Does selection favour the maintenance of porous species boundaries?

The endpoint of speciation has been viewed as complete isolation and the absence of gene flow between species. If the influx of genes from another species is maladaptive because species have different adaptations and genetic backgrounds, selection should favour the closing of species boundaries and zero gene flow, a process known as reinforcement. Recently, numerous cases of gene flow between species have been identified, many of which involved adaptive introgression of beneficial alleles. These cases could reflect transient states on the way to closed species boundaries or the result of declining strength or efficacy of selection for reinforcement as the level of gene flow approaches zero. An alternative hypothesis, however, is that selection favours porous species boundaries that allow beneficial alleles to cross, especially in changing environments. This perspective evaluates the conditions that would be needed for selection to favour porous species boundaries and the evidence for them. A contrast is made between hybridization in sexual eukaryotes and gene transfer via homologous recombination in bacteria. Current evidence is inconclusive on whether non-zero gene flow is favoured by selection. Studies are needed that quantify selection gradients on rates of gene flow and test for evolution towards intermediate values, especially experiments that manipulate conditions and track evolution for multiple generations. Estimation of gene flow networks for more clades and regional assemblages using emerging genome data will also allow the evolutionary determinants of interspecific gene flow to be better understood.

Short- and Long-Term Renal Function After Partial Nephrectomy: Comparison of Solitary and Multifocal Renal Masses

INTRODUCTION

Multifocal partial nephrectomy (MPN) is a critical management strategy for extirpation of multiple distinct renal masses; however, its short- and long-term impact on renal function remains poorly described. Herein we compared absolute glomerular filtration rate (GFR) and change from baseline at multiple time points after MPN and standard partial nephrectomy (SPN).

METHODS

Perioperative and pathologic characteristics of 1307 partial nephrectomies performed from 2009 to 2020 were identified. 3:1 propensity score methods were used to match MPN and SPN cohorts based on preoperative characteristics known to impact renal function. Differences in GFR, perioperative outcomes, and overall and recurrence-free survival were assessed. Absolute and relative change from baseline GFR was compared at 5 time points for 36 months after partial nephrectomy.

RESULTS

After propensity score matching, 192 SPNs and 64 MPNs with a median GFR of 80.2 mL/min were compared. MPN was associated with a greater decline in GFR of between 11% and 18% for the first year compared to a decline of 7% to 10% for SPN. This difference stabilized after 24 months. However, no differences in overall survival or recurrence-free survival were observed. Median follow-up time was 46.7 months.

CONCLUSIONS

Long-term renal function after MPN remains similar to SPN despite greater declines in the first year after excision of multifocal renal masses.

Laparoscopic partial splenectomy in distal pancreatectomy may preserve splenic function

INTRODUCTION

Splenectomy is known to carry a risk of infection with encapsulated organisms and associated sepsis. Current Australian guidelines recommend intensive vaccination schedules and long-term antibiotic therapy. We postulate that in some clinical scenarios where distal pancreatectomy (DP) and splenectomy is being performed, a partial splenectomy is feasible. This may preserve splenic function and help retain immunocompetence.

METHODS

Five patients underwent laparoscopic distal pancreatectomy with partial splenectomy (LDPPS). The DP is performed with proximal division and resection of the splenic artery and vein. The inferior portion of the spleen is removed en bloc with the distal pancreas with ligasure and linear cutting staplers. The line of demarcation on the spleen after the division of the splenic artery identifies the portion supplied by the short gastric vessels. Temporary clamping of the short gastrics during splenic parenchymal transection reduces blood loss. All operations were completed laparoscopically and within 4 h.

RESULTS

The pathology of resected lesions includes a serous cystadenoma, a pseudocyst, an IPMN and two small medial pancreatic ductal adenocarcinomas. The benign lesions involved splenic vessels at the hilum, making Kimura or Warshaw procedures untenable. No patient required blood transfusion. One patient suffered a postoperative collection consistent with postoperative pancreatic fistula requiring a drain for 10 days. Follow-up ranged from 6 to 24 months. Following surgery, all patients had a perfused splenic remnant on imaging and benign blood films, which suggests retained splenic function.

CONCLUSION

Preserving some spleen when performing distal pancreatectomy may provide long-term benefits for patients.

Cost-utility analysis of robotic arm-assisted medial compartment knee arthroplasty

Aims

To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).

Methods

This was a five-year follow-up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ-5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated.

Results

rUKA was associated with a relative 0.012 QALY gain at five years, which was associated with an incremental cost per QALY of £13,078 for a unit undertaking 400 cases per year. A cost per QALY of less than £20,000 was achieved when ≥ 300 cases were performed per year. However, on removal of the cost for a revision for presumed infection (mUKA group, n = 1) the cost per QALY was greater than £38,000, which was in part due to the increased intraoperative consumable costs associated with rUKA (£626 per patient). When the absolute cost difference (operative and revision costs) was less than £240, a cost per QALY of less than £20,000 was achieved. On removing the cost of the revision for infection, rUKA was cost-neutral when more than 900 cases per year were undertaken and when the consumable costs were zero.

Conclusion

rUKA was a cost-effective intervention with an incremental cost per QALY of £13,078 at five years, however when removing the revision for presumed infection, which was arguably a random event, this was no longer the case. The absolute cost difference had to be less than £240 to be cost-effective, which could be achieved by reducing the perioperative costs of rUKA or if there were increased revision costs associated with mUKA with longer follow-up.

Experimental Analysis of the Mechanical Response of Masonry Columns Partially Confined with PBO FRCM (Fabric Reinforced Cementitious Mortar) Composites

An experimental investigation on partially PBO (short of Polyparaphenylenebenzobisthiazole) FRCM (Fiber Reinforced Cementitious Mortar) confined clay brick masonry columns has been conducted. Ten small-scale specimens measuring 445 mm high with a square cross-section of the 250 mm side have been tested under monotonic axial loading until collapse. Two columns were unconfined, while the remaining ones were confined with single-layer PBO FRCM jackets varying the geometric configuration along their height. The vertical spacing ratio sf'/sf, being sf' and sf the center-to-center and the net spacings between two consecutive jackets, respectively, was considered as the key parameter of the confinement configuration. The failure modes, stress-strain curves and peak axial stress and strain values are reported. The experimental results have been compared to the predictions of models found in the Italian guidelines CNR DT 215/2018 and the American ACI 549-R20 standards. The main aspects analyzed involved (i) the evaluation of the effectiveness of partial confinement on the mechanical response of columns, (ii) the definition of the mechanical and geometrical parameters that influence the structural response of partially confined columns, and (iii) the development of appropriate analytical models for the prediction of the resisting capacity of masonry columns partially confined with PBO FRCM.

A rare case of partial cor triatriatum diagnosed at an adult age: a case report

Background

Cor triatriatum sinistra (CTS) is a rare condition where the left atrium (LA) is divided by a thin membrane into an upper and lower chamber. Incidentally, the diagnosis is made in late adulthood, usually because of a favourable variant such as in our patient who presented with partial CTS.

Case summary

We present the case of a 62-year-old female who presented with COVID-19. She was known for longstanding symptoms of dyspnoea on exertion as well as a minor stroke several years ago. Computed tomography on admission suggested there was a mass in the LA but transthoracic echocardiography and cardiac magnetic resonance imaging revealed the diagnosis of partial CTS in which the superior compartment received pulmonary venous drainage from the right lung and the left-sided pulmonary veins drained into the inferior chamber. Since there were signs of chronic pulmonary oedema she successfully underwent balloon dilatation of the membrane resulting in remission of symptoms and normalization of the pressure in the accessory chamber.

Discussion

Partial CTS is a rare variant of CTS. Since part of the pulmonary veins drains in the lower chamber of the LA (and thereby unload the right ventricle), it is a favourable variant and patients may present later in life when membrane orifices calcify or it may be discovered as an incidental finding. In some patients requiring intervention, balloon dilatation of the membrane may be considered as an alternative to surgical removal of the membrane by thoracotomy.

Partial Two-Stage Exchange for Infected Total Hip Arthroplasty: A Treatment to Take into Account

INTRODUCTION

Two-stage revision is the gold standard for chronic periprosthetic joint infection (PJI). The removal of well-fixed implants, especially the femoral component, can be extremely difficult and additional osteotomies may be needed, which is time-consuming and results in bone stock loss. When the femoral stem is osseointegrated, there is no clear indication for the use of partial two-stage revision. The primary objective was to assess infection eradication after surgery.

