Enhanced recovery for acute open lower limb fracture 'fix and flap'

INTRODUCTION

Enhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following 'fix & flap', return to theatre, rate of successful flap salvage, flap failure and deep infection rates.

METHODS

An observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases.

RESULTS

161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %.

CONCLUSION

In isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

Comparison Between Mini-Percutaneous Nephrolithotomy and Standard Percutaneous Nephrolithotomy in Management of Large Renal Stones: A Randomized, Controlled Clinical Trial

Objectives: The aim of this study was to compare mini-percutaneous nephrolithotomy (PNL) and standard PNL in management of renal stones (20-40 mm) with regard to the operative time, fluoroscopy time, blood loss, stone-free rate, and postoperative complications. Subjects and Methods: This prospective, randomized comparative study was carried out on 93 patients divided into two groups: Group A included 44 patients who underwent standard PNL, whereas Group B included 49 patients who underwent mini-PNL. Results: Standard PNL showed shorter operative time, yet longer hospitalization and nephrostomy and catheterization time. The mean drop in hemoglobin level was significantly lower in the mini-PNL group. In the 1st postoperative week, the stone-free rate was higher in the standard PNL group, but this was statistically insignificant. However, 4 weeks postoperatively, the stone-free rate was significantly higher in Group A. Postoperative pain and the need for postoperative analgesia were significantly higher in standard PNL patients. Conclusions: Standard PNL achieved a higher stone-free rate and shorter operative time, while mini-PNL had the advantage of shorter hospitalization time and lower incidence of pain and postoperative complications.

Soft tissue coverage of the ankle: An algorithm for appropriate flap selection and the experiences of a newly established Major Trauma Network

INTRODUCTION

Replication of the thin and pliable native skin around the ankle remains a challenge for plastic surgeons treating soft tissue defects in this region. Flap reconstruction constitutes the mainstay of management of such injuries. Subsequent management often entails revisional debulking surgery to permit normal footwear and an acceptable aesthetic outcome. In light of limited elective operating capacity throughout the covid-19 pandemic, we adopted an algorithm to inform reconstruction in such injuries and limit the need for revisional surgeries. This study presents this algorithm, which considers patient age, functional status, co-morbidities, body habitus and defect location.

METHODS

Retrospective analysis of a prospectively maintained database of all patients undergoing lower limb soft tissue reconstruction over 21 months was performed. All flap-based reconstructions of ankle defects were included; direct closures and skin grafts were excluded. All trauma patients were managed via a combined orthoplastic approach as per BOA-BAPRAS standards. All patients had Computed Tomography Angiography prior to their definitive reconstruction. Lower Extremity Functional Scale (LEFS) scores were analysed for patients with over 12 months of postoperative follow up, where available.

RESULTS

71 flaps were performed in 69 patients. Open ankle fracture was the most common cause (86%); other indications included osteomyelitis and surgical wound dehiscence. Mean age was 50 (13-87 years) with a higher proportion of males to females (ratio 1.25:1). There were 26 pedicled flaps (18 Medial Plantar Artery and 8 Peroneus Brevis) and 45 free flaps (22 Anterolateral thigh, 11 Superficial Circumflex Iliac Artery Perforator, 11 Gracilis and 1 Medial Sural Artery Perforator). Mean follow-up is 13.6 months. There were three flap failures, and four patients subsequently underwent delayed below knee amputation despite successful soft tissue healing. For the patients with a minimum of 12 months follow up, LEFS scores with an average of 51% were achieved (range 15-88%). Four patients have been listed for revisional/debulking surgery.

CONCLUSION

Although soft tissue defects around the ankle can be difficult to manage, with careful planning and addressing each patient individually, supported by an algorithmic approach, good functional and aesthetic outcomes can be achieved with low rates of secondary revision surgery.

Free flaps for lower limb soft tissue reconstruction - A systematic review of complications in 'Silver Trauma' patients

BACKGROUND

There are 12.5 million people aged 65 years and older living in the UK. The annual incidence of open fracture is 30.7 per 10,000 person-years. In females, 42.9% of all open fractures occur in patients ≥ 65 years.

METHODS AND MATERIALS

Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study is registered with PROSPERO (CRD42020209149). The aim was to compare the complication profiles of free fasciocutaneous flaps and free muscular flaps in patients aged over 60 years undergoing lower limb soft tissue reconstruction following an open lower limb fracture. The search strategy based on strict inclusion criteria included PubMed, Embase and Google Scholar.

RESULTS

15 papers were identified, including 46 patients with 10 free fasciocutaneous flaps and 41 free muscle flaps. There were 3 complications in the fasciocutaneous group (30%) and 9 complications in the muscle group (22%). There was a total of 1 secondary procedure in the fasciocutaneous group and 4 in the muscle group.

DISCUSSION

There is insufficient data to provide statistical comparison between free fasciocutaneous versus free muscle flaps for lower limb reconstruction performed in those aged over 60 years. This systematic review highlights evidence for the successful use of free tissue transfer in the older population following an open fracture injury and requiring lower limb reconstruction. There is no evidence to suggest the superiority of one tissue type over the other, with the inference that well vascularised tissue is the most significant factor impacting outcome.

