Knowledge of surgeons and practical stances of healthcare institutions in the Ile-de-France region toward sustainable development: A cross-sectional study

PURPOSE OF THE STUDY

Climate change represents one of the gravest threats to health. Surgical activities mobilize a large number of resources which contribute to increased emission of CO2 and anesthetic gases in the environment. The objective of this study was to assess the level of knowledge of surgeons and the practical stances of healthcare establishments toward sustainable development.

METHODS

This was a descriptive cross-sectional study, lasting 2 months. From 1 May 2021 to 30 June 2021, surgeons were asked via an online questionnaire to participate.

RESULTS

A total of 131 out of the 457 contacted surgeons responded. A majority practiced in the private sector, 48.9% knew little about the rules of sustainable development in operating theaters, and 43.5% had an average level. The sustainable development charter was available in only 23% of establishments, while 19% had a sustainable development committee, and specific sustainable development actions were carried out in 27%.

CONCLUSION

The level of knowledge of surgeons in Île-de-France on sustainable development was low. In general, surgical units were not complying with the rules of good practice on CO2 reduction. It is necessary to find strategies to reduce the impact of operating theaters on the environment.

Lower Intraoperative and Immediate Postoperative Complications in Robotic Versus Conventional Primary Total Hip Arthroplasty: A Retrospective Cohort Analysis of Over 360,000 Patients

PURPOSE

Although a trend of an improved alignment with robotic total hip arthroplasty (THA) over conventional methods has surfaced from recent series, it is unknown whether these results translate into meaningful enhancements in postoperative outcomes. To address this lack in the literature, we compared the perioperative morbidity and mortality with robotic and conventional THA in a large national cohort of 367,894 patients. We hypothesized that no significant differences would exist in the outcomes between the two groups.

METHODS

Records were extracted from 2016-2019 from the National Inpatient Sample (NIS) database Healthcare Cost and Utilization Project which is the largest in-patient database in the United States. From 367,894 THAs, robotics were employed for 7,863 patients. The remaining 360,031 conventional THAs served as controls. The two groups were compared for demographics, admission, and hospital stay details including costs, and mortality and morbidity data including medical and surgical complications. Descriptive statistics were used for demographic data while analytical statistics including t-tests, chi-squared tests, Fischer exact test, and Pearson chi-squared tests were used for perioperative outcomes. Statistical significance was set at p<0.005.

RESULTS

Demographic distributions between robotic and conventional THA groups displayed similar age and sex characteristics. Shorter mean lengths of stay (1.87 days) were seen in robotic THA versus conventional THA (2.33 days) while higher costs were noted for the former (mean $68,686.71 vs $66,840.39) (p<0.005). Low overall mortality (0.03% robotic, 0.09% conventional) was seen in both groups (p>0.005). Higher comparative incidences of anemia, acute renal failure, and pneumonia were seen in conventional THA (p<0.005) while no significant differences were noted for other complications including myocardial infarction, pulmonary embolism, deep vein thrombosis, and cardiac arrest (p>0.005). Among others, lower dislocation rates, mechanical complications, periprosthetic joint infection, and periprosthetic fractures were seen with robotic THA (p<0.005). Wound complications and superficial infection rates did not differ between the two groups (p>0.005).

CONCLUSIONS

Evidence has emerged from our results to support more routine adaptation of the robotic option of performing a THA. These can be based on lower local, systemic, and mechanical complications as demonstrated by the present study. Further evaluation of these results in follow-up would help establish the foothold of robotic surgery in total hip replacement in the modern context.

Maximum outcome with minimal resources: report of a multiligamentous knee injury managed with 'modified confluent tunnel technique'

Multiligamentous knee injuries (MLKIs) are rare and challenging to manage in many aspects. The injury requires prompt diagnosis, reconstruction of multiple ligaments, and management of associated neurovascular injuries. Another important aspect that surgeons should consider is resource availability. Successful management of a case of MLKI using the cost-effective 'modified confluent tunnel technique' is described in this case report. We used confluent tunnels for intra- and extra-articular ligament reconstructions at the femoral side. We incorporated the weave technique for medial collateral ligament (MCL) reconstruction, and Larson's technique for posterolateral corner (PLC) reconstruction in this construct, and augmented the anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction with the remaining PLC and MCL grafts, respectively. This was cost-effective and resulted in good functional outcomes. The technique also helped us to avoid tunnel convergence which is an expected complication in MLKI surgeries.

Evaluation of in vitro anticancer potential of pharmacological ethanolic plant extracts Acacia modesta and Opuntia monocantha against liver cancer cells

Abstract Acacia modesta (AM) and Opuntia monocantha (OM) are distributed in Pakistan, Afghanistan and India. Both of these plants have different pharmacological properties. This study was designed to evaluate anticancer potential of Acacia modesta (AM) and Opuntia monocantha (OM). Liver cancer cell line HepG2 was used for assessment of anticancer activity. For the evaluation of anti-proliferative effects, cell viability and cell death in all groups of cells were evaluated via MTT, crystal violet and trypan blue assays. For the evaluation of apoptosis ELISA of p53 performed. Furthermore, LDH assay to find out the ability of malignant cells to metabolize pyruvate to lactate and antioxidant enzymes activity (GSH, CAT and SOD) at the end HPLC was performed to find active compound of AM and OM. Cytotoxicity (MTT), Viability assays (trypan blue, crystal viability, MUSE analysis) showed more dead, less live cells in plant treated groups with increase of concentration. Scratch assay for the anti-migratory effect of these plants showed treated groups have not ability to heal scratch/wound. ELISA of p53 for cellular apoptosis showed more release of p53 in treated groups. Antioxidant assay via glutathione (GSH), superoxide dismutase (SOD), catalase (CAT) showed less anti-oxidative potential in treated cancer groups. LDH assay showed more lactate dehydrogenase release in treated groups compared with untreated. HPLC analysis showed the presence of phytochemicals such as steroids, alkaloids, phenols, flavonoids, saponins, tannins, anthraquinone and amino acids in AM and OM plant extracts. Based on all these findings, it can be concluded that ethanolic extracts of Acacia modesta and Opuntia monocantha have promising anti-cancer potential.