METHODS

Retrospective study of specific case series. A total of eight patients with a chronic uncemented PJI, in the setting of complex revision surgeries, were treated with partial two-stage revision, which included selective retention of the well-fixed femoral component and complete acetabular removal. Stem retention was carried out regardless of the bacteria or associated comorbidities.

RESULTS

All patients were re-revision cases with at least two previous surgeries (range, 2-4). Complex revisions were performed in five cases (non-articulated spacer) and simple revisions in three cases (articulated spacer). The minimum follow-up time was 24 months (range, 24-132 months). The infection eradication rate at final follow-up was 100%.

CONCLUSION

Partial two-stage reconstruction is a promising technique for the treatment of chronic PJI in patients with a well-fixed stem and complex re-revision acetabular procedures. Further prospective studies and prolonged follow-ups are required to confirm our results.

Clinical Outcomes of Surgical Repair for Partial Distal Biceps Tendon Tears

PURPOSE

The purpose of this study was to describe the outcomes of patients treated with surgical repair of partial tears of the distal biceps tendon.

METHODS

The study was a retrospective review of repairs of partial tears of the distal biceps tendon performed by multiple surgeons from January 1, 2015 to October 15, 2020. Inclusion criteria consisted of preoperative magnetic resonance imaging indicative of distal biceps pathology without a complete tear and surgical treatment with intraoperative confirmation of a partial tear. The presence of preceding trauma, duration of symptoms, and postoperative complications were documented. Patients were contacted for outcome assessment using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Elbow Evaluation outcome measures. Clinical outcomes were obtained from 56 of 74 (76%) eligible patients with an average follow-up of 46 months (range: 15-85 months).

RESULTS

After surgery, the median QuickDASH was 2.3 (interquartile range, 0-9.7), and the median Patient-Reported Elbow Evaluation score was 1 (interquartile range, 0-12). Postoperative QuickDASH scores were significantly lower than the preoperative scores. Known traumas preceding the symptoms and duration of symptoms before surgery were not significantly associated with the outcome. Of all eligible patients, 30 complications were reported in 25 (34%) patients and included 2 reruptures, 2 cases of heterotopic ossification, 1 deep infection, 1 case of implant irritation, 21 neuropraxias, and 3 hematomas. Five (7%) patients underwent 6 reoperations including 1 revision for a rerupture, 1 irrigation and debridement, 2 heterotopic ossification excisions, 1 hematoma evacuation, and 1 implant removal.

CONCLUSIONS

The results suggest that the repair of partial distal biceps tendon tears is a viable treatment option with significant improvement in QuickDASH. There was no significant relationship between the postoperative outcome and duration of symptoms or known traumas preceding the symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Total versus partial adrenalectomy in bilateral pheochromocytoma - a systematic review and meta-analysis

BACKGROUND

In patients with bilateral pheochromocytoma, partial adrenalectomy offers the chance to preserve adrenal function and avoid the need for lifelong steroid supplementation. However, the risk of tumour recurrence raises questions about this procedure. The aim of our study was to compare partial and total adrenalectomy in bilateral pheochromocytoma through a systematic review with meta-analysis.

METHODS

A systematic search was carried out using databases (MEDLINE, EMBASE, Scopus, Web of Science, CENTRAL) and registers of clinical trials (ClinicalTrials.gov, European Trials Register, WHO International Trials Registry Platform). This meta-analysis included studies up to July 2022 without language restrictions. A random effects model meta-analysis was performed to assess the risk of tumor recurrence, steroid dependence and morbidity in these patients.

RESULTS

Twenty-five studies were included in the analysis involving 1444 patients. The relative risk (RR) of loss of adrenal hormone function during follow-up and the need for steroid therapy was 0.32 in patients after partial adrenalectomy: RR 0.32, 95% Confidence Interval (CI): 0.26-0.38, P < 0.00001, I2 = 21%. Patients undergoing partial adrenalectomy had a lower odds ratio (OR) for developing acute adrenal crisis: OR 0.3, 95% CI: 0.1-0.91, P=0.03, I2 = 0%. Partial adrenalectomy was associated with a higher risk of recurrence than total adrenalectomy: OR 3.72, 95% CI: 1.54-8.96, P=0.003, I2 = 28%.

CONCLUSION

Partial adrenalectomy for bilateral pheochromocytoma is a treatment that offers a chance of preserving adrenal hormonal function, but is associated with a higher risk of local tumor recurrence. There was no difference for the risk of metastasis and in overall mortality among the group with bilateral pheochromocytomas undergoing total or partial adrenalectomy. This study is in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) Guidelines (10, 11).

SYSTEMATIC REVIEW REGISTRATION

https://osf.io/zx3se.

Structure-Activity Relationship Development Efforts towards Peripherally Selective Analogs of the Cannabinoid Receptor Partial Agonist BAY 59-3074

Selective modulation of peripheral cannabinoid receptors (CBRs) has potential therapeutic applications in medical conditions, including obesity, diabetes, liver diseases, GI disorders and pain. While there have been considerable efforts to produce selective antagonists or full agonists of CBRs, there has been limited reports on the development of partial agonists. Partial agonists targeting peripheral CBRs may have desirable pharmacological profiles while not producing centrally mediated dissociative effects. Bayer reported that BAY 59-3074 is a CNS penetrant partial agonist of both CB1 and CB2 receptors with efficacy in rat models of neuropathic and inflammatory pain. In this report, we demonstrate our efforts to synthesize analogs that would favor peripheral selectivity, while maintaining partial agonism of CB1. Our efforts led to the identification of a novel compound, which is a partial agonist of the human CB1 (hCB1) receptor with vastly diminished brain exposure compared to BAY 59-3074.

Comparison of cytoreductive partial versus radical nephrectomy in metastatic renal cell carcinoma: To be on the horns of a dilemma

BACKGROUND

Cytoreductive radical nephrectomy (cRN) with immunotherapy is the treatment of choice in patients with metastatic renal cell carcinoma (mRCC). Limited data are available on the role of cytoreductive partial nephrectomy (cPN) in mRCC. This study is a systematic review and meta-analysis of the evidence regarding survival rates comparing cPN versus cRN.

METHODS

PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were reviewed in December 2021 according to PRISMA. Four articles including 2669 patients were selected to enroll in the study. The identified reports were reviewed and their methodological quality was subjected to total quality assessment. The outcomes were cancer specific survival (CSS) and overall survival rate (OS).

RESULTS

Totally 2669 patients, 542 in cPN and 2127 in cRN groups enrolled in final analysis. Of the preoperative data, there were significant differences in preoperative size of tumor between cRN and cPN patients (p < 0.001), however Fuhrman grades were comparable between groups (low grade: p = 0.51, high grade: p = 0.76). There were comparable results in 1-year (p = 0.07), 2-year (p = 0.08), and 3-year (p = 0.71) CSS rates between cPN versus cRN. There was no significant difference between cPN versus cRN in OS rate (p = 0.61).

CONCLUSION

There are comparable results between cPN and cRN in CSS and OS rate. However, due to a lack of data, future study will need to do more extensive studies using prospectively recorded patient features to evaluate the cPN and cRN in the metastatic setting.

Evaluation of clinical tests for partial distal biceps tendon ruptures and tendinitis

BACKGROUND

The clinical diagnosis of partial distal biceps tendon ruptures or tendinosis can be challenging. Three clinical tests have been described to aid in an accurate and timely diagnosis: biceps provocation test, tilt sign, and resisted hook test. However, not much is known about the sensitivity, specificity, and inter-rater reliability as the available evaluations are based on small groups or are case based. Furthermore, these tests have not been compared together in the same patient group.

METHODS

Two dedicated elbow surgeons each included 20 consecutive patients in whom distal biceps tendon pathology was suspected. Patients with a complete distal biceps tendon tear were excluded. As a control, the same number of consecutive patients with various elbow pathologies other than distal biceps tendon problems was included. All 3 tests were performed both in control patients and in patients with suspected biceps tendon pathology. Magnetic resonance imaging (MRI) in the flexion-abduction-supination view and/or surgical exploration was performed in both groups. The findings of the clinical tests were determined before the results of MRI and other technical investigations were analyzed. The values of sensitivity, specificity, and accuracy were calculated.

RESULTS

The combined sensitivity, specificity, and accuracy values for the biceps provocation test were 95%, 97%, and 96%, respectively. For the resisted hook test, the combined values were 78%, 76%, and 77%, respectively. The combined values for the tilt sign were 58%, 55%, and 56%, respectively. When the biceps provocation test and the resisted hook test were combined in a parallel testing setup, the sensitivity increased to 98% whereas the specificity was 73%. The sensitivity and specificity of the biceps provocation test and the tilt sign in a parallel testing setup were 97% and 53%, respectively. Finally, the sensitivity and specificity of the tilt sign and the resisted hook test in a parallel testing setup were 90% and 41%, respectively.