378 Comparison of Outcomes Between Early and Delayed Weight Bearing Following Lower Limb Free Flaps

Aim

Post-operative protocols following lower limb free flap surgery are not well defined with a lack of consensus in the literature around limb dependency and weight bearing. The aim was to compare the complication rate for lower limb free flaps before and after the introduction of an enhanced lower limb free flap protocol with earlier dangling (day 3 vs day 4) and weight bearing (day 5 vs day 14) post lower limb free flap surgery.

Method

All lower limb free flaps between June 2020-October 2021 were identified from a departmental flap database. Patient data was collected retrospectively from the comprehensive lower limb free flap database, medical notes and electronic records. Exclusion criteria was any patient prescribed non-weight bearing due to the method of bone fixation.

Results

A total of 30 patients, 14 pre- and 16 post-enhanced protocol were identified for comparison. Mean age was 43 (17–72) with a M:F of 2:1 and RTC as the most common mechanism of injury. There was no difference in the type of flap reconstruction between groups, with the anterolateral thigh flap the most common in both groups. No differences were identified in the number of complications related to dependency/weight bearing before and after the introduction of the enhanced protocol, with mean length of stay reduced from 12 to 11 days.

Conclusions

The new enhanced protocol remains the standard of care in our unit, as we demonstrated a reduction in length of stay with no difference in complication rates following lower limb free flap surgery.

Clinical and urodynamic findings before and after surgical repair of pelvic organ prolapse in women with lower urinary tract symptoms. A prospective observational study

OBJECTIVES

To investigate the association between urodynamic findings and lower urinary tract symptoms (LUTS) before and after surgical treatment of POP.

METHODS

Seventy-four patients with stage II or more anterior POP associated with LUTS and eligible for surgical repair of POP were included in this prospective study. All cases had clinical evaluation and urodynamic testing (UDS) before and 6 months after surgical repair of POP.

RESULTS

Mean age was 45±9 years. Mean BMI was 28±6 kg/m². Most cases were multiparous, had stage III cystocele (50/74, 68%), and an associating apical prolapse (37/74, 50%). Native tissue repair was done in 53/74 (72%) cases with a concomitant anti-incontinence procedure (AIP) in 41/74 (55%) for overt (26/74, 35%) or occult (15/74, 20%) stress urinary incontinence (SUI). Preoperative UDS revealed detrusor overactivity (DO) in 19/56 (34%) patients of those presenting with storage LUTS and an obstructed P_detQ_max in 20/26 (77%) patients presenting with voiding LUTS. At the 6-month postoperative follow-up, 61/74 (82%) patients had marked improvement of their LUTS, SUI resolved in 39/41 (95%) patients and 1/33 (3%) patient developed de novo SUI. Preoperative DO and post-void residual urine volume (PVR) were not related to the postoperative improvement, or persistence of LUTS. Meanwhile, detrusor underactivity (DU) was detected both on preoperative and postoperative UDS of 4 patients with persistent voiding LUTS.

CONCLUSIONS

Patients had significant improvement in LUTS after POP surgery with or without an AIP. DU was associated with persistence of voiding LUTS. Meanwhile, preoperative DO and PVR were of limited prognostic value.

Contact dermatitis in hemodialysis patients at Al Wakra hospital

Background: Patients undergoing hemodialysis are exposed to various potential allergens from medication, dialysis catheters, topical antiseptics, and different adhesive dressings. Many patients develop a local allergic reaction and get itchy rashes, which may get infected, leading to significant morbidity and preventable health cost. In this study, we aimed to report the incidence of contact dermatitis (CD) and its potential complications in hemodialysis (HD) patients at the Al Wakra Hospital Dialysis unit.

Methods: We performed a retrospective chart review of documented local allergic reactions at vascular access sites for the HD patients at the Al Wakra Hospital.

Results: Currently, 102 patients are getting maintenance HD through catheters or arteriovenous (AV) fistula. Twelve (14.4%) patients developed CD (7 [58%] had cuffed jugular dialysis catheter, and 5 [42%] had an AV fistula). Most patients (75%) developed CD in the early period of dialysis initiation, and 25% developed it later in the course. Most patients responded to removing adhesive plasters and dressing the vascular access site using gauze only and topical steroids (hydrocortisone 1% cream/mometasone 0.1% cream). Two (16.6%) of the 12 patients developed vascular access site infection, of whom 1 had an AV fistula and developed a severe rash with cellulitis leading to sepsis and 2 admissions, although blood cultures remained negative. The patient responded to IV antibiotics and local mometasone 0.1% cream. Complete removal of all adhesive tapes helped prevent recurrence of the rash. Later, dressing of the AV fistula site was performed only with a cotton gauze. The second patient had a jugular catheter and developed an allergic rash leading to cellulitis and tunnel infection. Swab culture showed Staphylococcus aureus from the exit site sensitive to cloxacillin/cefazolin. The patient improved after local and oral antibiotics and removal of adhesive tapes. The catheter was not removed, and the patient did well.

