34, CD73, CD166, CD10, CD49e and CD59, while the most commonly found negative markers were CD31, CD45, CD14, CD11b, CD34, CD19, CD56 and CD146. In addition, a number of other markers appeared in the literature including HLA-ABC, HLA-DR, SH2, SH3, STRO-1, VEGF2, vWF, ABCG2, SSEA-1 (CD15), PDGFR, alpha- SMA, c-Kit (CD117), OCT4+ and CCR5X (CD195).

CONCLUSION

A minimum panel of positive and negative markers for identifying ASCs can be recommended. The following markers should be positive: CD90, CD44, CD29, CD105, CD13, CD34, CD73, CD166, CD10, CD49e and CD59. The following markers should be negative: CD31, CD45, CD14, CD11b, CD19, CD56 and CD146. In addition to this, the positive expression of HLA- ABC and STRO- 1 should be seen along with the negative expression on HLA-DR. This review, however, has also found that there are a number of disagreements over the expression and existence of various markers, namely CD31, CD34, c- Kit (CD117) and STRO-1.

The biplanar open wedge high tibial osteotomy preserving the tibial tubercle

BACKGROUND

High tibial osteotomy (HTO) is a treatment option for relatively young patients with isolated medial compartment arthritis of the knee. Medial open wedge osteotomies allow easier control of correction, but can lead to patella infera as a result of distalization of the tibial tubercle. This retrospective study reports results of a biplanar tibial tubercle preserving HTO, designed to preserve patellar height.

METHODS

The study is a retrospective analysis of 12 consecutive patients (11 men, 1 woman) average age 39.6 years who underwent the procedure between 2009 and 2012. A biplanar open wedge tibial osteotomy was performed and stabilised with a medial locking plate. Patients were allowed full weight bearing at 6 weeks. Preoperative and postoperative function was recorded on the Oxford knee score, Lysholm score and Tegner activity scale. Minimum follow up was 26 months.

RESULTS

All patients had healing of the osteotomy with no delayed union. Eleven patients reported improvement in symptoms with an average preoperative Oxford score of 26 and postoperative score of 39 out of 48. The Lysholm score improved from 58 to 72 out of 100. There was one point improvement in Tegner activity scale. There was no statistical difference in patellar height before and one year after surgery. The correction in varus averaged 8.3°.

CONCLUSION

The biplanar High tibial Osteotomy allows preservation of patellar height, while achieving desired varus correction.

Capacity of the national influenza surveillance system in Afghanistan, a chronic conflict setting

Influenza surveillance is needed to monitor potential public health threats from the emergence of novel influenza viruses. This study assessed the capacity and performance of the national influenza surveillance system in Afghanistan from 2007 to 2014. Data were collected by review of hospital registers and the National Influenza Centre (NIC) database, interviews with influenza focal points at 9 influenza sentinel surveillance sites and the Centre staff, and observation of the sites. Out of 6900 specimens collected, influenza virus was detected in 253 (3.6%), predominantly H1N1 (63%); most of these cases were detected during the 2009 pandemic. The NIC had the capacity for virus isolation and PCR identification and performed reasonably until 2011 when support of the Naval American Medical Research Unit 3 was withdrawn. The limitations identified in the system indicated the need for: more complete data, improved technical competence and trained human resources, updating of the infrastructure/facilities, and the presence of standard operating procedures throughout surveillance.

Characteristics of severe acute respiratory infectionassociated hospitalization in Yemen, 2014/15

This study aims to describe etiological agents, demographic details of patients, seasonality and underlying conditions among patients hospitalized due to viral severe acute respiratory infection (SARI) in Yemen. We carried out a retrospective descriptive analysis of data from January 2014 to December 2015. Nasopharyngeal swabs were taken from each patient for laboratory testing. A total of 1346 diagnostic specimens were tested, of which 733 (54%) were positive for influenza viruses. Influenza A(H3) and A(H1N1) pdm09 predominated. Respiratory syncytial virus (RSV) was reported predominantly among children (41%). Males (61%) were more affected than females. The median age was 1 year (range 0.5-94.0). The median length of hospitalization was 6 days. Chronic cardiovascular disease was the most commonly reported underlying condition, but 67% had no documented underlying disease. Respiratory viruses, particularly RSV, adenovirus and influenza, were commonly associated with hospitalization for SARI.

The H1N1 influenza pandemic of 2009 in the Eastern Mediterranean Region: lessons learnt and future strategy

A novel strain of influenza A virus H1N1 surfaced in Mexico in April 2009 and quickly spread across the globe, turning an epidemic into a pandemic. Within two months, the World Health Organization (WHO) declared an international health emergency and raised the threat bar from level V to level VI, i.e. containment to mitigation. During this time, the WHO Regional Office for the Eastern Mediterranean worked closely with its Member States, other stakeholders and WHO headquarters to manage the situation. This report examines the steps taken as part of this response. Programme documents were reviewed and key personnel interviewed for this study. A hallmark of the response was the establishment of the Strategic Health Operations Centre to bring together experts from different technical backgrounds at regional level. Several lessons were learnt that can provide the basis for standard operating procedures, protocols and guidelines for emergency events in future.