CONCLUSIONS

The biceps provocation test yielded higher accuracy than the resisted hook test and the tilt sign. When the biceps provocation test and the resisted hook test were combined, the sensitivity increased to 98%. We advise integration of these tests in daily practice to minimize delays in the diagnosis of partial distal biceps tendon ruptures, distal biceps tendon bursitis, or tendinosis. MRI in the flexion-abduction-supination view is still advised to distinguish between a partial biceps tendon rupture and tendinosis or bursitis at the distal biceps tendon insertion as this may influence further treatment.

Acute complete and partial distal biceps tendon ruptures: what have we learned? A review

Acute distal biceps tendon (DBT) pathology includes bicipitoradial bursitis, tendinosis, partial and complete tears.

Diagnosis of complete DBT tears is mainly clinical, whereas in partial tears medical imaging is a valuable addition to the clinical diagnosis.

New insights in clinical and medical imaging of partial tears may reduce time to diagnosis and may guide the treatment plan.

Most complete tears are best treated with primary repair using either a single-incision or double-incision approach with good clinical outcome.

The double-incision technique has a higher risk of heterotopic ossification, whereas a single-incision technique carries a higher risk of nerve-related complications.

Intramedullary fixation may be a viable solution to negate the risk of posterior interosseus nerve lesions in single-incision repairs.

DBT endoscopy can be used to treat low-grade partial tears and tendinosis.

Cite this article: EFORT Open Rev 2021;6:956-965. DOI: 10.1302/2058-5241.6.200145

Insular interictal positron emission tomography hypometabolism in patients with ictal asystole

We aimed to explore brain area(s) involved in the generation of ictal asystole (IA) by analyzing the interictal positron emission tomography (PET) metabolism of patients with IA recorded by video-electroencephalography or video-stereo-electroencephalography. We identified in our cohort of focal epilepsy patients who had undergone presurgical evaluation those who had a recorded period of IA of more than 3 s. We investigated the anatomometabolic changes (interictal ¹⁸ F-fluorodeoxyglucose PET) of these patients in comparison with (1) healthy subjects with similar age and sex distribution (n = 19) using whole-brain voxel-based analysis (p-voxel < .001, p-cluster < .05, uncorrected) and (2) patients without IA with similar age and seizure onset zone (n = 55). We found 12 patients with IA. Epilepsy was mainly temporal (four right temporal mesial, four bitemporal, two left temporal lateral, one right temporal lateral, and one right temporal "plus"). Seven patients had negative magnetic resonance imaging. Whole-brain statistical analysis of PET imaging was performed at the voxel level, showing that in comparison to healthy subjects and to epileptic patients without IA, a hypometabolism in the right posterior insula characterized epileptic patients with IA. Our study suggests involvement of the right posterior insula-a part of the central autonomic network-in the pathophysiological mechanism of IA.

Bisindole Alkaloids from the Alstonia Species: Recent Isolation, Bioactivity, Biosynthesis, and Synthesis

Bisindoles are structurally complex dimers and are intriguing targets for partial and total synthesis. They exhibit stronger biological activity than their corresponding monomeric units. Alkaloids, including those containing C-19 methyl-substitution in their monomeric units, their synthetic derivatives, and their mismatched pairs can be attractive targets for synthesis and may unlock better drug targets. We herein discuss the isolation of bisindoles from various Alstonia species, their bioactivity, putative biosynthesis, and synthesis. The total synthesis of macralstonidine, macralstonine, O-acetylmacralstonine, and dispegatrine, as well as the partial synthesis of alstonisidine, villalstonine, and macrocarpamine are also discussed in this review. The completion of the total synthesis of pleiocarpamine by Sato et al. completes the formal synthesis of the latter two bisindoles.

Is the flexion-abduction-supination magnetic resonance imaging view more accurate than standard magnetic resonance imaging in detecting distal biceps pathology?

BACKGROUND AND HYPOTHESIS

Partial biceps tendon pathology is difficult to diagnose. The flexion-abduction-supination (FABS) magnetic resonance imaging (MRI) view has been advocated to improve the accuracy of MRI investigation. The purpose of this study was to evaluate the accuracy of the FABS view MRI in the diagnosis of distal biceps tendon pathology.

METHODS

The study included 50 patients with surgically confirmed distal biceps tendon pathology and 50 patients with other elbow disorders. In both groups, standard elbow MRI (retrospective review of previously obtained MRI data) was performed in half of the patients whereas FABS views MRI were obtained in the other half. These were evaluated by 2 independent musculoskeletal radiologists. The sensitivity and specificity of both MRI views were determined. Tendinosis and grade of rupture were reported from MRI and then compared with surgical findings.

RESULTS

There were no significant differences in sensitivity and specificity in detecting partial distal biceps injuries when the FABS view MRI (sensitivity, 84%; specificity, 86%) and standard MRI (sensitivity, 76%; specificity, 98%) were compared. The interobserver reliability was 92% for the FABS view MRI with biceps pathology and 68% for standard MRI. In the control group, the interobserver reliability was 88% for the FABS view MRI and 96% for standard MRI. FABS MRI was significantly better regarding grade of injury.

CONCLUSIONS

No significant differences in sensitivity and specificity were found between the FABS view and standard elbow MRI in the diagnosis of partial distal biceps tendon injuries, with high sensitivity and specificity for both views. Inter-rater reliability was better for FABS views, and FABS views were significantly more accurate than surgical findings in grading the extent of pathology.

Clinical performance of cantilevered resin-bonded fixed partial dentures for single tooth replacement in elderly patients

Objective

To evaluate the clinical performance of cantilevered resin-bonded fixed partial dentures (CRBFPDs) in single tooth replacement in elderly patients at Qingdao Stomatological Hospital.

Methods

In total, 186 CRBFPDs in 153 patients were made from cobalt-chrome alloy. Panavia F 2.0 was used as a luting agent after air-abrasion. Restoration were evaluated at 3-month intervals with regard to function, esthetics, and possible complications.

Results

CRBFPDs were evaluated after intervals of 12 to 40 months. The average clinical service time (i.e., length of time in situ at examination, including re-cementation after debonding) was 26.2 ± 13.6 months. Among these CRBFPDs, 87 (46.8%) were bridges in the maxilla, while 99 (53.2%) were bridges in the mandible. Most CRBFPDs (184, 98.9%) survived throughout the study period, while two (1.1%) were regarded as failed. The majority of debonded bridges had been used to replace the maxillary central incisor (60%).

Conclusion

Our findings confirm the successful clinical performance of CRBFPDs with tooth preparation designs involving mesial and distal vertical grooves in elderly patients.

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure

Background

Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life.

Aims

In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy.

Method

This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received.

Results

In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group.

Conclusion

LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Partial rupture of the distal biceps brachii tendon: a magnetic resonance imaging analysis

BACKGROUND

This study is the largest cohort of partial distal biceps brachii tendon ruptures in the literature that was analyzed according to rupture morphology of the long and short tendon heads.

METHODS

Patients with partial distal biceps tendon ruptures were identified using an institutional enterprise data warehouse query at a single institution. A retrospective chart review was performed to record patient demographics, past medical history, and injury mechanism for each patient. Each patient's magnetic resonance images were reviewed to determine injury patterns, specifically the extent of long head (LH) and short head (SH) tendon involvement, and associated injuries. Rupture morphologies were correlated with mechanism of injury, diabetes status, and smoking history.

RESULTS

Seventy-seven patients were included in the study. The average age was 52 years (±11.9, range: 23-90 years); 67% were male, with an average body mass index of 28.3 (±4.3). A smoking history was reported in 31.2% of patients and 5.2% were diabetic. The partial ruptures were caused by a traumatic mechanism in 57.1% of cases, 23.4% were atraumatic, and 19.5% had an unknown mechanism. The most common injury morphology was a partial LH rupture with an intact SH tendon (33.8%). Isolated complete ruptures of the LH represented the least common injury morphology. Injury morphology was significantly related to mechanism (P < .01). Traumatic ruptures had a higher percentage of SH involvement compared with the atraumatic group (77.3% vs. 37.7%, respectively). In contrast, atraumatic ruptures involved the LH tendon in 89% of cases, with only 37.7% of cases involving the SH tendon. Patients with a history of smoking were more likely to have an atraumatic mechanism (P = .01). A history of diabetes was unrelated to mechanism (P = .20).