Conclusion: The incidence of CD at our dialysis unit is 14.4%. Previously published reports from other dialysis units showed a lower incidence of 1.25%. Early identification and diagnosis of allergic rash at the vascular access site and avoidance of adhesive plasters and other potential allergens prevent complications like infection and loss of precious vascular accesses in these patients.

Evaluation of Galdakao-modified Valdivia position in endoscopic management of malignant ureteric obstruction

Background

Malignant ureteric obstruction (MUO) due to pelvic malignancies is challenging for endourological management and carries high failure rates for retrograde cystoscopic ureteric stenting.

Methods

We adopted Galdakao-modified Valdivia (GMV) position in the management of MUO in an operating room equipped with a C-arm fluoroscopy unit and an ultrasound device. We prospectively studied the added value of this approach in 50 cases who failed retrograde ureteric stenting.

Results

Thirty-seven (74%) cases were done under a high level of spinal anesthesia. Mean operative time was 62 min. Antegrade ureteric stenting succeeded in 45/50 (90%) patients who failed retrograde ureteric stenting. GMV position facilitated simultaneous retrograde and antegrade management of MUO. Eight patients (16%) underwent auxiliary cystoscopic procedures to reduce the mass over the ureteric orifice (UO) guided by antegrade methylene blue or over a probing antegrade guidewire. Nephrostomy tube was inserted in the same setting in 16/50 (32%) cases. Antegrade flow of contrast to the bladder (P < 0.001) and ureteric kinks rather than tight stenosis or infiltration of UO (P = 0.014) were significantly associated with the success of antegrade ureteric stenting. No major complications were encountered.

Conclusion

GMV position is an ideal choice for management of MUO as it allows simultaneous access to the lower and the upper urinary systems to accomplish ureteric stenting either in a retrograde or an antegrade fashion as well as the ability to insert a nephrostomy tube in the same setting, thus shortening the inpatient care and this should be the standard of care in cases with MUO.

Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures

INTRODUCTION

Open lower extremity fractures pose a challenge for treating surgeons. All surgical strategies have the common aim to facilitate fracture healing. Fracture union, however, should be critically considered in the context of functional recovery and not in isolation. Both local and free tissue transfer have benefits and drawbacks.

AIM

This study aims to compare the functional outcomes of open tibial diaphyseal fractures managed with internal fixation, comparing outcomes of those receiving free tissue transfer as opposed to local flaps METHODS: This study follows the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) criteria. Data were collected retrospectively from a prospectively maintained database at our institution. Inclusion criteria included a non-comminuted Gustilo type-IIIB open tibial diaphyseal fracture requiring intramedullary nailing. Forty three patients with local flaps and 180 patients with free flaps were included RESULTS AND CONCLUSION: 233 patient underwent reconstruction for open fracture using local flaps (n=43) or free flaps (n=180). In the context of Gustilo type-IIIB non-comminuted, mid-tibial diaphyseal fractures treated with intramedullary nailing, free fasciocutaneous flap reconstructions leads to significantly improved functional outcomes in patients of all ages when compared to local fasciocutaenous flaps. (77 ± 19 v 50 ± 22 % for local flaps; P < 0.001).

498 The Bristol Sign - A Technical Tip to Confirm Skin Flap Vascularity

Introduction

In modern medicine, free flap reconstruction has become the gold standard when faced with soft tissue defects. The impressive cosmesis, and adaptability of free flaps means that we can securely state that we are in the era of Plastic Surgery defined by free flap reconstruction. However, as part of free flap reconstruction, clinical monitoring of the flap is a central tenet post-operatively. Different departments have different protocols for this.

Method

In our unit, it is practice to insert a single interrupted stitch overlying the Doppler site just before dressings. This localises the site of the pedicle for Doppler monitoring, and allows the surgeon to examine the quality of the blood droplets, demonstrating flap perfusion.

Results

The use of the stitch is considered practical, replicable, and safe, and aids in providing gold standard monitoring post-operatively. The additional analysis of the blood droplet is another sign, in itself, of a healthy flap, and excludes venous congestion.

Conclusions

The Bristol stitch is a useful adjunct to free flap reconstruction. It’s localisation of the Doppler signal allows medical and nursing staff to confidently approach post-operative monitoring, and the blood elicited by the stitch insertion is a useful sign of flap vascularity and venous status.

Importance of Postoperative Use of External Warming Devices in Flap Reconstructive Surgery

Flap failure, partial or complete, can have great negative impact on the patient and the reconstructive outcome. The effect of thermal regulation on flap survival is well recognized. This article focuses on the importance of external warming devices as a standard on postoperative flap care to avoid any temperature-related vascular compromise. PubMed, Medline, and EMBASE search had been performed. More than 60 papers have been reviewed. Out of them, that 29 references have been included in this review. The authors emphasize on the importance of strict postoperative flap temperature control with active warming devices as a standard of practice to minimize any related microcirculatory changes.