Prevalence, molecular characterization and antibiogram of Mycoplasma bovis isolated from milk in Pakistan

Mycoplasma bovis is a highly contagious pathogen that causes clinical or subclinical mastitis. The present study was aimed for the isolation, molecular characterization and antibiogram determination of M. bovis from raw milk samples. Milk samples were collected randomly from lactating cows and buffaloes from different tehsils of district Faisalabad, Pakistan. Samples were inoculated on modified Hayflick medium and biochemical tests were performed for further confirmation of isolated M. bovis. Out of total 400 milk samples, 184 (46%) samples were found positive for culture method. The 16S-rRNA gene polymerase chain reaction was performed for molecular characterization of isolated M. bovis strains. Out of total 400 milk samples, 240 (60%) positive for M. bovis through PCR method were examined. The 16S-rRNA gene PCR positive isolated M. bovis strains were sequenced and results were compared using Maximum-likelihood method and sequenced strains of M. bovis were aligned and analyzed by Clustal W software. Antibiogram of isolated M. bovis strains was analyzed by disc diffusion assay against eight commonly used antibiotics. Tylosin (30μg) and Tilmicosin (15ug) showed inhibition zones of 32.34 ± 1.10 mm and 17.12 ± 0.93 mm respectively against isolated M. bovis which were found sensitive. Isolated M. bovis was found resistant to other commonly used antibiotics. Statistical analysis revealed that p-value was < 0.05 and the odds ratio was >1.0 at 95% CI. This study complemented the lack of epidemiological knowledge of molecular characterization, comparative effectiveness and resistance trends of isolated M. bovis strains against commonly used antibiotics.

Antimicrobial activity of essential oils of Curcuma longa and Syzygium aromaticum against multiple drug-resistant pathogenic bacteria

The present study was conducted to investigate the antimicrobial potential of essential oils of Curcuma longa and Syzygium aromaticum against multidrug-resistant pathogenic bacteria. Four identified bacterial isolates including Methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Klebsiella pneumoniae, and Acinetobacter baumannii were selected and their antibiotic sensitivity was checked by disc diffusion assay. C. longa and S. aromaticum were subjected to steam distillation to obtain their essential oils. The crude essential oils were fractioned by employing column chromatography. Crude essential oils and their fractions were evaluated for their antibacterial activity by agar well diffusion assay and minimum inhibitory concentrations were calculated. All the selected bacterial isolates showed resistance to three or more than three antibiotic groups and were declared as multidrugresistant (MDRs). Crude essential oils of C. longa and S. aromaticum exhibited antimicrobial activity against all selected isolates but S. aromaticum activity was better than the C. longa with a maximum 19.3±1.50 mm zone of inhibition against A. baumannii at 1.04 µL/mL MIC. GC/MS analysis revealed the abundance of components including eugenol, eugenyl acetate, b- caryophyllene, and a- Humulene in both crude oil and fractions of S. aromaticum. While the main components of C. longa essential oil were Ar-tumerone, a-tumerone, b- Tumerone, I-Phellandrene, a-zingibirene, b- sesquiphellandrene, and p- Cymene. This study highlights that plant-based essential oils could be a promising alternative to antibiotics for which pathogens have developed resistance. C. longa and S. aromaticum carry compounds that have antimicrobial potential against multiple drug-resistant bacteria including MRSA. E. coli, K. pneumoniae and A. baumannii.

When used in animals, a neem (Azadirachta indica)-based ectoparasiticide performs better than a synthetic one

Finding alternate ways to relieve animals from the ectoparasites is one of the most important aspects under One-Health concept. Herbal ectoparasiticides offer a promising alternate to chemical ectoparasiticides. The present study was designed to evaluate the ectoparasiticide efficacy of Nimboliâ (Neem: Azadirachta indica extract) in various animal species, keeping in view the objectives of One-Health. The ectoparasiticide efficacy of Nimboliâ was also compared with a commercial chemical ectoparasiticide Tagafon (Hydroxyethyl Phosporic Acid). Various animals infested with ticks, fleas, lice, flies, and maggots and presented at clinics were treated with Nimboliâ(n=36)and Tagafon (n=19). Mean time taken by each ectoparasiticide to knock-down various ectoparasites was recorded. The present study suggested significantly higher efficacy of Nimboliâ against ticks, fleas, lice, flies and maggots as compared with Tagafon. The mean time taken by Nimboli® to knockdown various ectoparasites of same and different kinds and their larvae was also less compared to the mean time taken by Tagafon. The present study indicated that Nimboliâ is an eco-friendly ectoparasiticide that is safe-to-use both for animals and their handlers, hence can replace chemical ectoparasiticides. The present study highlights the importance of herbal ectoparasiticides, especially those containing neem in the treatment and control of ectoparasites in animals. This information have special relevance for countries that have native neem trees such as Sri Lanka, Pakistan, India, Indonesia, Malaysia, Myanmar, Senegal, and Thailand. Since herbal ectoparasiticides are biodegradable, they offer an added advantage of maintaining ecological health.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

L1 Nerve Root Ganglioneuroma: Surgical Tip on excising this Well-Differentiated and Rarely Appreciated Tumor

Introduction

Ganglioneuroma (GN) is a rare benign tumor of neural crest origin mostly found in the abdomen, but may occasionally present at sites including the cervical, lumbar, or sacral spine. GN of lumbar spine is a rare occurrence.

Case Report

A 52-year-old man presented with GN in the L1 nerve root, who underwent successful resection of the tumor and stabilization of spine using a single posterior approach.

Conclusion

GN should be considered as a differential in any case of paraspinal mass. A high index of clinical suspicion and correlation with radiological findings is necessary in differentiating a large benign tumor from a malignant growth. Complete surgical excision is the treatment of choice; however, the approach to the mass is dictated by the tumor size and location.

AB1409 EVALUATING HOW EFFECTIVELY PATIENTS WITH A NEW INFLAMMATORY ARTHRITIS ARE BEING TRIAGED INTO THE APPROPRIATE CLINIC AT A TERTIARY CARE HOSPITAL IN THE UK: A RETROSPECTIVE AUDIT

Background

Inflammatory arthritis is associated with significant morbidity and costs to the NHS, social care, and wider economy. Early diagnosis and treatment are essential to reduce the impact of the disease. Therefore, it is important that referrals for a new inflammatory arthritis are appropriately triaged to be seen in the early inflammatory arthritis (EIA) clinic so that they can be seen and started on disease modifying anti-rheumatoid drugs (DMARDs) without delay. The British Society of Rheumatology guidance for inflammatory arthritis states that patients must be seen within three weeks of referral and started on DMARDs within six weeks.

Objectives

To evaluate how effectively people referred with a new EIA are currently being triaged.

To evaluate whether we are meeting the national standards.

Methods

We performed a retrospective review of the medical notes of all new patients who were seen in the EIA clinic from 01/09/21-31/11/21. During this same time period, we will also reviewed all the patients who had been newly diagnosed and started on a DMARD in the other Rheumatology clinics (e.g., general rheumatology, vasculitis).

We collected data on referral date, referral source (e.g., GP), date of clinic assessment, clinic type (e.g., EIA clinic or other Rheumatology clinic), diagnoses made, days’ wait from referral to assessment and days’ wait from referral to commencing DMARD.