CONCLUSION

Partial ruptures of the distal biceps brachii tendon represent a spectrum of patterns with varying involvement of the LH and SH tendons. Injury morphology was significantly related to mechanism (P < .01). LH tendon involvement was seen in 88.9% of atraumatic cases, whereas SH tendon involvement was seen in 77.3% of traumatic cases. A more comprehensive understanding of partial rupture patterns is critical to further understand the risk factors that may preclude to worse clinical outcomes, and aid in deciding which patients would benefit from operative vs. nonoperative management.

Surgical, Oncological, and Functional Outcomes of Transoral Robotic Supraglottic Laryngectomy

OBJECTIVES/HYPOTHESIS

To investigate the surgical, oncological, and functional outcomes of transoral robotic surgery (TORS) for the treatment of supraglottic squamous cell carcinoma.

STUDY DESIGN

Retrospective chart review.

METHODS

The charts of patients treated by TORS supraglottic laryngectomy (SGL) in an academic medical center were reviewed. The following outcomes were studied according to the tumor location: average robotic setup and operative times, mean estimated blood loss, postoperative complications, need of tracheotomy, refeeding characteristics, mean hospital stay, need of neck dissection and adjuvant therapy, 5-year local and regional controls, overall survival (OS), and disease-free survival (DFS).

RESULTS

Seventy-five patients underwent TORS SGL. Tumors were classified as cT1 (32%), cT2 (52%), and cT3 (16%). Average robotic setup and operative times and the mean estimated blood loss were 15 minutes, 55 minutes, and 20 mL, respectively. The mean follow-up period ranged from 2 to 5 years. The 5-year OS and DFS were 80.2% and 94.3%, respectively. Overall, 34.6% of patients received adjuvant radiotherapy. The majority of patients (92%) restarted an oral diet within 24 to 48 hours postsurgery. Transient tracheotomy was performed in 8% of patients. Postoperative hemorrhages occurred in 12 patients (16.0%), lengthening the hospital stay (mean = 6.8 days). There were no outcome differences regarding the tumor location.

CONCLUSIONS

TORS is an effective and safe therapeutic approach for early- and intermediate-stages cancers. Oncological outcomes may be quite similar to other surgical approaches, including transoral laser and open surgeries. Future randomized controlled studies are needed for comparing TORS SGL with other surgical procedures.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1060-1065, 2021.

Partial Purine Nucleoside Phosphorylase Deficiency Helps Determine Minimal Activity Required for Immune and Neurological Development

Introduction: Complete or near complete absence of the purine nucleoside phosphorylase (PNP) enzyme causes a profound T cell immunodeficiency and neurological abnormalities that are often lethal in infancy and early childhood. We hypothesized that patients with partial PNP deficiency, characterized by a late and mild phenotype due to residual PNP enzyme, would provide important information about the minimal PNP activity needed for normal development. Methods: Three siblings with a homozygous PNP gene mutation (c.769C>G, p.His257Asp) resulting in partial PNP deficiency were investigated. PNP activity was semi-quantitively assayed by the conversion of [14C]inosine in hemolysates, mononuclear cells, and lymphoblastoid B cells. PNP protein expression was determined by Western Blotting in lymphoblastoid B cells. DNA repair was quantified by measuring viability of lymphoblastoid B cells following ionizing irradiation. Results: A 21-year-old female was referred for recurrent sino-pulmonary infections while her older male siblings, aged 25- and 28- years, did not suffer from significant infections. Two of the siblings had moderately reduced numbers of T, B, and NK cells, while the other had near normal lymphocyte subset numbers. T cell proliferations were normal in the two siblings tested. Hypogammaglobulinemia was noted in two siblings, including one that required immunoglobulin replacement. All siblings had typical (normal) neurological development. PNP activity in various cells from two patients were 8-11% of the normal level. All siblings had normal blood uric acid and increased PNP substrates in the urine. PNP protein expression in cells from the two patients examined was similar to that observed in cells from healthy controls. The survival of lymphoblastoid B cells from 2 partial PNP-deficient patients after irradiation was similar to that of PNP-proficient cells and markedly higher than the survival of cells from a patient with absent PNP activity or a patient with ataxia telangiectasia. Conclusions: Patients with partial PNP deficiency can present in the third decade of life with mild-moderate immune abnormalities and typical development. Near-normal immunity might be achieved with relatively low PNP activity.

Effect of Partial Pars Plana Vitrectomy in Two Cases: Removal of Intraocular Foreign Body and Intraocular Lens Dropped Into Vitreous

The aim of this case study was to present the effect of partial pars plana vitrectomy (PPV) in two cases that is due to the presence of an intraocular foreign body (IOFB) and intraocular lens (IOL) that has dropped into the intravitreal area. The first case was a 30-year-old man with IOFB in the right eye, and the second case was a 34-year-old woman whose IOL was dropped into vitreous after trauma. In cases, IOFB and IOL were extracted from vitreous performed by partial PPV without complication. Partial PPV was effective despite without complete vitrectomy. With minimal/partial vitrectomy approach, most of the vitreous tissues was left in place. We believe that this approach will reduce the rate of complications, such as cataract and retinal detachment.

Cementation of Tooth-colored Restorations - A Survey among Dentists in Germany

Purpose: To survey dentists in Germany regarding their preferred cementation regimen for fixed dental prostheses (FDPs) fabricated from various restorative materials. Materials and Methods: An online survey was developed for completion by dentists in Germany between 08/2019 and 02/2020. The questionnaire gathered information about the cementation regimen (conventional, including the acid-base cements zinc-oxide phosphate or any glass-ionomer cement; self-adhesive; adhesive; don’t know) that the participant would preferably select for the insertion of single- or multi-unit FDPs fabricated from various restorative materials. Data were also collected on demographic and personal characteristics. Results: A total of 721 dentists completed the survey, and the data from 688 questionnaires were included in the analysis. Conventional cementation was the option of choice for restorations fabricated from alloy/porcelain-fusedto- metal among 91.0% of the participants and for restorations fabricated from polycrystalline ceramics among 42.9% of the participants. Adhesive cementation was preferred for restorations fabricated from feldspathic/leucitereinforced glass ceramics (77.9%), lithium-disilicate glass ceramics (67.5%), zirconia-reinforced lithium-silicate glass ceramics (42.0%), and CAD/CAM resin composites (63.8%). Uncertainties regarding the appropriate cementation protocol for restorations fabricated from CAD/CAM resin composites were reported by 15% of the participants. More than 20% of the participants selected a technique that is less or not at all recommended for the cementation of restorations fabricated from zirconia-reinforced lithium-silicate glass ceramic and CAD/CAM resin composites. Conclusion: The results of the survey suggest that dentists in Germany select the cementation regime depending on the restorative material. Some of the participating dentists selected cementation regimens that are less or not at all recommended for restorations fabricated from zirconia-reinforced lithium-silicate glass ceramic and CAD/CAM resin composites, or were not sure about the appropriate cementation protocol.

Laparoscopic partial adrenalectomy using near-infrared imaging: the initial experience

INTRODUCTION

To present our initial clinical experience with laparoscopic partial adrenalectomy using indocyanine green dye with near-infrared fluorescence imaging.

MATERIAL AND METHODS

A total of eight patients underwent transperitoneal laparoscopic partial adrenalectomy using indocyanine green dye with near-infrared fluorescence imaging in our clinic. After 5 mg intravenous indocyanine green dye administration, we resected the mass under the guidance of near-infrared fluorescence imaging and white light visualization in an effort to completely excise the mass while sparing uninvolved adrenal tissue.

RESULTS

Seven patients underwent unilateral and one patient underwent bilateral laparoscopic partial adrenalectomy. The median tumor size was 43 mm. The surgery was successfully performed with negative margins in all patients. The tumors were hypofluorescent relative to normal adrenal tissue with indocyanine green dye with near-infrared fluorescence imaging in patients with Cushing's syndrome, aldosteronoma, and adrenal cyst. However, pheochromocytoma and angiomyolipoma were noted to be isoflourorescent and hyperfluorescent relative to normal adrenal parenchyma, respectively.

CONCLUSIONS

Laparoscopic partial adrenalectomy using intraoperative indocyanine green dye with near-infrared fluorescence imaging seems to be safe and feasible. This technology may ultimately be helpful in resecting lesions with more precise surgical margins by identifying the vascular structure during laparoscopic partial adrenalectomy. Abbreviations: LTA: Laparoscopic total adrenalectomy; LPA:Laparoscopic partial adrenalectomy; ICG: Indocynanine green; NIRF: Near-infrared fluorescence; HPA: Hypothalamic-pituitary-adrenal.