Burden of acute respiratory disease of epidemic and pandemic potential in the WHO Eastern Mediterranean Region: A literature review

There are gaps in the knowledge about the burden of severe respiratory disease in the Eastern Mediterranean Region (EMR). This literature review was therefore conducted to describe the burden of epidemicand pandemic-prone acute respiratory infections (ARI) in the Region which may help in the development of evidence-based disease prevention and control policies. Relevant published and unpublished reports were identified from searches of various databases; 83 documents fulfilled the search criteria. The infections identified included: ARI, avian influenza A(H5N1), influenza A(H1N1)pdm09 and Middle East respiratory syndrome coronavirus (MERS-CoV) infection. Pneumonia and ARIs were leading causes of disease and death in the Region. Influenza A(H1N1) was an important cause of morbidity during the 2009 pandemic. This review provides a descriptive summary of the burden of acute respiratory diseases in the Region, but there still remains a lack of necessary data.

Middle East respiratory syndrome coronavirus: current knowledge and future considerations

A literature review of publically available information was undertaken to summarize current understanding and gaps in knowledge about Middle East respiratory syndrome coronavirus (MERS-CoV), including its origin, transmission, effective control measures and management. Major databases were searched and relevant published papers and reports during 2012-2015 were reviewed. Of the 2520 publications initially retrieved, 164 were deemed relevant. The collected results suggest that much remains to be discovered about MERS-CoV. Improved surveillance, epidemiological research and development of new therapies and vaccines are important, and the momentum of recent gains in terms of better understanding of disease patterns should be maintained to enable the global community to answer the remaining questions about this disease.

Contribution of laboratories in the WHO Eastern Mediterranean Region to the selection of candidate seasonal influenza vaccine, 2010-2015

The World Health Organization (WHO) formulates recommendations for viruses to be included in vaccines for the influenza seasons in the northern and southern hemispheres on the basis of analyses by its collaborating centres (CCs). This report describes the contribution of influenza laboratories and national influenza centres in countries in the WHO Region for the Eastern Mediterranean to the selection process of seasonal and pre-pandemic influenza virus subtypes. Data submitted by 22 countries to FluNet and FluID between September 2010 and June 2015 were analysed. National Influenza Centres (NICs) in 12 countries (55%) reported data, 5 (23%) to both FluNet and FluID and 7 (32%) only to FluNet. The WHO CC in London characterized 78% of the samples, and the CC in Atlanta, characterized 21%. The contribution of influenza laboratories and NICs from this Region to global influenza surveillance is appreciable. However, enhancing the contribution through initiatives such as the Pandemic Influenza Preparedness Framework is still needed.

Adult native knee extensor mechanism ruptures

Extensor mechanism rupture is a serious event requiring prompt diagnosis and treatment. Patella fractures are reportedly six times more frequent than soft tissue injuries such as quadriceps or patella tendon ruptures. Classically quadriceps and patella tendon ruptures are seen more in males, with those over 40 predominantly suffering from quadriceps tendon ruptures, often associated with an underlying condition, whereas patella tendon ruptures are mostly associated with sport injuries and are commonly seen in the under 40s. Almost all types of extensor mechanism ruptures benefit from early management which typically involves surgery. Diagnosis can be deemed easy to make by demonstrating inability to actively extend the knee, this however can be easily overlooked and missed in a busy emergency department leading to a late diagnosis and necessitating more complex surgery. Earlier surgical intervention and rehabilitation tend to produce improved outcomes.

Can 'Hot Spotting' Prove to be a Useful Tool to Identify Disproportionate ED Use in the Rural General Hospital Setting?

'Hot spotting' allows the identification of areas with disproportionate use of Emergency Department (ED) services. To date, 'hot spotting' has focused on large urban centres. The aim of this study was to determine if there are geographic hotspots for ED use in the rural general hospital. ED attendances were logged between 1st July 2013 and 30th June 2014. Frequent users and super users were isolated. Addresses were cross referenced against national census data to determine number of users per 500 population in geographically distinct regions. The number of frequent users ranged from 1.00/500 population to 4.88/500 population. Four out of nineteen areas had > or equals; 4 frequent users per 500 population. There was no correlation between number of users and distance from MGH (p=0.44). 77% of frequent users presented with mixed aetiologies. Nineteen percent of frequent attenders presented via GP referral only, 13% attended via self-referral only and 88% attended via GP and self-referral routes.