We then calculated the conversion rate (percentage of referrals triaged to the EIA clinic that have an EIA) and detection rate (percentage of new EIA patients that are seen in the EIA clinic (as opposed to in non-urgent clinics)). The standard for conversation rate (CR) was 50% and for detection rate (DR) was 95%.

Results

Of all the patients seen in the EIA clinic (n=73), 36 had a new diagnosis of an EIA, giving a CR of 49%. Of all the new diagnoses of EIA made during that time-period (n=53), 36 were appropriately triaged to be seen in the EIA clinic, giving a detection rate 68%. Those new referrals who had been appropriately seen in the EIA clinic had an average of 5 weeks wait from referral to assessment/ commencement of DMARD. In contrast, those new referrals who had been seen in other clinics had an average of 10 weeks from referral to assessment/ commencement of DMARD.

A previous audit performed before the COVID-19 pandemic (01/11/19- 01/01/20) showed a CR of 25% (115 patients seen in EIA clinic, 29 new diagnoses) and a DR of 69% (29 new diagnoses, 20 seen in EIA clinic).

Conclusion

Those patients with a new EIA who are appropriately seen in the EIA clinic do not meet the national guidance for being seen within three weeks of referral but do meet the guidance for starting a DMARD withing six weeks. However, those new EIA who are seen outside the EIA clinic do not meet either of these standards, with a delay of 10 weeks to be seen/ started on a DMARD. Given that only 68% of people with a new EIA are being correctly triaged to be seen in the EIA clinics, it highlights that there is a need for an improvement in the triage process (currently being done manually by Rheumatologists). Interestingly, when comparing our findings to the audit done pre-COVID-19 pandemic, the CR has improved whilst the DR has stayed steady. The next steps include exploring using additional data collected from patients electronically to improve the CR/ DR rates, as well as artificial intelligence informed modelling.

Disclosure of Interests

None declared

Photosynthetic acclamatory response of Panicum antidotale Retz. populations to root zone desiccation stress

Growth of plants is severely reduced due to water stress by affecting photosynthesis including photosystem II (PSII) activity and electron transport. This study emphasised on comparative and priority targeted changes in PSII activity due to progressive drought in seven populations of Panicum antidotale (P. antidotale) collected from Cholistan Desert and non-Cholistan regions. Tillers of equal growth of seven populations of P. antidotale grown in plastic pots filled with soil were subjected progressive drought by withholding water irrigation for three weeks. Progressive drought reduced the soil moisture content, leaf relative water content, photosynthetic pigments and fresh and dry biomass of shoots in all seven populations. Populations from Dingarh Fort, Dingarh Grassland and Haiderwali had higher growth than those of other populations. Cholistani populations especially in Dingarh Grassland and Haiderwali had greater ability of osmotic adjustment as reflected by osmotic potential and greater accumulation of total soluble proteins. Maximum H2O2 under water stress was observed in populations from Muzaffargarh and Khanewal but these were intermediate in MDA content. Under water stress, populations from Muzaffargarh and Dingarh Fort had greater K+ accumulation in their leaves. During progressive drought, non-Cholistani populations showed complete leaf rolling after 23 days of drought, and these populations could not withstand with more water stress condition while Cholistani populations tolerated more water stress condition for 31 days. Moreover, progressive drought caused PSII damages after 19 days and it became severe after 23 days in non-Cholistani populations of P. antidotale than in Cholistani populations.

Effect of body mass index on cardiac injury/cardiovascular outcomes in coronavirus disease 2019: a systematic review and meta-analysis

 

Coronavirus disease 2019 has affected millions of people worldwide. Its clinical spectrum ranges from completely asymptomatic to significant respiratory and non-respiratory symptoms leading to critical illness, including death. We aimed to study the effects of body mass index (BMI) on cardiovascular and other critical illness outcomes in these patients in the USA. We conducted a systematic search of three databases for the period of November 2019 to August 2020 and selected 37 studies for analysis. One study showed a non-significant difference in cardiac injury among BMI groups, but there is a paucity of data on cardiovascular outcomes among different BMI groups; hence, meta-analysis was not done for cardiovascular outcomes. Both high BMI and cardiac injury are independent predictors of poor outcomes in these patients. Pooled analysis showed obesity as a significant risk factor for intensive care unit admission (OR=1.547, CI=1.208–1.981, P=0.001) and intubation /mechanical ventilation (OR=1.744, CI=1.363–2.231 P=0.000). Therefore, BMI should be considered an important part of risk stratification, and vaccination should be prioritized for obese patients when it becomes widely available.

Funding Acknowledgement

Type of funding sources: None. Risk of intubation

341 Alder Hey Experience of Paediatric Virtual Fracture Clinic During The COVID-19 Pandemic

Introduction

The SARS-CoV2/COVID-19 pandemic represented an unprecedented emergency prompting a drive to minimise non-essential patient contact and the need for a virtual fracture clinic (VFC); an uncommon practice in paediatric units. Management of paediatric fractures requires a greater degree of vigilance to safeguard children. The current climate has created social challenges that theoretically increase the risk of harm and exploitation to children. This study investigates VFC in the management of paediatric fractures to determine the efficiency of such a process and the risk of safeguarding.

Method

A protocol was devised in affiliation with BSCOS for the immediate management and streamlining of paediatric fractures into VFC. We retrospectively audited 235 VFC consults over a 1-month period. Patient sex was roughly evenly distributed, and age ranged from 9 months to 16 years (mean 8.4 years).

Results

42% of patients were recalled for a face-to-face (F2F) review (26% expedited), primarily for clinical assessment, plaster complaints and imaging requirements. 33% were discharged and 15% continued follow-up in VFC. All clavicle fractures were discharged. Forearm, hand, foot and elbow injuries were more likely to be discharged. Lower leg, upper arm and knee presentations more frequently required a F2F review. 2.3% of cases required safeguarding reviews.

Conclusions

Given the rapid transition to VFC without the use of triage we have determined a number of non-complex fractures safely managed and discharged via VFC. The low percentage of recall due to safeguarding concern highlights this may not be a barrier to the continuation of virtual care outside of the context of a pandemic.

1392 Challenges of Heart Surgery on A Patient with Anorexia Nervosa: A Rare Case Report of The Perilous Effects on The Myocardium

This peculiar case highlights the detrimental effects of Anorexia Nervosa (AN) on myocardial tissue, and the significant impact this can have on surgical outcome.

A 49-year-old female with history of AN presented acutely unwell with confusion, dizziness, deranged electrolytes and metabolic acidosis. She had lost significant weight in the past month with suspected laxative abuse. She required intubation due to extensive bilateral pulmonary effusions and multiple organ failure. Echocardiogram showed appearance of a rheumatic mitral valve with severe stenosis, a mean gradient of 16mmHg and moderate regurgitation.