Partial 2-Stage Exchange for Infected Total Hip Arthroplasty: An Updated Report

BACKGROUND

Management of an infected total hip arthroplasty (THA) is challenging. The eradication of infection as well as complications of component removal must all be considered. This study is an update on previous reports of treating periprosthetic infection of the hip with a partial 2-stage exchange with retention of the femoral component.

METHODS

A retrospective review of our practice's arthroplasty registry from 2000 to 2018 revealed 41 hips with 2-year minimum follow-up that were treated with a 2-stage partial exchange for an infected THA. All first-stage procedures allowed an articulating construct with 1 of 3 variations: cemented constrained liner (13 hips), StageOne Hip Cement Spacer Mold (14 hips), or an antibiotic polymethylmethacrylate head molded from a bulb syringe (14 hips). Of 41 cases, 34 were culture positive, with 3 cases having methicillin-resistant Staphylococcus.

RESULTS

Mean follow-up was 5.5 years (range, 1.5-18.5 years). The second-stage reimplantation was accomplished in 39 of the 41 hips (95%) at a mean interval of 9.2 weeks (range, 5-9 weeks). Two patients underwent repeat radical debridement with removal of all components before reimplantation for persistent clinical evidence of infection. Thirty-three of the 41 hips (81%) were infection free at most recent follow-up. The mean postoperative Harris hip score at most recent evaluation was 63.6 (range, 24-100).

CONCLUSION

Eradication of periprosthetic joint infections, while minimizing patient morbidity, continues to be a challenge. Partial 2-stage exchange may be considered in cases where removal of a well-fixed femoral component may result in significant bony destruction.

Contemporary Perioperative Morbidity and Mortality Rates of Minimally Invasive vs Open Partial Nephrectomy in Obese Patients with Kidney Cancer

Aims: To compare early postoperative morbidity and mortality rates in obese patients (body mass index ≥30 kg/m²) who underwent minimally invasive partial nephrectomy (MIPN) vs open partial nephrectomy (OPN), utilizing the National Surgical Quality Improvement Program (NSQIP) database. Materials and Methods: The NSQIP database was queried to identify obese patients who underwent either MIPN or OPN between 2008 and 2016. Patient demographics, comorbidities, operative time (OT), length of stay (LOS), and 30-day postoperative complications, readmissions, and mortality rates were recorded and compared between the two groups. Multivariable logistic regression analysis was used to determine the adjusted odds of early postoperative complications in MIPN vs OPN. Results: A total of 6041 obese MIPN patients and 3064 obese OPN patients were identified. Mean OT (minutes ± standard deviation) was longer for MIPN vs OPN (197.2 ± 71.0 vs 189.6 ± 82.4, p < 0.001), while mean LOS (3.8 ± 2.8 days vs 5.8 ± 3.5 days, p < 0.001) and 30-day complications (8.5% vs 19.8%, p < 0.001) were lower. No difference in 30-day postoperative mortality rates between MIPN (0.4%) and OPN (0.5%) was observed (p = 0.426). In the adjusted analysis, the odds of any complication within 30 days in the MIPN group were 61% lower, blood transfusion 73% lower, pneumonia 38% lower, sepsis 70% lower, acute renal failure 64% lower, superficial surgical site infection 40% lower, and reoperation 47% lower, compared with OPN patients. Conclusions: When compared with OPN in obese patients, the likelihood of 30-day postoperative morbidity was significantly lower in MIPN patients. However, the odds of 30-day mortality rates were similar between the groups.

Primary Closure of a Partial Superior Sternal Cleft in a 27-day-old Neonate: Case Report with Short Review of Literature

A sternal cleft is a chest wall malformation resulting from a failure of sternal fusion. It is a rare anomaly with an incidence of 2:100,000 live births representing less than a percent of all chest wall deformities. The aim of surgery is to provide bony protection over the mediastinal structures. We present a 27-day-old neonate with an upper partial sternal cleft for whom successful primary sternal closure was performed.

Partial Capitate Shortening Osteotomy and Its Impact on Lunate Revascularization: Mid-Term Results

Background

Treatment of Kienböck disease is still a clinical challenge. The treatment used in each instance is decided according to stage of the disease at presentation. Good clinical and radiological results could be obtained with partial capitate shortening osteotomy. However, mid-term results of this technique and its effect on lunate revascularization are not well known.

Objectives

The aim of this study was to report our results of partial capitate shortening osteotomy in the treatment of stage II and IIIA Kienböck disease.

Methods

Ten patients were enrolled in the study with a mean age of 37.7 years old (standard deviation [SD] = 9.6). Patients were evaluated clinically in terms of range of motion, DASH and VAS scores, satisfaction with the outcome, and grip/tip/palmar/key pinch strength compared to the contralateral side. Radiological evaluation consisted of Lichtman staging on plain radiographs and lunate revascularization on magnetic resonance imaging (MRI) at both preoperative and postoperative evaluations.

Results

The mean duration of follow-up was 55.2 (SD = 24) months. The mean DASH and VAS scores were 14.3 (SD = 6.7) and 1.5 (SD = 1.3), respectively. For patient satisfaction, the mean score was 3.6 (SD = 0.6). The Lichtman stage of 7 patients remained unchanged. Lunate revascularization was detected with MRI in 6 patients.

Conclusions

Although the number of patients in the study prevents more strict conclusions, our results are promising, and the technique presented offers minimally but observable lunate revascularization and high success rates in preventing the progression of the disease.

Evaluation of Renal Function with Administration of 6% Hydroxyethyl Starch and 4% Gelatin in Major Abdominal Surgeries: A Pilot Study

Background:

Synthetic colloids, both starches and gelatins, are commonly used as intravascular fluid replacements on account of increased vascular persistence. The safety on renal outcomes during perioperative use is poorly understood.

Aims:

We evaluated renal outcomes of hydroxyethyl starch 6% (HES) and gelatins 4% (G) in patients undergoing elective abdominal surgery. The primary outcome was serum creatinine measurements at baseline, 12 h, 36 h, and 1 week postoperatively (T₀, T₁₂, T₃₆, and D₇). The secondary outcomes were measurements of prothrombin time (PT), international normalized ratio (INR), fibrinogen, and activated partial thromboplastin time (aPTT) at baseline, 12 h, and 36 h postoperatively.

Setting and Design:

A prospective randomized study was conducted at a tertiary care institute.

Materials and Methods:

Seven-five adult patients received either HES (Group H) or gelatin (Group G) at 20-ml/kg body weight or only crystalloids (Group C) during surgery. Statistical tests used were one-way ANOVA, Student's t-test, Pearson correlation method, and Chi-square test.

Results:

Serum creatinine assessed at T₀, T₁₂, T₃₆, and D₇ was comparable between the three groups. PT/INR and aPTT showed no significant increase in values of T₁₂ and T₃₆ in comparison to T₀. Fibrinogen level was significantly higher in Group C at T₁₂ and T₃₆. Intraoperative vasopressor use, need for product transfusion, length of intensive care unit stay, and return of bowel function were similar between the three groups.

Conclusions:

Intraoperative use of HES (130/0.4) or gelatin (4%) at 20-ml/kg body weight was not associated with renal dysfunction or altered PT and aPTT in adult patients undergoing elective abdominal major surgeries.

Frequency and Stratification of Epileptogenic Lesions in Elderly With New Onset Seizures

Objective: To evaluate prospectively the frequency of epileptogenic lesions in a consecutive cohort of elderly patients presenting with new onset unprovoked seizures, and who underwent a complete evaluation including dedicated epilepsy protocol MRI.

Methods and materials: We included all consecutive patients 60 years or older who participated in a prospective study on new onset epilepsy. The work-up included the acquisition of a dedicated epilepsy protocol MRI and a 3 h video/EEG recording. We evaluated the frequency and types of epileptogenic lesions in the whole cohort and stratified those variables by age, gender, types and number of seizures at presentation. We also correlated the EEG findings with the clinical characteristics and neuroimaging results.

Results: Of the 101 patients enrolled in the study and who underwent an epilepsy protocol MRI, an epileptogenic lesion was identified in 67% of cases. The most common etiologies were vascular events, followed by tumoral causes and traumatic brain injuries. Epileptogenic lesions were more likely to be identified in patients who presented with only focal aware and impaired awareness seizures. In addition, patients with tumoral epilepsy were significantly more likely to only experience those seizure types compared to patients with other pathological substrates. Interictal/ictal discharges were detected in the EEG of 21% of patients. Epileptiform discharges were significantly more frequent in patients with an epileptogenic lesion on brain MRI, especially in those with a brain tumor.