Oncologic outcome of radical prostatectomy versus radiotherapy as primary treatment for high and very high risk localized prostate cancer

OBJECTIVE

To compare the oncologic outcomes of radical prostatectomy (RP) versus external beam radiotherapy (EBRT) ± androgen deprivation therapy for primary treatment of high risk localized prostate cancer (CaP).

METHODS

We retrospectively reviewed a prospectively-populated database for cases who underwent primary treatment for high risk localized CaP, had more than 2 years follow-up, and were treated since 2006. A total of 335 cases were studied of whom 291 underwent RP and 44 underwent EBRT. Clinical characteristics, biochemical progression-free survival (BPFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS) were compared.

RESULTS

EBRT cases were older (p < .01; mean 71 years vs. 61 years) and had longer PSA doubling time (PSADT) (p = .03; median 4.8 years vs. 3.5 years) than RP. Race, pretreatment PSA and biopsy Gleason score were similar. Median follow-up was 5.1 (range: 2.3-12.8) years for RP versus 3.3 (range: 2-12.4) years for EBRT. Three- and 5-year BPFS were 42% and 36% after RP versus 86% and 75% after EBRT (p < .01). The rate of adjuvant/salvage therapy was 58% after RP versus 20% after EBRT (p < .01). Three- and 5-year MFS were 80% and 77% after RP versus 91% and 91% after EBRT (p = .11). Three-year CSS was 98% in both groups and OS was 97% after RP versus 94% after EBRT (p = .73).

CONCLUSIONS

RP had higher rates of biochemical failure and adjuvant or salvage treatment versus EBRT in high risk localized CaP. MFS trended toward benefit after EBRT, but CSS and OS remained high in both groups.

AB1146 REAL-LIFE PRACTICES IN MANAGEMENT OF REPRODUCTIVE HEALTH IN SLE AND APS BY OBSTETRICIANS AND RHEUMATOLOGISTS IN EGYPT. (AN ONLINE-BASED QUESTIONNAIRE)

Background:

Systemic lupus erythematosus (SLE) is an auto-immune disease that affect women in their reproductive age. Antiphospholipid syndrome (APS) is a hypercoagulable immune disease that occur as a primary condition or in assosiation with SLE.

The reproductive aspects as contraception, fertility, pregnancy are crucial to consider for proper management of SLE/APS.

Addressing these issues require collaboration between rheumatologists and obstetricians, improving their knowledge and ensuring that both are acquainted with the updated guidelines.

Objectives:

To assess the knowledge and practice of Egyptian obstetricians and rheumatologists in management of reproductive health issues in SLE and APS, and to detect common misconceptions.

Methods:

This research was conducted via google form online survey based on points discussed in EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with SLE and/or APS.1It was sent to target obstetricians and rheumatologists by internet clouds like (Facebook, twitter, LinkedIn) from August to November 2019. It included five domains; demographic data, general knowledge and attitudes about pregnancy in SLE and APS, contraception, drugs, and assisted reproductive techniques (ART)

After submitting answers, respondents were shown a link directing them to the 2016 EULAR recommendations.1

Results:

This study was conducted on 254 physicians, 62% obstetricians and 38% rheumatologists. 64.6% were between the ages of 30-35 years.

For general knowledge, 52% of Obstetricians considered pregnancy in inactive SLE to be risky. (79.4%vs54.1%) of (rheumatologists and obstetricians) respectively test for aPL in SLE patients. More than 70% in both groups were well informed on the increased rate of fetal and maternal complications in both SLE and APS.

For fetal surveillance, 87% and 90% of obstetricians preformed first and second trimester U/S, and 79% preformed second trimester Doppler.

For contraception, (57.7%vs56.7%) discuss contraceptive choices with their patients. The majority considered it safe to use IUDs (73.9%vs76%) and condoms (84.7vs85.4%) in both SLE and APS patients. On the other hand, for hormonal contraception- Levonorgestrol IUD, Depoprovera, COCP, and POP- only 14.6%, 22.9%, 26.1%, 24.8% of rheumatologists and 18.5%, 27.2%, 29.9%, 26.8% of obstetricians considered them unsafe to use in APS.

Concerning treatment, the majority considered low dose presnidone to be safe during pregnancy (94.8 %vs80%) and breastfeeding (87.6%vs64.3%). The majority also agreed on avoidance of Methotrexate (94.8%vs84.1%) and Cyclophosphamide (89.7%vs66.2%). However, regarding Hydroxychloroquine and Azathioprine use in pregnancy there was a significant discrepancy between rheumatologists and obstetricians, (89.7 %vs42%) and (78.4%vs36.9%) believed them safe to use in pregnancy. For Mycophenolate Mofetil, (80.4%vs46.5%) said that it should be avoided in pregnancy. Regarding ART (45.4%vs71%) considered it safe to use in stable SLE/APS.