Urgent surgical intervention to replace the valve was indicated. Following replacement of the mitral valve, torrential bleeding ensued after coming off bypass. This had resulted from a dramatic atrio-ventricular dissociation. Attempts to repair the deficit were hampered by extremely fragile myocardial tissue. Unfortunately, despite extensive efforts to repair the damage and control bleeding, it was ultimately in vain.

Histology of the myocardium in AN patient has revealed evidence of diffuse endocardial and interstitial fibrosis and myxoid material deposition. This case is the first to illustrate the sequelae of AN on myocardial tissue with its subsequent peri-operative impact. Before surgical intervention we suggest that maximal efforts to optimize nutrition should be undertaken pre-operatively, seeking to reverse the structural changes caused by AN. This case highlights the need for further exploration of the effects that a patient’s nutritional status can have on the quality of tissue being operated on.

1376 Latex Allergies: Seeking an Alternative to Minimise Risk in The Operating Theatre

Introduction

Natural Rubber Latex (NRL) gloves have been ubiquitously used in surgical practice. Over the past few decades, there have been many reports of NRL allergies associated with their use presenting a safety hazard to both patients and healthcare workers. Powder-free and latex-free gloves have been shown to offer reductions in incidence of allergic reactions, as well as cost savings.

Method

We performed a literature search to identify the rates of reaction to latex across the population in addition to the associated costs including litigation costs, costs of admission, and lost work time associated. We further looked at the rates of perforation of alternatives and the costs associated with such a transition.

Results

The UK prevalence of sensitisation amongst healthcare workers has been estimated to be 10%. The average cost of litigation to the employer was found to be $21,402 per claim. The mean cost of inpatient care for anaphylaxis has been cited as £469.88, with additional costs such as follow-up representing approximately £400. A 14-month study found cost savings of $10,000pa with a switch to non-latex gloves. Furthermore, an overall perforation rate of 80% in a latex-free glove compared to 34.4% in a latex glove.

Conclusions

From a business perspective, there is evidence of cost-savings arising from a switch to latex-free gloves, however, formal cost-effectiveness analyses would inform future decisions. Furthermore, comfort and reducing the chances of allergic reactions through removing the offending allergen all represent benefits of switching to latex-free gloves, however, non-inferiority analyses will inform future strategies both locally and nationally.

Co-existent abdominoperitoneal tuberculosis with endometrial cancer: A diagnostic and surgical challenge

The presence of abdominoperitoneal tuberculosis (APTB) complicates the diagnosis, staging and management of endometrial cancer. Lymph node involvement in APTB may mimic metastatic lymphadenopathy in patients with endometrial cancer. To our knowledge, there have only been 2 previous case reports on this topic. We will describe 3 cases of endometrial cancer co-existing with APTB. The 1st case is a 57-year-old female who underwent elective total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLHBSO) and bilateral pelvic lymph node dissection (PLND). The final diagnosis is Stage 3C1 endometrial endometroid carcinoma with mucinous differentiation. The 2nd case is a 70-year-old female with who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) and PLND. The final diagnosis is a Stage 1A endometrioid adenocarcinoma. The 3rd case is a 63-year-old female who underwent TAHBSO and PLND and the final diagnosis was a mixed high-grade serous (90%) and endometrioid (10%) carcinoma of the endometrium. In these cases, the importance of surgical staging is emphasised to accurately stage endometrial cancer. Moreover, thorough peri-operative optimisations by a multi-disciplinary team are essential to improve the outcomes of surgery.

471 LET’S TALK DEMENTIA

Introduction

By 2021 over one million people will be living with dementia (1) costing the government an estimated £30bn a year (2). However, cognitive decline is often misdiagnosed or missed completely in hospital admissions, resulting in delays in detection and treatment for patients. Quick and simple screening tools such as the Abbreviated Mental Test Score (AMTS) could help provide early detection and faster treatment times for such patients. Data from Queen Elizabeth Hospital Kings Lynn showed that only 56.8% of patients over the age of 75 were being assessed for cognitive function on admission, while the national targets are set at 90%.

Methods

A multi-cycle, trust wide, quality improvement project was used to improve screening outcomes for dementia in QEHKL. A baseline measure of screening was taken by QEHKL coding department. Five PDSA (Plan Do Study Act) cycles were undertaken, implementing interventions to aid screening at each stage. Examples include improved medical clerking booklets, trust wide education and allocated ward ‘Dementia Champions’. Performance was assessed by auditors, through patient notes and discharge letters.

Results

Over a 4-month period, 432 patient notes were inspected on six medical wards. Results after interventions showed a significant rise in Dementia Screening from 58.7% to 89.8%. AMTS completion was 70.7% in September 2020 on medical wards which improved to 85.7% in November 2020. Results were collected during the COVID-19 pandemic however, COVID wards were excluded.

Conclusion

The QI project has highlighted that education and accessible tools can improve cognitive screening numbers. An important note is, due to increased pressures during the COVID pandemic it is plausible that screening rates were adversely affected. Despite this, our figures still show positive improvement. The next cycle of our project includes surgical wards and we expect by the time of presentation to have this data to show.

Hajdu-Cheney Syndrome: A Report on Successful Halting of Acro-osteolysis

CASE

The phenomenon of acro-osteolysis often intrigues clinicians and patients alike, as it causes bone resorption. One such condition is Hajdu-Cheney syndrome. We report our experience in identifying and halting the active bone resorption in a patient and his father with 2-year follow-up results.

CONCLUSION

Management included identification of the NOTCH2 mutation and treatment with antiresorptive measures. In addition, genetic counseling and antenatal counseling are recommended to explain the risk of inheritance.

Lateral Epicondylitis-Narrative Review on Surgical Options for Recalcitrant Cases

PURPOSE

Lateral epicondylitis or lateral elbow tendinopathy is a common condition which needs to be addressed appropriately. This condition usually responds well to non-operative treatment. However, an orthopaedic physician needs to be aware of the recalcitrant cases and equip surgical armamentarium to provide adequate care.

METHODOLOGY

The literature search was performed on PubMed, Medline and Google scholar using the keywords Tennis elbow, recalcitrant, thorntons technique, surgical options, for this narrative review.

CONCLUSION

This article focuses on the causes for recalcitrant tendinopathy and review of its surgical options.

Correction to: The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum/significant arcuate uterine anomaly in infertile patients in the era of transvaginal 3D ultrasound scan

An amendment to this paper has been published and can be accessed via the original article.

Proximal fibular osteotomy: Systematic review on its outcomes

BACKGROUND

The morbidity and burden of knee osteoarthritis affecting millions of lives worldwide has created a constant pursuit in finding the ideal treatment for knee osteoarthritis. There has been a paradigm shift in the surgical treatment of osteoarthritis ever since the initial description of Volkmann’s tibial osteotomy. This review focuses on one such recent procedure, the proximal fibular osteotomy (PFO) for medial compartment knee osteoarthritis. This review encompasses the history, evidence, risk factors, outcomes and technical considerations of PFO.