Conclusions: Our results stress the importance of obtaining a dedicated epilepsy protocol MRI in elderly patients with new onset seizures. An epileptogenic lesion will be identified in approximately two thirds of patients with important implications regarding initiation of treatment. In addition, the data underscore the value of distinguishing the types of seizures experienced at presentation as this will apprise the treating physician on the likelihood of identifying an epileptogenic lesion and on the probable etiologies.

Lacosamide monotherapy in clinical practice: A retrospective chart review

OBJECTIVE

To assess effectiveness and tolerability of first-line and conversion to lacosamide monotherapy for focal seizures.

MATERIALS AND METHODS

Retrospective, non-interventional chart review of lacosamide monotherapy patients aged ≥16 years in Europe. Outcomes included retention rate at observational point (OP) 3 (12 ± 3 months), seizure freedom rates at OP2 (6 ± 3 months) and OP3 and adverse drug reactions (ADRs).

RESULTS

A total of 439 patients were included (98 first-line and 341 conversion to monotherapy; 128 aged ≥65 years [25 first-line and 103 conversion to monotherapy]). First-line and conversion to monotherapy retention rates were 60.2% (59/98; 95% confidence interval [CI] 49.8%-70.0%) and 62.5% (213/341; 57.1%-67.6%), respectively. Kaplan-Meier estimates of 12-month retention rates were 81.2% and 91.4% for first-line and conversion to monotherapy, respectively. First-line and conversion to monotherapy retention rates in patients aged ≥65 years were 60.0% (38.7%-78.9%) and 68.9% (59.1%-77.7%), respectively. At OP2, 66.3% of first-line and 63.0% of conversion to monotherapy patients were seizure free. At OP3, 60.2% of first-line and 52.5% of conversion to monotherapy patients were seizure free. In the ≥65 years subgroup, seizure freedom rates at OP2 were 72.0% and 68.0% for first-line and converted to monotherapy, respectively, and at OP3, 68.0% and 56.3%, respectively. Overall, 52 of 439 (11.8%) patients reported ADRs (16.4% in ≥65 years subgroup), most commonly dizziness (5.0%), headache (2.1%) and somnolence (1.6%).

CONCLUSIONS

Lacosamide was effective and well tolerated as first-line or conversion to monotherapy in a clinical setting in adult and elderly patients with focal seizures.

Long-term outcomes of partial prostate treatment with magnetic resonance imaging-guided brachytherapy for patients with favorable-risk prostate cancer

BACKGROUND

Partial prostate treatment has emerged as a potential method for treating patients with favorable-risk prostate cancer while minimizing toxicity. The authors previously demonstrated poor rates of biochemical disease control for patients with National Comprehensive Cancer Network (NCCN) intermediate-risk disease using partial gland treatment with brachytherapy. The objective of the current study was to estimate the rates of distant metastasis and prostate cancer-specific mortality (PCSM) for this cohort.

METHODS

Between 1997 and 2007, a total of 354 men with clinical T1c disease, a prostate-specific antigen (PSA) level < 15 ng/mL, and Gleason grade ≤3 + 4 prostate cancer underwent partial prostate treatment with brachytherapy to the peripheral zone under 0.5-Tesla magnetic resonance guidance. The cumulative incidences of metastasis and PCSM for the NCCN very low-risk, low-risk, and intermediate-risk groups were estimated. Fine and Gray competing risk regression was used to evaluate clinical factors associated with time to metastasis.

RESULTS

A total of 22 patients developed metastases at a median of 11.0 years (interquartile range, 6.9-13.9 years). The 12-year metastasis rates for patients with very low-risk, low-risk, and intermediate-risk disease were 0.8% (95% confidence interval [95% CI], 0.1%-4.4%), 8.7% (95% CI, 3.4%-17.2%), and 15.7% (95% CI, 5.7%-30.2%), respectively, and the 12-year PCSM estimates were 1.6% (95% CI, 0.1%-7.6%), 1.4% (95% CI, 0.1%-6.8%), and 8.2% (95% CI, 1.9%-20.7%), respectively. On multivariate analysis, NCCN risk category (low risk: hazard ratio, 6.34 [95% CI, 1.18-34.06; P = .03] and intermediate risk: hazard ratio, 6.98 [95% CI, 1.23-39.73; P = .03]) was found to be significantly associated with the time to metastasis.

CONCLUSIONS

Partial prostate treatment with brachytherapy may be associated with higher rates of distant metastasis and PCSM for patients with intermediate-risk disease after long-term follow-up. Treatment of less than the full gland may not be appropriate for this cohort.

Evaluation of Quantitative and Qualitative Renal Outcome Following Nephron Sparing Surgery

Purpose:

Preservation of renal function after nephron-sparing surgery (NSS) is multifactorial and the impact of individual factors on it is still a debate. This prospective study investigates the impact of factors responsible for quantitative and functional outcome after NSS.

Patients and Methods:

Fifty-two patients of localized renal mass (≤7 cm) were included in the study. A contrast-enhanced computed tomography abdomen was performed for characterization of tumor. Glomerular filtration rate (GFR) was calculated using Tc99m-diethylenetriamine pentaacetic acid (DTPA) scan and Cockcroft-Gault (CG) formula. All relevant intra- and peri-operative events were noted. Follow-up work up performed at 3 months.

Results:

Overall, the mean ischemia time was 30.6 min, with 7.7% decrease in renal volume in the operated moiety. In follow-up, the total and ipsilateral GFR decreased. Change in renal parenchymal volume, total GFR by CG and DTPA, split GFR of tumor-bearing moiety was significant in follow-up. Size, stage, polar location of tumor, duration of surgery, type of ischemia, preoperative chronic kidney disease, and need of blood transfusion did not affect change in renal volume and function in the follow-up period.

Conclusion:

Renal parenchymal loss and duration of ischemia have impact on the follow-up renal function.

Twenty-seven mutations with three novel pathologenic variants causing biotinidase deficiency: a report of 203 patients from the southeastern part of Turkey

BACKGROUND

Biotinidase deficiency (BD) is an autosomal recessive inborn error of metabolism characterized by neurologic and cutaneous symptoms and can be detected by newborn screening. Newborn screening for BD was implemented in Turkey at the end of 2008.

METHODS

In total, 203 patients who were identified among the infants detected by the newborn screening were later confirmed to have BD through measurement of serum biotinidase activity. We also performed BTD mutation analysis to characterize the genetic profile.

RESULTS

Twenty-seven mutations were identified. The most commonly found variants were c.1330G>C (p.D444H), c.1595C>T (p.T532M), c.470G>A (p.R157H), and c.198_104delGCGGCTGinsTCC (p.C33Ffs ) with allele frequencies of 0.387, 0.175, 0.165 and 0.049, respectively. Three novel pathogenic and likely pathogenic variants were identified: p.W140* (c.419G>A), p.S319F (c.956C>T) and p.L69Hfs*24 (c.192_193insCATC). We also identified three mutations reported in just one patient in the past (p.V442Sfs*59 [c.1324delG], p.H447R [c.1340A>G] and p.198delV [c.592_594delGTC]). Although all of the patients were asymptomatic under the treatment of biotin, only one patient, who had the novel c.419G>A homozygous mutation became symptomatic during an episode of acute gastroenteritis with a presentation of ketosis and metabolic acidosis. Among the screened patients, 156 had partial and 47 had profound BD.

CONCLUSIONS

We determined the mutation spectra of BD from the southeastern part of Turkey. The results of this study add three more mutations to the total number of mutations described as causing BD.

Myoclonic movement after general anesthesia: A case report and review of the literature

RATIONALE

Myoclonic movement is a rare side effect after general anesthesia. Since we use various intravenous agents during general anesthesia recently, it is troublesome to find out the exact cause of this neurologic complication.

PATIENT CONCERNS

A 31-year-old female patient without any past medical history underwent hip arthroscopic surgery under general anesthesia.

DIAGNOSES

Although there was no specific event during the operation, she showed a sudden myoclonic movement confined to left upper extremity in recovery room.

INTERVENTIONS

We administered anticonvulsant agents intrvenously, the myoclonus was stopped shortly but recurred over again. As we stopped the patient-controlled analgesia due to nausea, the symptom halted.

OUTCOMES

There was no significant abnormality in electroencephalography or brain diffusion magnetic resonance imaging, which was taken after the event.