Conclusion:

The gaps in knowledge identified include the use of hormonal contraception in APS patients and the proper utilization of important medications to prevent and treat lupus flares. Initiation of shared Rheumatology/ obstetric clinics and focusing on the identified educational topics, would lessen the gap in knowledge and discrepancies in practice improve overall patient management.

References:

[1]Andreoli L et al. Ann Rheum Dis. 2017;76(3):476-85.

Disclosure of Interests:

None declared

A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly

INTRODUCTION

Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding.

METHODS

A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score).

RESULTS

33 paediatric patients and 99 elderly patients were identified. Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections. Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation.

DISCUSSION

These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.

Association between genotype and disease complications in Egyptian patients with beta thalassemia: A Cross-sectional study

In beta thalassemia, the degree of globin chain imbalance is determined by the nature of the mutation of the β-gene. β° refers to the complete absence of production of β-globin on the affected allele. β⁺ refers to alleles with some residual production of β-globin. The homozygous state results in severe anemia that necessitates regular blood transfusion. On the other hand, frequent blood transfusion can lead to iron overload resulting in progressive dysfunction of the heart, Liver as well as multiple endocrinopathies. We studied the impact of genotype on the development of disease complications in patients with β thalassemia. A Cross sectional study was carried on 73 patients with beta thalassemia. Genotyping was determined by DNA sequencing technique. Routine investigations as well as MRI liver and heart were performed to assess iron overload. We found that β⁺β⁺ was the most common genotype in our patients followed by β°β° and β°β⁺. Mean Liver iron content (LIC) was significantly higher in β°β° compared to β°β⁺ and β⁺β⁺ genotypes and mean cardiac T2* was significantly lower in β°β° compared to β°β⁺ and β⁺β⁺ genotypes. Hepatic complications, hepatitis C, cardiac complications and some endocrinopathies were significantly higher in patients with β°β° genotype compared to other genotypes which explain the role of the underlying genetic defect in thalassemia patients in development of disease complications.

Pain after ortho-plastic reconstruction of lower limb injuries: A snapshot study

INTRODUCTION

The incidence of pain after flap reconstruction of complex lower limb injury is poorly reported in the literature, and yet represents a significant source of morbidity in these patients. In our centre (Southmead Hospital, Bristol, England) patients who have had flap reconstruction for complex lower limb injury are followed up at a joint ortho-plastics lower limb clinic run weekly. The aim of this study was to report the incidence of pain in such patients at follow-up in the specialist clinic. The impact of the experience of pain upon the quality of life, and the efficacy of analgesia was assessed these cases.

PATIENTS AND METHODS

This was a cross sectional snapshot study of a cohort of complex lower limb patients attending our lower limb ortho-plastics outpatient clinic between the dates of: 17/5/16 and 28/6/16. Any patient attending clinic with previous flap reconstruction for lower limb injury was asked to complete the BPI (Brief Pain Index) questionnaire, and details regarding their injury and surgery were collected.

RESULTS

There was a 100% response rate, with 33 patients completing the questionnaire. 28 out of the 33 patients (85%) reported ongoing pain. There was no significant relationship between time post operatively and average pain scores (Spearman's Rank R = 0.077), nor was there significant difference by age or gender. Over 25% of the patients with pain were not taking analgesia, however those using simple analgesia (paracetamol, NSAIDS) derived on average over 70% pain relief.

CONCLUSIONS

Pain in a common complication following flap reconstruction for complex lower limb injury reported in 85% of our cohort. This pain does not seem to be correlated with time, gender or age, and responds well to simple analgesia in most cases. This emphasises the importance of asking about pain at follow up, and taking simple measures to improve pain outcomes.

Evaluation of the risk factors associated with the development of post-transurethral resection of the prostate persistent bacteriuria

Objectives

To determine the preoperative, intraoperative and postoperative risk factors that influence the development of persistent post-transurethral resection of the prostate (TURP) urinary tract infection (UTI) defined as pyuria and/or bacteriuria remaining for 3 weeks after surgery.

Patients and methods

This is a prospective study including 100 patients scheduled for TURP. Urine analysis and culture was performed immediately after catheter removal, then at 1 and 3 weeks postoperatively, and the results were correlated to various preoperative, intraoperative and postoperative potential risk factors to detect any significant relation to persistent UTI.

Results

There was a statistically significant relationship between bacteriuria and the following risk factors: old age, past history of diabetes mellitus, large prostatic size, positive preoperative urine analysis and culture, preoperative catheter use, previous urological interventions, large size of sheath, long duration of operation, postoperative catheter events and postoperative manual wash.

Conclusions

Many risk factors have been found to contribute to the development of post-TURP UTI and avoiding these factors can enhance recovery of patients undergoing TURP.