AIM

To understand the evidence and its techniques, and whether this could be an alternative solution to the problem of knee osteoarthritis in the developing world.

METHODS

The phrases “proximal fibular osteotomy” and “knee osteoarthritis” were searched (date of search December 20, 2019) on PubMed to identify articles evaluating the biomechanical and clinical outcomes of PFO in patients with knee osteoarthritis. A total of 258 were retrieved. After reviewing the summary of the texts, 22 articles written in English were marked for abstract review. Articles that were case studies or cadaver experiments were excluded. The abstracts of the remaining articles were read, and only those that focused on the history, outcomes of case studies and technical considerations of PFO were included in the review. A total of 12 articles were included in this review.

RESULTS

At least six studies reported improvement in the visual analogue scale(VAS) from the average preoperative VAS score [6.32, 95% confidence interval (CI) = (4.05, 8.59)] to average postoperative VAS score [1.23, 95%CI: (-1.20, 3.71)], which was statistically significant. Similarly, the American Knee Society Score (KSS) functional score improved from an average preoperative KSS functional score [43.11, 95%CI: (37.83, 48.38)] to postoperative KSS functional score [66.145, 95%CI: (61.94, 70.35)], which was statistically significant. The femorotibial angle improved by around 7^º, and the hip knee ankle angle improved by around 6^º.

CONCLUSION

With the existing data, it seems that PFO is a viable option for treating medial joint osteoarthritis in selected patients. Long term outcome studies and progression of disease pathology are some of the important parameters that need to be addressed by use of multicenter randomized controlled trials.

The developed Arabic version of the Hearing Handicap Inventory for the Elderly

Background

Hearing impairment ranks third on the list of chronic health conditions of the elderly, after arthritis and hypertension. As average lifespans increase, it is likely that the proportion of people with hearing loss will also increase. The purpose of the study was to develop, standardize, and apply an Arabic version of the Hearing Handicap Inventory for the Elderly (HHIE).

Results

The mean age of the 100 subjects included in the pretest was 64.92 ± 5.937 with age ranged from 60 to 84 years. The average score for each item (simple, clear, and relevant) for each separate question obtained more than 80% which is considered valid. One hundred percent of the participants reported that the entire inventory appeared simple, clear, and relevant, we further implied the jury opinion; the total score average of our jury for the entire inventory was calculated to determine the face validity of the questionnaire and found to be 89.81%. Responses of all participants for each question were collected and showed questions 8, 21, 6, 7, and 14 obtained the highest response results for both yes and sometimes. The HHIE showed high reliability (p value < 0.001) for all questions. The demographic data of the forty participants showed no statistically significant difference between the complaining group of hearing loss and the non-complaining group as regards age and gender. There was a highly statistically significant difference between the complaining group and the non-complaining group regarding the HHIE. The sensitivity of the HHIE was 79% for severe auditory handicapping and only 24% for mild-to-moderate auditory handicapping.

Conclusion

The developed Arabic version of the HHIE has high reliability, validity, simplicity, and clarity which found consistent with the original English questionnaire and it performed well in the detection of hearing loss in elderly Egyptians. It can be applied in a large population and for use in surveys.

Beneficial role of acetylcholine in chlorophyll metabolism and photosynthetic gas exchange in Nicotiana benthamiana seedlings under salinity stress

Acetylcholine (ACh) is believed to improve plant growth. However, regulation at biochemical and molecular levels is largely unknown. The present study investigated the impact of exogenously applied ACh (10 µm) on growth and chlorophyll metabolism in hydroponically grown Nicotiana benthamiana under salt stress (150 mm NaCl). Salinity reduced root hydraulic conductivity while ACh-treated seedlings exhibited a significant increase, resulting in increased relative water content. Salinity induced a reduction in chlorophyll biosynthetic intermediates, such as protoporphyrin-IX, Mg-photoporphyrin-IX and protochlorophyllide, which were significantly ameliorated in the presence of ACh. This influence of ACh on chlorophyll synthesis was confirmed by up-regulation of HEMA1, CHLH, CAO and POR genes. Gas exchange parameters, i.e. stomatal conductance, internal CO2 concentration and transpiration rate, increased with ACh, thereby alleviating the salinity effects on photosynthesis. In addition, the salinity-induced enhancement of lipid peroxidation declined after ACh treatment through modulation of the activity of the assayed antioxidant enzymes (superoxide dismutase and peroxidase). Importantly, ACh significantly reduced the uptake of Na and increased uptake of K, resulting in a decline in the Na/K ratio. Results of the present study indicate that ACh can be effective in ameliorating NaCl-induced osmotic stress, altering chlorophyll metabolism and thus photosynthesis by maintaining ion homeostasis, hydraulic conductivity and water balance.

Exploration of a New Source of Sustainable Nanomaterial from the Koh-e-Suleiman Mountain Range of Pakistan for Industrial Applications

The present study aimed to explore a new source of montmorillonite and to develop an extraction and purification protocol for its isolation from raw clay samples acquired from the Koh-e-Suleiman mountain range in Pakistan. The process involved the collection of raw clay from the source, identification and quantification of montmorillonite. Granulometric extraction and purification protocols increased the montmorillonite content from 21.8-25.1% in the raw clay to 90.1-93.9% after small-scale extraction and 85.33-89.33% on a larger scale. A techno-economic analysis highlighted the practicality and economic benefits of large-scale extraction for industrial applications. This study highlights the existence of a substantial new source of this valuable clay which is currently used across multiple industries including construction, pottery making, pharmaceuticals, cosmetics and engineering. It is intuitively expected that the large-scale extraction of the material will improve the economic condition of the region by providing employment opportunities to locals and may be a valuable resource for export.

The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum/significant arcuate uterine anomaly in infertile patients in the era of transvaginal 3D ultrasound scan

Background

To determine the accuracy of measurement of internal indentation length on transvaginal 3D ultrasound scan (TV 3D US) in detecting patients with an incomplete uterine septum (IUS) or a significant arcuate uterine anomaly (AUA) based on the actual length as measured on diagnostic hysteroscopy. We compared the mean internal indentation length on TV 3D US and on diagnostic hysteroscopy in patients with IUS or a significant AUA.