LESSONS

Clinicians should carefully consider the pharmacologic characteristics and neurologic adverse effects of all administered agents when myoclonus occurs after general anesthesia.

Scaphoid Healing Required for Unrestricted Activity: A Biomechanical Cadaver Model

PURPOSE

To determine if scaphoid fractures with bridging bone of 50% of their width treated with a centrally placed screw will restore biomechanical integrity equivalent to that of the intact scaphoid.

METHODS

Twenty-four fresh cadaver scaphoids were used. Six were left intact to serve as the control group. Six were osteotomized 50% of their width and made up the osteotomy without screw group. Six were included in the 50% osteotomy plus compression screw group. The remaining 6 were to be treated with an osteotomy of 25% or 75% with a screw, based upon the results of the 50% osteotomy with screw group. Biomechanical testing was performed using an Instron testing machine, with a load applied to the scaphoid's distal pole. Load to failure and stiffness were measured.

RESULTS

Intact scaphoids had an average load to failure of 610.0 N. The average load to failure of the 50% osteotomy group without a screw was 272.0 N and with a screw was 666.3 N. There was no significant difference in load to failure between the 50% osteotomy plus screw and the intact scaphoid. The 75% osteotomy plus screw was found to have a load to failure of 174.0 N, significantly lower than the intact scaphoid. The 50% osteotomy plus screw had a significantly higher stiffness than the intact scaphoid control.

CONCLUSIONS

A 50% intact scaphoid with a centrally placed screw showed similar load to failure and significantly higher stiffness than the intact scaphoid when tested in cantilever bending.

CLINICAL RELEVANCE

This study demonstrates that patients with scaphoid waist fractures who undergo surgery with a compression screw may be able to return to unrestricted activity with 50% partial healing.

Total Ossicular Replacement Prosthesis: A New Fat Interposition Technique

Objective:

To compare audiometric results between the standard total ossicular replacement prosthesis (TORP-S) and a new fat interposition total ossicular replacement prosthesis (TORP-F) in pediatric and adult patients and to assess the complication and the undesirable outcome.

Study design:

This is a retrospective study.

Methods:

This study included 104 patients who had undergone titanium implants with TORP-F and 54 patients who had undergone the procedure with TORP-S between 2008 and 2013 in our tertiary care centers. The new technique consists of interposing a fat graft between the 4 legs of the universal titanium prosthesis (Medtronic Xomed Inc, Jacksonville, FL, USA) to provide a more stable TORP in the ovale window niche. Normally, this prosthesis is designed to fit on the stapes’ head as a partial ossicular replacement prosthesis.

Results:

The postoperative air-bone gap less than 25 dB for the combined cohort was 69.2% and 41.7% for the TORP-F and the TORP-S groups, respectively. The mean follow-up was 17 months postoperatively. By stratifying data, the pediatric cohort shows 56.5% in the TORP-F group (n = 52) compared with 40% in the TORP-S group (n = 29). However, the adult cohort shows 79.3% in the TORP-F group (n = 52) compared with 43.75% in the TORP-S group (n = 25). These improvements in hearing were statistically significant. There were no statistically significant differences in the speech discrimination scores. The only undesirable outcome that was statistically different between the 2 groups was the prosthesis displacement: 7% in the TORP-F group compared with 19% in the TORP-S group (P = .03).

Conclusions:

The interposition of a fat graft between the legs of the titanium implants (TORP-F) provides superior hearing results compared with a standard procedure (TORP-S) in pediatric and adult populations because of its better stability in the oval window niche.

Immediate vs. delayed endosseous integration of maxi implants: a torque removal animal study

Background. Delayed loading is one of the concerns in implant patients. Immediate loading can solve the problem and make patients more satisfied. The present study aimed to compare the removal torque of maxi implants under different loading (immediate and delayed) patterns. Methods. This split-mouth experimental study included 2 dogs. Impressions were made and then all the premolars were extracted under general anesthesia. After a three-month healing period, 3 implants were inserted in each quadrant (a total of 12 implants). Anterior and posterior implants (the case group) were splinted by an acrylic temporary bridge in order to make the middle implants (the control group) off the occlusion. The dogs were sacrificed after 6 weeks and bone blocks were submitted for removal torque test. Data were analyzed with ANOVA (P<0.05). Results. Mean torque values for the cases and control groups were 46.82±25.58 and 59.88±15.19, respectively (P=0.582; not significant). Conclusion. It may be concluded that immediate loading does not reduce the reverse torque values of maxi implants. This supports the advantages of immediate loading for maxi implants.

Anterosuperior rehabilitation with metal-free fixed prosthesis based on zirconia

The loss of upper front dental elements causes functional and psychosocial problems to the affected individuals. In this case report, the treatment planning considered hard and soft tissue loss for a complex fixed partial denture (FPD) rehabilitation. The six-element, all-ceramic FPD was manufactured using a computer-aided design/computer-aided manufacturing system with zirconia framework, veneered with leucite-reinforced ceramic. Ceramic artificial gum was also produced to guarantee tooth-facial proportions as well as lip support, promoting both esthetics and phonetics. The material's mechanical properties allowed for the coupling of the esthetic and mechanical requirements, proving an alternative to the well-established metal-ceramic technology, optimizing biomimetic. One of the endodontic-treated abutment teeth required a radicular retainer with cast metal post, but because of the opacity of zirconia, the esthetics of the prosthesis was not compromised. The low silica content of high resistance ceramics such as zirconia hampers the adhesive cementation, with numerous studies advocating for different cementation protocols, with no clear scientific consensus so far. In the present case, the internal surface of the FPD was initially blasted with aluminum oxide, followed by the application of a universal adhesive system containing 10-methacryloyloxydecyl dihydrogen phosphate. Finally, cementation to the dental structure was conducted with dual-cure self-adhesive resin cement.

Mother and daughter with adolescent-onset severe frontal lobe dysfunction and epilepsy

Familial cases of early-onset prominent frontal lobe dysfunction associated with epilepsy have not been reported to date. We report a mother and her only daughter with incapacitating behavioral manifestations of frontal lobe dysfunction and epilepsy of variable severity. The possibility of a hitherto undescribed genetic condition is discussed.

Magnetoencephalographic signatures of insular epileptic spikes based on functional connectivity

Failure to recognize insular cortex seizures has recently been identified as a cause of epilepsy surgeries targeting the temporal, parietal, or frontal lobe. Such failures are partly due to the fact that current noninvasive localization techniques fare poorly in recognizing insular epileptic foci. Our group recently demonstrated that magnetoencephalography (MEG) is sensitive to epileptiform spikes generated by the insula. In this study, we assessed the potential of distributed source imaging and functional connectivity analyses to distinguish insular networks underlying the generation of spikes. Nineteen patients with operculo-insular epilepsy were investigated. Each patient underwent MEG as well as T1-weighted magnetic resonance imaging (MRI) as part of their standard presurgical evaluation. Cortical sources of MEG spikes were reconstructed with the maximum entropy on the mean algorithm, and their time courses served to analyze source functional connectivity. The results indicate that the anterior and posterior subregions of the insula have specific patterns of functional connectivity mainly involving frontal and parietal regions, respectively. In addition, while their connectivity patterns are qualitatively similar during rest and during spikes, couplings within these networks are much stronger during spikes. These results show that MEG can establish functional connectivity-based signatures that could help in the diagnosis of different subtypes of insular cortex epilepsy. Hum Brain Mapp 37:3250-3261, 2016. © 2016 Wiley Periodicals, Inc.

Microbiological analysis after complete or partial removal of carious dentin using two different techniques in primary teeth: A randomized clinical trial

Background:

The management of deep carious lesions can be done by various techniques but residual caries dilemma still persists and bacterial reduction in cavities treated by either partial or complete caries removal techniques is debatable. So the objective of the present randomized clinical trial was to compare microbial counts in cavities submitted to complete caries removal and partial caries removal using either hand instruments or burs before and after 3 weeks of restoration.

Materials and Methods:

Primary molars with acute carious lesions in inner half of dentine and vital pulp were randomly divided into three groups of 14 each: Group A: Partial caries removal using hand instruments atraumatic restorative treatment (ART) only; Group B: Partial caries removal using bur; Group C: Complete caries removal using bur and caries detector dye. Dentine sample obtained after caries removal and 3 weeks after restoration, were subjected to microbial culture and counting (colony-forming units [CFU]/mg of dentine) for total viable bacterial count, Streptococcus spp., mutans streptococci, Lactobacillus spp.