Oral magnesium supplementation improves glycemic control and lipid profile in children with type 1 diabetes and hypomagnesaemia

Dietary supplementation with magnesium (Mg) in addition to classical therapies for diabetes may help in prevention or delaying of diabetic complications.We aimed to evaluate the status of serum Mg in children with type 1 diabetes and assessing its relationship to glycemic control and lipid profile. Then evaluating the effect of oral Mg supplementation on glycemic control and lipid parameters.We included 71 children at Pediatric Endocrinology Outpatient Clinic, Zagazig University, Egypt with type 1 diabetes and assessed HBA1c, lipid profile, and serum Mg at the start of study. Patients with serum Mg level < 1.7 mg/dL were given 300 mg Mg oxide for 3 months. After that we reevaluated HBA1c, lipid profile, and serum Mg in all patients.The study included 71 patients with type 1 diabetes (32 males and 39 females); their mean age was 9.68 ± 3.99 years. The mean serum Mg level was 1.83 ± .27 mg/dL. Hypomagnesemia was detected in 28.2% study patients. Serum Mg was found to be positively correlated with high density lipoprotein, mean corpuscular volume and platelet count (P < 0.001), and negatively correlated with age, HbA1c, triglycerides, total cholesterol, low density lipoprotein, and duration of diabetes (P < 0.001). There was significant reduction in HBA1c in group given Mg supplementation. HBA1c was initially 10.11% ± 0.87%. After 3 months of oral Mg supplementation it is reduced to 7.88% ± 0.42% (P < 0.001). There was statistically significant difference in lipid parameters in hypomagnesemic diabetic patients before and after Mg supplementation with significant reduction in serum triglycerides, LDL, and total cholesterol following Mg supplementation with P < 0.001. Although HDL shows a significant increase after Mg supplementation in hypomagnesemic diabetic children with P < 0.001.Correction of hypomagnesemia in type 1 diabetic children with oral Mg supplements is associated with optimization of glycemic control and reduction of atherogenic lipid fraction as well as increase in protective lipid fraction.

Towards enhancement of a lexicon-based approach for Saudi dialect sentiment analysis

Sentiment analysis (SA) techniques are applied to assess aspects of language that are used to express feelings, evaluations and opinions in areas such as customer sentiment extraction. Most studies have focused on SA techniques for widely used languages such as English, but less attention has been paid to Arabic, particularly the Saudi dialect. Most Arabic SA studies have built systems using supervised approaches that are domain dependent; hence, they achieve low performance when applied to a new domain different from the learning domain, and they require manually labelled training data, which are usually difficult to obtain. In this article, we propose a novel lexicon-based algorithm for Saudi dialect SA that features domain independence. We created an annotated Saudi dialect dataset and built a large-scale lexicon for the Saudi dialect. Then, we developed our weighted lexicon-based algorithm. The proposed algorithm mines the associations between polarity and non-polarity words for the dataset and then weights these words based on their associations. During algorithm development, we also proposed novel rules for handling some linguistic features such as negation and supplication. Several experiments were performed to evaluate the performance of the proposed algorithm.

Modified gold nanoparticles for intracellular delivery of anti-liver cancer siRNA

To overcome the rapid enzymatic degradation and low transfection efficiency of siRNA, the delivery carriers for siRNA is a therapeutic demand to increase its stability. Gold nanoparticles (AuNPs) modified by branched polyethyleneimine (bPEI) were developed as an efficient and safe intracellular delivery carriers for siRNA. The current study implied that siRNA designed against an oncogene c-Myc could be delivered by a modified AuNPs complex without significant cytotoxicity. The comparative semi-quantitative and quantitative real time PCR were used to measure the c-Myc gene expression after transfection with naked siRNA and siRNA/bPEI/AuNPs, but AuNPs interfered with PCR. However, the c-Myc protein translation was successfully detected in the transfected HuH7 cells with naked siRNA and siRNA/bPEI/AuNPs and it was found to be inhibited by siRNA/bPEI/AuNPs more than naked siRNA. The results validate the successful silencing of c-Myc gene. Accordingly, it may confirm the promising and effective delivery of siRNA by bPEI/AuNPs. The complex enhances the cellular uptake of siRNA without significant cytotoxicity and confirms that bPEI modified AuNPs could be used as a good candidate for safe cellular delivery of siRNA.

How Effective Are Percutaneous Liver-Directed Therapies in Patients with Non-Colorectal Liver Metastases?

BACKGROUND

The purpose of this review is to demonstrate the clinical indications, technical developments, and outcome of liver-directed therapies in interventional oncology of non-colorectal liver metastases.

METHODS

Liver-directed therapies are classified into vascular transarterial techniques such as chemoperfusion (TACP), chemoembolization (TACE), radioembolization (selective internal radiation therapy (SIRT)), and chemosaturation, as well as thermal ablation techniques like microwave ablation (MWA), radiofrequency ablation (RFA), laser-induced thermotherapy (LITT), cryotherapy, and irreversible electroporation (IRE). The authors searched the database PubMed using the following terms: 'image-guided tumor ablation', 'thermal ablation therapies', 'liver metastases of uveal melanoma', 'neuroendocrine carcinoma', 'breast cancer', and 'non-colorectal liver metastases'.