Results

This is a retrospective study of 546 patients who were found to have IUS (134) or significant AUA (412) on diagnostic hysteroscopy and who had TV 3D US prior to surgery. The mean internal indentation length measured in millimeter on hysteroscopy was significantly higher than the mean internal indentation length measured on TV 3D US in patients with IUS (16.7 + 5.5 vs 5.5 + 4.2; P < 0.001), in patients with significant AUA (12.9 + 2.8 vs 3.9 + 4.6; P < 0.001), and in the overall population (13.8 + 4.0 vs 4.3 + 4.5; P < 0.001). The same findings were obtained when the comparison was limited to patients who had moderate significant internal indentation length (10–14 mm) and those with significant internal indentation length (15–25 mm).

Conclusion

Data in this study suggests that the mean internal indentation length in patients with IUS or AUA can be underestimated on TV 3D US. A diagnostic hysteroscopy is the only gold standard to make the correct diagnosis in these patients.

Spontaneous Recurrent Hemarthrosis Post Total Knee Arthroplasty Treated with Selective Embolization - A Case Report and Review of Literature

INTRODUCTION

Spontaneous recurrent hemarthrosis of the knee following a total knee arthroplasty is a rare complication with varying time of onset from 2 months to 18 years. It needs a prompt diagnosis and treatment to prevent complications of stiffness, chronic pain, and limited function. We present a case of spontaneous recurrent hemarthrosis presenting at 3 months following a total knee arthroplasty with a follow-up to 1 year.

CASE REPORT

A 66-year-old male presented at 3 months following a right total knee arthroplasty with a history of increased pain and swelling of the knee joint. Initially, he was treated with anti-inflammatories when the pain and swelling recurred, an aspiration demonstrated hemarthrosis of the knee. Further evaluation demonstrated no infection, a femoral angiography demonstrated prominence of medial superior and inferior geniculate arteries with a tumor blush appearance. Therapeutic embolization of both the arteries resulted in complete resolution of the symptoms in 1 month with return of full knee function. At the end of 1-year follow-up, the patient had return of full knee function with no pain and no recurrence.

CONCLUSION

An algorithmic approach is helpful in identifying the etiology of spontaneous recurrent hemarthrosis of knee and a course of conservative treatment should always be the first line of treatment. Angiography and selective arterial embolization of the geniculate arteries can be an effective treatment in the management of recurrent spontaneous hemarthrosis.

P5487Premature coronary artery disease among Egyptian patients with acute coronary syndrome; data from the cross-sectional cardio-risk project

Background

Egypt is the most populous country in Middle East and North Africa and has one of the highest rates of the cardiovascular (CV) deaths in the region. Despite governmental primary preventive efforts, very little is known about the prevalence and characteristics of premature coronary artery disease (CAD) among Egyptian patients with Acute Coronary syndrome (ACS).

Methods

From November 2015 to August 2018, data were collected from 3224 patients with ACS in 30 coronary care centers covering 11 governorates across Egypt, spanning the Mediterranean coast, Nile Delta, and Upper Egypt, with focus on premature CAD (defined as ACS before age 55 years in males and 65 years in females).

Results

The prevalence of premature CAD was 51%. They were significantly more females (35% versus 16%, P<0.001) with significantly higher level of education. Risk factors' (RFs) distribution showed a significantly higher prevalence of Type-1 Diabetes Mellitus (6% versus 4%, P=0.005), obesity (42% versus 33%, P<0.001) and smoking (50% versus 47%, P<0.001) in patients with premature CAD when compared to others. Interestingly, rates of documented dyslipidemia were similar between groups (49% versus 47%, P=0.45) with no significant difference in low density lipoprotein-cholesterol levels (131.7±48.5 versus 130.2±45.2 mg/dl, P=0.4). Patients with premature CAD tended to present more frequently with ST-elevation myocardial infarction (STEMI) (50% versus 46%, P=0.035), with higher rates of treatment using primary percutaneous coronary intervention compared to others (48% versus 44%, P=0.04). They were also significantly less likely to receive Coronary Artery Bypass Graft (4% versus 6.5%, P=0.003).

Conclusion

Prevalence of premature CAD is high among Egyptian patients with ACS, due to noticeably larger burden of traditional CV RFs especially smoking and possibly familial hypercholesterolemia. Much effort is still needed in screening for early detection of RFs of atherosclerosis together with more widespread adoption of diagnostic scores for FH such as Dutch Lipid Network criteria.

Acknowledgement/Funding

AstraZeneca

Regenerative Effect of Bone Marrow-derived Mesenchymal Stem Cells in Thioacetamide-induced Liver Fibrosis of Rats

The present study determined the regenerative effect of bone marrow-derived stem cells (BMSCs) on thioacetamide (TA)-induced liver fibrosis in rats. A total of 30 male Wistar rats were randomly divided into sham control and treatment groups. The rats of the sham control group were subdivided into three groups and sampled on the 14th, 18th, and 20th weeks after fibrosis induction. The rats of the treatment group were subdivided into two groups and sampled on the 4th and 6th weeks after BMSCs treatment. Fibrosis was induced by the intraperitoneal administration of 200 mg/kg of TA twice a week for a period of 14 weeks. All the animals underwent liver function tests and histopathologic evaluation 4 and 6 weeks after BMSCs transplantation. The BMSCs were characterized using osteogenic induction and reverse transcription-polymerase chain reaction. The BMSCs were plastic adherent, spindle-shaped, and positive for osteogenic differentiation. They expressed CD73 and were negative for CD45. The infiltration of inflammatory cells and deposition of collagen fibers were noticed after TA administration. A significant decline in inflammatory cells and a healing process were detected 4 weeks after cell transplantation. The amelioration in hepatic tissue was significant 6 weeks after cell therapy. Following the injection of BMSCs, a nonsignificant decrease was visible in aspartate transaminase level; however, this decline was significant for alanine aminotransferase level. The alkaline phosphatase and albumin levels showed an increasing trend after cell administration. The transplantation of BMSCs resulted in a significant regenerative effect after hepatic injuries. Therefore, it was shown that BMSCs transplantation can open a new window and be a therapy of choice in the amelioration of liver fibrosis.

Biologically active scaffolds: Synthesis, characterization and studies of oxino bis-pyrazoles by environmental friendly method

In the present communication, synthesis of bis-pyrazolones containing aryl motifs (4-14) and their α-glucosidase inhibitory activity, hemolytic and antihemolytic activities were reported. The newly synthesized compounds were characterized by analytical techniques such 1H-NMR, 13C-NMR, IR, mass spectrometry and compound No 4 additionally by X-ray crystallography. Compounds 4, 12, 14 were obtained in more than 85% yield. In comparison to typical acarbose (IC50 = 37.38±0.12μM), all synthesized compounds showed potent activity with IC50 values between 31.26±0.11 to 396.25±0.18μM. The most potent compounds 6, 8 and 11 showed IC50 values within the range of 31.26±0.11 to 37.48±0.12μM. Compounds 7, 10, 12 and 13 showed IC₅₀ values within the range of 65.23±0.12 to 154.87±0.16μM, while compounds 4, 5 and 9 showed moderate inhibition with IC₅₀ values 286.56±0.16 to 396.25±0.18μM. Structure-activity relationship (SAR) studies, suggests that electron withdrawing groups played a crucial role in enhancing α-glucosidase inhibitory effects of title compounds. In addition, results of the hemolytic and antihemolytic activity studies indicated that compound 13 possessed moderate levels of hemolytic and highest anti- hemolytic activity while 8 showed low anti- hemolytic and high hemolytic activity.