Results:

Three techniques of caries removal showed significant (P < 0.05) reduction in all microorganisms studied after 3 weeks of evaluation, but there was no statistically significant difference in percentage reduction of microbial count among three groups.

Conclusion:

Results suggest the use of partial caries removal in a single session as compared to complete caries removal as a part of treatment of deep lesions in deciduous teeth in order to reduce the risk of pulp exposure. Partial caries removal using ART can be preferred for community settings as public health procedure for caries management.

Accuracy of Visual Estimates of Partial Flexor Tendon Lacerations

PURPOSE

To determine whether hand surgeons could accurately and consistently estimate the size of partial flexor tendon lacerations.

MATERIALS AND METHODS

Thirty-two partial flexor tendon lacerations were made in the flexor digitorum profundus tendons of a fresh-frozen cadaveric hand. Four hand surgeons and 5 residents estimated the size of the lacerations. Estimates were repeated 3 days later. Magnified images of the laceration cross-section were used to calculate the true size of each laceration. Inter- and intrarater reliability were calculated using the intraclass correlation coefficient. Accuracy was measured with the mean bias error and the mean absolute error.

RESULTS

Interrater and intrarater reliabilities were both high. There was a high level of consistency for both surgeons and residents. In terms of accuracy, there was a 3% bias toward underestimation. The mean absolute error was 11%. There was no statistically significant difference between the accuracy of attending hand surgeons and that of residents. Participants were less accurate when estimating lacerations close to a 60% laceration threshold for surgical repair (lacerations in the 50%-70% range). For lacerations within this range, an incorrect management decision would have been made 17% of the time, compared with 7% of the time for lacerations outside that range.

CONCLUSIONS

The accuracy and reliability of surgeon estimates of partial flexor tendon laceration size were high for surgeons and residents. Accuracy was lower for lacerations close to the threshold for repair.

CLINICAL RELEVANCE

Visual estimation is acceptable for evaluating partial flexor tendon lacerations, but it may be less reliable for lacerations near the threshold for repair. Therefore, surgeons should be cautious when deciding whether or not to repair partial lacerations in the borderline range.

Development of acute cholecystitis following laparoscopic partial cholecystectomy

In cases where the dissection of Calot's triangle is difficult during laparoscopic cholecystectomy, laparoscopic partial cholecystectomy is an alternative to total cholecystectomy to prevent bile duct damage. However, recurrent symptoms and bile duct problems associated with the remaining gallbladder tissue may develop in patients over time. The case of a 45-year-old male who underwent laparoscopic partial cholecystectomy one year previously is presented here. In the postoperative period, as a result of tests for the continuing symptoms of cholecystitis, stones and surrounding abscess were detected in the remaining gallbladder tissue, so open completion cholecystectomy was applied. In acute cholecystitis, as severe inflammation of the hilar structures does not allow safe dissection, partial cholecystectomy can be applied. However, in these patients, there is a risk of recurrence of cholecystitis symptoms and the development of biliary pancreatitis and choledocolithiasis because of the remaining tissue. Therefore, it should not be forgotten that endoscopic and/or surgical intervention may be necessary at least in some patients.

"Clip-strasse": A novel complication following partial nephrectomy

This report presents the case of a 63-year-old man who presented with recurrent visible haematuria and loin pain 18 months after open partial nephrectomy for renal cell carcinoma. A computed tomography urogram revealed three obstructing calculi in the mid- to distal ureter with hydronephrosis. Rigid ureteroscopy revealed three calcified objects in the pelvic ureter. These had the appearance of calcified Weck® clips. A laser was used to remove the calcification, confirming the presence of three Weck clips, which had been used for haemostasis during the partial nephrectomy. These were removed with graspers after balloon dilatation of the distal ureter. This phenomenon of multiple clips migrating with stone formation and obstruction of the ureter was named "clip-strasse".

A simple and effective prognostic staging system based on clinicopathologic features of intrahepatic cholangiocarcinoma

Incidence and mortality of intrahepatic cholangiocarcinoma (ICC) are increasing. However, its prognostic predictive system associated with outcome after surgery remains poorly defined. In this study, we conducted retrospective survival analyses in a primary cohort of 370 patients who underwent partial hepatectomy for ICC (2005 and 2009). We found that seven variables were significantly independent predictors for overall survival (OS): serum prealbumin (hazard ratio [HR]: 1.447; p = 0.015), carbohydrate antigen 19-9 (HR: 1.438; p = 0.009), carcinoembryonic antigen (HR: 1.732; p = 0.002), tumor number (HR: 1.781; p < 0.001), vascular invasion (HR: 1.784; p < 0.001), regional lymphatic metastasis (HR: 2.003; p < 0.001) and local extrahepatic metastasis (HR: 1.506; p = 0.008). Using these independent predictors, we created a simple clinicopathologic prognostic staging system for predicting survival of ICC patients after resection. The validity of the prognostic staging system was prospectively assessed in 115 patients who underwent partial hepatectomy between January 2010 and December 2010 at the same institution. The prognostic power was quantified using likelihood ratio test and Akaike information criteria. Compared with the 6(th) and 7(th) AJCC staging systems, the new staging system in the primary cohort had a higher predictive accuracy for OS in terms of homogeneity and discriminatory ability. In the validation cohort, the homogeneity and discrimination of the new staging system were also superior to the two other staging systems.

CONCLUSIONS

The new staging system based on clinicopathologic features may provide relatively higher accuracy in prognostic prediction for ICC patients after tumor resection.

Oral health-related quality of life of removable partial denture wearers and related factors

This study aims to investigate the oral health-related quality of life (OHRQoL) in a group of removable partial denture (RPD) wearers in Shiraz (Iran), using the Persian version of the Oral Health Impact Profile (OHIP-14). Two hundred removable partial denture wearers had completed a questionnaire regarding patients' demographic characteristics and denture-related factors. In addition, the OHIP-14 questionnaire was filled out by interviewing the patients. Two measures of interpreting the OHIP-14 scales were utilised: OHIP-14 sum and OHIP-14 prevalence. The relationship of the patients' demographic characteristics and denture-related factors, with their OHRQoL was investigated. The mean OHIP-14 sum and OHIP-14 prevalence of RPD wearers were 13·80 (±10·08) and 44·5%, respectively. The most problematic aspects of OHIP-14 were physical disability and physical pain. Twenty-seven percentage and 24% of participants had reported meal interruption and eating discomfort, respectively. OHIP-14 prevalence and OHIP-14 sum were found to be significantly associated with factors representing RPD wearer's oral health such as self-reported oral health and frequency of denture cleaning. Furthermore, OHIP-14 prevalence and OHIP-14 sum were significantly associated with factors related to frequency of denture use such as hours of wearing the denture during the day and wearing the denture while eating and sleeping. Therefore, it can be concluded that the OHRQoL of the patients of the study was generally not optimal and found to be strongly associated with oral health.

Value of neuroimaging in epilepsy: An experience from Pakistan

Purpose:

To detect the possible structural brain lesions in the patients suffering from various kinds of epilepsy during the routine neuroimaging.

Materials and Methods:

Prospective study of 366 epileptic patients conducted at epilepsy clinic, Rawalpindi-Islamabad Pakistan in an outpatient setting. MRI or CT scan of the brain without contrast was advised in all patients to detect any underlying pathology.

Results:

A total 21.31% scans were found to be abnormal. Many cases of familial, idiopathic epilepsy and patients without any neurological deficit were found to have structural brain lesions, which might be responsible for their seizures.

Conclusion:

CT/MRI scan of the brain should be advised in all patients of epilepsy regardless of cause and type of epilepsy. The presence of neurological deficit should not be the sole indication for neuroimaging.

Partial triceps disruption: a case report

Partial triceps tendon disruptions are a rare injury that can lead to debilitating outcomes if misdiagnosed or managed inappropriately. The clinician should have a high index of suspicion when the mechanism involves a fall onto an outstretched arm and there is resultant elbow extension weakness along with pain and swelling. The most common location of rupture is at the tendon-osseous junction. This case report illustrates a partial triceps tendon disruption with involvement of, primarily, the medial head and the superficial expansion. Physical examination displayed weakness with resisted elbow extension in a flexed position over 90°. Radiographs revealed a tiny fleck of bone proximal to the olecranon, but this drastically underestimated the extent of injury upon surgical exploration. Magnetic resonance imaging is essential to ascertain the percentage involvement of the tendon; it can be used for patient education and subsequently to determine treatment recommendations. Although excellent at finding associated pathology, it may misjudge the size of the tear. As such, physicians must consider associated comorbidities and patient characteristics when formulating treatment plans.