RESULTS

Various combinations of the above-mentioned therapy protocols are possible. In neuroendocrine carcinomas, oligonodular liver metastases are treated successfully via thermal ablation like RFA, LITT, or MWA, and diffuse involvement via TACE or SIRT. Although liver involvement in breast cancer is a systemic disease, non-responding nodular metastases can be controlled via RFA or LITT. In ocular or cutaneous melanoma, thermal ablation is rarely considered as an interventional treatment option, as opposed to TACE, SIRT, or chemosaturation. Rarely liver-directed therapies are used in pancreatic cancer, most likely due to problems such as biliary digestive communications after surgery and the risk of infections. Rare indications for thermal ablation are liver metastases of other primary cancers like non-small cell lung, gastric, and ovarian cancer.

CONCLUSION

Interventional oncological techniques play a role in patients with liver-dominant metastases.

Risk factor analysis of pulmonary hemorrhage complicating CT-guided lung biopsy in coaxial and non-coaxial core biopsy techniques in 650 patients

PURPOSE

To evaluate the risk factors involved in the development of pulmonary hemorrhage complicating CT-guided biopsy of pulmonary lesions in coaxial and non-coaxial techniques.

MATERIALS AND METHODS

Retrospective study included CT-guided percutaneous lung biopsies in 650 consecutive patients (407 males, 243 females; mean age 54.6 years, SD: 5.2) from November 2008 to June 2013. Patients were classified according to lung biopsy technique in coaxial group (318 lesions) and non-coaxial group (332 lesions). Exclusion criteria for biopsy were: lesions <5mm in diameter, uncorrectable coagulopathy, positive-pressure ventilation, severe respiratory compromise, pulmonary arterial hypertension or refusal of the procedure. Risk factors for pulmonary hemorrhage complicating lung biopsy were classified into: (a) patient's related risk factors, (b) lesion's related risk factors and (d) technical risk factors. Radiological assessments were performed by two radiologists in consensus. Mann-Whitney U test and Fisher's exact tests for statistical analysis. p values <0.05 were considered statistically significant.

RESULTS

Incidence of pulmonary hemorrhage was 19.6% (65/332) in non-coaxial group and 22.3% (71/318) in coaxial group. The difference in incidence between both groups was statistically insignificant (p=0.27). Hemoptysis developed in 5.4% (18/332) and in 6.3% (20/318) in the non-coaxial and coaxial groups respectively. Traversing pulmonary vessels in the needle biopsy track was a significant risk factor of the development pulmonary hemorrhage (incidence: 55.4% (36/65, p=0.0003) in the non-coaxial group and 57.7% (41/71, p=0.0013) in coaxial group). Other significant risk factors included: lesions of less than 2 cm (p value of 0.01 and 0.02 in non-coaxial and coaxial groups respectively), basal and middle zonal lesions in comparison to upper zonal lung lesions (p=0.002 and 0.03 in non-coaxial and coaxial groups respectively), increased lesion's depth from the pleural surface (p=0.021 and 0.018 in non-coaxial and coaxial groups respectively), increased distance of traversed lung in the needle track of more than 2.5 cm (p=0.001 in both groups). Insignificant risk factors were patient's age, gender or emphysema in both groups (p value >0.1 in both groups). Concomitant incidence of pneumothorax was 32.3% (21/65) in non-coaxial group and 36.6% (26/71) in coaxial group. Pulmonary hemorrhage in the majority of cases was treated conservatively.

CONCLUSION

Pulmonary hemorrhage complicating CT-guided core biopsy of pulmonary lesions, showed insignificant difference between coaxial and non-coaxial techniques. Significant risk factors of pulmonary hemorrhage included small and basal lesions, increased lesion's depth from pleural surface, increased length of aerated lung parenchyma crossed by biopsy needle and passing through vessels within the lung during puncture.

Desmettianosides A and B, bisdesmosidic furostanol saponins with molluscicidal activity from Yucca desmettiana

Bioactivity-guided separation of the aqueous methanolic extract of Yucca desmettiana leaves, which in a preliminary screening exhibited significant molluscicidal activity, led to the isolation and structure elucidation of two new steroidal saponins (1 and 2). The structures of desmettianosides A and B, identified as bisdesmosidic furostanol glycosides with six and five sugar units, respectively, were established by detailed spectroscopic analyses of their NMR and MS data. Compounds 1 and 2 exhibited high molluscicidal activity against Biomphalaria alexandrina snails with LC100 values of 6 and 11 mg/L, respectively.

A new furoquinoline alkaloid with antifungal activity from the leaves of Ruta chalepensis L

Bioassay-guided separation with an eye toward antifungal activity led to the isolation of the new alkaloid 5-(1̀,1̀-dimethylallyl)-8-hydroxyfuro[2-3-b] quinoline (1) and the known biscoumarin daphnoretin (2) as the active constituents of the chloroform extract obtained from the leaves of Ruta chalepensis. The structures of the metabolites were elucidated on the basis of their spectral characteristics (NMR, UV, and MS) and were compared with the literature. The antifungal activity of the isolated compounds was evaluated against the phytopathogenic fungi Rhizoctonia solani, Sclerotium rolfsii, and Fusarium solani, which cause root-rot and wilt diseases in several economically important food crops such as potato, sugar beet, and tomato.