Spontaneous Recurrent Hemarthrosis Post Total Knee Arthroplasty Treated with Selective Embolization - A Case Report and Review of Literature

Introduction

Spontaneous recurrent hemarthrosis of the knee following a total knee arthroplasty is a rare complication with varying time of onset from 2 months to 18 years. It needs a prompt diagnosis and treatment to prevent complications of stiffness, chronic pain, and limited function. We present a case of spontaneous recurrent hemarthrosis presenting at 3 months following a total knee arthroplasty with a follow-up to 1 year.

Case Report

A 66-year-old male presented at 3 months following a right total knee arthroplasty with a history of increased pain and swelling of the knee joint. Initially, he was treated with anti-inflammatories when the pain and swelling recurred, an aspiration demonstrated hemarthrosis of the knee. Further evaluation demonstrated no infection, a femoral angiography demonstrated prominence of medial superior and inferior geniculate arteries with a tumor blush appearance. Therapeutic embolization of both the arteries resulted in complete resolution of the symptoms in 1 month with return of full knee function. At the end of 1-year follow-up, the patient had return of full knee function with no pain and no recurrence.

Conclusion

An algorithmic approach is helpful in identifying the etiology of spontaneous recurrent hemarthrosis of knee and a course of conservative treatment should always be the first line of treatment. Angiography and selective arterial embolization of the geniculate arteries can be an effective treatment in the management of recurrent spontaneous hemarthrosis.

The outcome of proximal humeral locking plates in the management of three and four part proximal humeral fractures in special cohort of young patients in high velocity trauma

BACKGROUND

Locking plate fixation provides satisfactory outcome following proximal humerus fractures. None of the previous studies selectively evaluate the outcome in young patients. This study evaluates outcome of locking plate system in the treatment of acute three- and four-part fractures in young patients.

METHODS

In this prospective study we included all patients who were less than 60 years, involved in high velocity trauma, had proximal humerus comminuted three part and four part fractures and were operated using locking plate at our centre, between August 2011 to August 2015. All the patients were followed up regularly. Assessment was done clinically using Constant and Murley scoring system and radiologically using signs of healing in the form of callus formation and cortical continuity.

RESULTS

Twenty-five eligible patients were operated during the study period. All patients were involved in motor vehicle collision. Average age of our patients was 41.2. The average duration of follow-up was 18.2 months(8 months to 27 months). 24 out of 25 fractures united clinically and radiologically at three months' follow-up. Average Constant and Murley score at final follow-up was 78.52. The results were excellent to good in 15 patients, fair in five patients and poor in five patients. Overall complication rate was 24%. Majority of them (20%) were restriction of movements of shoulders. None of our patients needed reoperation.

CONCLUSION

Locking plate system, in three part and four part proximal humerus fractures in young patients, provides secure and stable fracture fixation for early mobilization. Early results with locking plate system were promising in younger patients. In these patients, locking plate system has definite role to preserve the humeral head and there by maintain the functional activity level.

Spontaneous Retroperitoneal Hematoma Presenting as Femoral Neuropathy in a Patient on Low Molecular Weight Heparin Therapy

Introduction

Retroperitoneal hemorrhage has been sparsely reported with warfarin therapy. In this paper, we describe a case of spontaneous retroperitoneal hematoma causing femoral neuropathy following treatment with low molecular weight heparin.

Case Report

A 65-year-old gentleman had presented with acute onset left-sided thigh pain, paraesthesia, and weakness along with lower backache. On deeper introspection, our patient had, in the recent past, been thrombolyzed for pulmonary embolism. The clinical examination led us to suspect an acute lumbar pathology, and he was investigated on those lines. Imaging studies, however, revealed a massive retroperitoneal hemorrhage which was the cause of femoral neuropathy. In this case report, the presentation of this rare association has been discussed with special emphasis on clinical premonition in the background of anticoagulant therapy. Watchful and medical treatment yielded successful recovery at follow-up.

Conclusion

Cautious clinical assessment is needed in patients taking anticoagulant therapy. The presentation of a femoral neuropathy is often intriguing. Management options include careful observation and emergency decompression in cases of worsening neurological status.

Calcifying Tendinitis of Shoulder: A Concise Review

Calcifying Tendinitis (CT) shoulder a self limiting disorder characterized by deposition of calcium salts in rotator cuff muscles. The main symptom being pain followed by activity restriction resolving on its own in most cases. Symptomatic patients are initially managed by NSAIDs, Physiotherapy, Corticosteroid injections. ESWT involves acoustic waves causing fragmentation of deposits with pain releif. Ultrasound guided needling barbotage have shown promising results. Arthroscopic excision remains the definitive management for patients associated with complications as cuff tear and for uncomplicated patients. In calcifying tendinitis the initial evaluation, maintenance of function and appropriate choice of treatment modalities determines the prognosis.

Extra-articular deformities in arthritic knees-a grueling challenge for arthroplasty surgeons: An evidence-based update

Critical to the success of a total knee arthroplasty (TKA) is the anatomical alignment. This may appear as a challenge in an extra-articular deformity (EAD) that may be inherent in certain people or result from fracture malunion, congenital disorders, nutritional, metabolic and infective causes. This appraisal aimed at providing the reader with an up-todate overview of the research carried out on, and existent evidence of EAD correction while planning a TKA. We reviewed the current English literature on TKA in extra-articular knee deformities. Among the published data, a common initial approach of mandatory clinical and radiological assessment emerges as an obligatory step while handling cases with EAD. While several methods of managing the deformity and arthritis have been described, a broad division into intra-articular and extra-articular means can be deciphered. The relatively old-school, yet reliable thought process of extra-articular correction allows an all-inclusive restoration of alignment with the inherent complications related to the necessary osteotomy. A cohort of younger and more venturesome surgeons seem inclined towards performing navigated, intra-articular correction for mild to moderate and sometimes, severe deformities. The crux of the matter lies is obtaining a well-balanced knee without violating the all-important cruciates. Restoring the patient’s ambulatory status seems sooner with the intra-articular methods which are also more precise in determining the axes and while removing minimum bone. Greatest satisfaction is accomplished in those with less grotesque, rotationallyaligned knees while meticulously balancing soft-tissues and encouraging earlier weightbearing.

Impact of weight loss on sperm DNA integrity in obese men

The objective of the study was to determine whether weight loss in obese men improves their fertility with respect to DNA fragmentation index and morphology. Collected fertility parameters included DFI and morphology. Body mass index (BMI) was calculated for all patients with comparisons to their fertility parameters before and after weight loss using paired t test and chi-square tests. The mean BMI was significantly higher in group 1, before weight loss (33.18 kg/m2 ), than in group 2, after weight loss (30.43 kg/m2 ). Overall, 53.3% of men had DFI <20% while 43.8% had a DFI between 20% and 40%, and 2.9% of men had DFI >40%. The mean DFI of participants was higher before weight loss (20.2%) and had improved significantly after weight loss (17.5%) (p = <.001). The weight loss had significant positive correlation with percentage of DFI. There was a significant improvement in morphology after weight loss (p = <.05). In one of the largest cohorts of male fertility and obesity, DFI and morphology demonstrated significant relationship with adiposity, possibly contributing to subfertility in this population.

Dengue virus serotypes and epidemiological features of dengue fever in Faisalabad, Pakistan

Dengue infection has become a major public health threat in Pakistan, causing several outbreaks from 1994 to 2012. This cross-sectional study was carried out to determine viral serotypes responsible for major outbreak of dengue fever in Faisalabad, Pakistan during 2011. Total 50 patients (37 males and 13 females) reported within 2-4 days of onset of fever, positive for dengue NS1 antigen, were recruited for this study. The median age of the patients was 29 years. Laboratory findings indicate thrombocytopenia in 92.0%, decreased hemoglobin in 48.0%, and leukopenia in 38.0% patients at the time of admission. Liver enzymes were elevated in 100.0% patients. ALT levels were 7.0 times higher, while AST levels were 7.3 times higher than the normal values in dengue patients. Molecular epidemiology of the dengue fever revealed co-circulation of three different DENV serotypes in Faisalabad population. Among them 82.4% were positive for DENV2; 5.8% with DENV3; and 11.7% were reported with DENV4. Co-circulation of three different DENV serotypes in the city is an alarming situation, which could result in a more severe outbreak of DF (DHF/DSS) in the future.

The impact of single versus double blastocyst transfer on pregnancy outcomes: A prospective, randomized control trial

OBJECTIVE

To determine if elective single blastocyst transfer (e-SBT) compromises pregnancy outcomes compared to double blastocyst transfer (DBT) in patients with favorable reproductive potential.

METHODS

This Randomized Control Trial included 50 patients with SBT (Group 1) and 50 patients with DBT (Group 2). All women were <35 years and had favorable reproductive potential. Randomization criterion was two good quality blastocysts on day 5. Patients who did not get pregnant or who miscarried underwent subsequent frozen cycles with transfer of two blastocysts (if available) in both groups.

RESULTS

No significant difference was observed in the majority of the demographic data, infertility etiology, ovarian stimulation characteristics and embryology data between the two groups. There was a significantly lower clinical pregnancy (61.2% vs 80.0%), and delivery (49.0% vs 70.0%) rates, but no difference in implantation (59.2% vs 54.0%), miscarriage, or ectopic pregnancy rates between Group 1 and Group 2, respectively. There was a significantly higher multiple pregnancy rate in Group 2 (35.0%) compared to Group 1 (0%) [P=0.000]. When fresh and first frozen cycles were combined, there was a significantly lower cumulative clinical pregnancy (77.6% vs 96.0%, P=0.007) and delivery (65.3% vs 86.0%, P=0.016) rates in Group 1 compared to Group 2 respectively.

CONCLUSIONS

In patients with favorable reproductive potential, although e-SBT appears to reduce clinical pregnancy and live-birth rates, excellent pregnancy outcomes are achieved. Clinicians must weigh the benefits of DBT against the risk associated with multiple pregnancies in each specific patient before determining the number of blastocysts to be transferred.

Total Knee Arthroplasty In Patients With Parkinson's Disease- A Critical Analysis of Available Evidence

Background:

In this era of modern medicine, there is an increase in life expectancy and thereby an ageing population. Among this group one of the most common neurological disorder is Parkinson disease and one of the most common operation done in elderly population is a total joint arthroplasty. But total joint arthroplasty in Parkinson disease is a relatively uncommon entity. There is sparse literature available with regards to total knee arthroplasty (TKA) in Parkinson disease. This review focusses on the necessity, complications and previous experiences on TKA in PD based on the literature available.

Method:

The review was conducted after a series of advanced search in the following medical databases; Pub med, Biomed central, Cochrane and Google scholar for articles related to total knee replacement in patients with Parkinson’s disease. The following keywords were used; Total knee arthroplasty, Parkinson’s disease, Hoehn and Yahr, Flexion Contracture.

Results:

The review indicates that the functional outcome is comparable to that of controls in immediate post-operative phase, one year and three-year phase, but the long term functional outcome seems to deteriorate significantly.

Conclusion:

Total knee arthroplasty can serve as an effective tool in alleviating pain in short term as well as long term periods, whereas the functional outcome seems to deteriorate post operatively on a long-term basis. Nevertheless, TKA in PD is a challenging situation, thereby necessitating a holistic approach with the efforts from various specialists needed at each stage to ensure a successful operation.

Rationale of Cruciate Retaining Design in Rheumatoid Arthritis: A Review of Clinical Analysis and its Role in Rheumatoid Arthritis

Background:

Over the years, proponents of total knee designs (cruciate retaining and posterior stabilised) have conducted several long-term studies to claim the potential of these designs in several subsets of patients. Total knee arthroplasty (TKA) in patients with rheumatoid arthritis has also been one such domain where numerous studies were conducted in the past. A general perception among majority of arthroplasty surgeons is that, posterior stabilised (PS) is the implanted design of choice among patients with Rheumatoid arthritis (RA). However, with the available literature there is a significant disparity related to the selection of implants in patients with rheumatoid RA. In this review of literature, an attempt is made to identify the clinical performance and role of one such implant design, the cruciate retaining (CR) prosthesis in rheumatoid arthritis.

Method:

The review was conducted after a series of advanced search in the following medical databases; Pub med, Biomed central, Cochrane and Google scholar for articles related to long term follow up studies of cruciate retaining total knee arthroplasty in rheumatoid arthritis using the keywords cruciate retaining prosthesis, total knee arthroplasty, rheumatoid arthritis.

Results:

The available data demonstrate that the CR design is attributed with an excellent long term survivorship and functional outcome even in follow up studies up to twenty-five years.

Conclusion:

The advantages of using a CR design are long term survivorship, controlled femoral roll back and preservation of bone stock. Thus, the data gathered in this review lead to a consideration that the CR design is an implant design on par with PS design in patients with RA.