Long-term effects of a plant-based dietary portfolio of cholesterol-lowering foods on blood pressure

OBJECTIVE

To determine the effect on blood pressure of dietary advice to consume a combination of plant-based cholesterol-lowering foods (dietary portfolio).

METHODS

For 1 year, 66 hyperlipidemic subjects were prescribed diets high in plant sterols (1.0 g/1000 kcal), soy protein (22.5 g/1000 kcal), viscous fibers (10 g/1000 kcal) and almonds (22.5 g/1000 kcal). There was no control group. Seven-day diet record, blood pressure and body weight were monitored initially monthly and later at 2-monthly intervals throughout the study.

RESULTS

Fifty subjects completed the 1-year study. When the last observation was carried forward for non-completers (n=9) or those who changed their blood pressure medications (n=7), a small mean reduction was seen in body weight 0.7+/-0.3 kg (P=0.036). The corresponding reductions from baseline in systolic and diastolic blood pressure at 1 year (n=66 subjects) were -4.2+/-1.3 mm Hg (P=0.002) and -2.3+/-0.7 mm Hg (P=0.001), respectively. Blood pressure reductions occurred within the first 2 weeks, with stable blood pressures 6 weeks before and 4 weeks after starting the diet. Diastolic blood pressure reduction was significantly related to weight change (r=0.30, n=50, P=0.036). Only compliance with almond intake advice related to blood pressure reduction (systolic: r=-0.34, n=50, P=0.017; diastolic: r=-0.29, n=50, P=0.041).

CONCLUSIONS

A dietary portfolio of plant-based cholesterol-lowering foods reduced blood pressure significantly, related to almond intake. The dietary portfolio approach of combining a range of cholesterol-lowering plant foods may benefit cardiovascular disease risk both by reducing serum lipids and also blood pressure.

Effect on hematologic risk factors for coronary heart disease of a cholesterol reducing diet

BACKGROUND

A dietary portfolio of cholesterol-lowering ingredients has proved effective in reducing serum cholesterol. However, it is not known whether this dietary combination will also affect hematologic risk factors for coronary heart disease (CHD). Reductions in hematocrit and polymorphonuclear leukocytes have been reported to improve cardiovascular risk. We, therefore, report changes in hematological indices, which have been linked to cardiovascular health, in a 1-year assessment of subjects taking an effective dietary combination (portfolio) of cholesterol-lowering foods.

METHODS

For 12 months, 66 hyperlipidemic subjects were prescribed diets high in plant sterols (1.0 g/1000 kcal), soy protein (22.5 g/1000 kcal), viscous fibers (10 g/1000 kcal) and almonds (23 g/1000 kcal). Fifty-five subjects completed the study.

RESULTS

Over the 1 year, data on completers indicated small but significant reductions in hemoglobin (-1.5+/-0.6 g/l, P=0.013), hematocrit (-0.007+/-0.002 l/l, P<0.001), red cell number (-0.07+/-0.02 10(9)/l, P<0.001) and neutrophils (-0.34+/-0.13 10(9)/l, P=0.014). Mean platelet volume was also increased (0.16+/-0.07 fl, P=0.033). The increase in red cell osmotic fragility (0.05+/-0.03 g/l, P=0.107) did not reach significance.

CONCLUSIONS

These small changes in hematological indices after a cholesterol-lowering diet are in the direction, which would be predicted to reduce CHD risk. Further research is needed to clarify whether the changes observed will contribute directly or indirectly to cardiovascular benefits beyond those expected from reductions previously seen in serum lipids and blood pressure.

Rehabilitation of Complex, Massive, and Aged Pipeline Infrastructure in the Gulf of Suez

The paper describes the Rehabilitation program developed by GUPCO to ensure that its offshore production facilities retain in safe operating condition through a monitoring and preventive approach. During last five years significant increase in the amounts of acid gases (H2S & CO2) was noticed as some reservoirs have soured under the action of substantial water flood operations and the new high H2S wells.

Moreover water cut in produced fluids has steadily increased over the years andnow averages about 60 %, with some fields as high as 90 %. These problems are further aggravated by activity of Sulphate Reducing Bacteria (SRB) in some producing reservoirs. The aging of oil production reservoirs and associated facilities has resulted in significant corrosion problems and repeated failures throughout offshore facilities.

An extensive range of corrosion mechanisms have been observed, various equipment failures described, including those from offshore, pipeline and onshore process equipment. However, some have been particularly troublesome either in terms of their economic loss potential, their tenacity or the threats posed to personnel safety and the environment. These are briefly surveyed in the paper. Also we discuss the re-qualification programs of the existing offshore platforms and define our criteria to evaluate the adequacy and acceptability of the rehabilitation programs including design, construction, operation, inspection and maintenance of pipelines operations.

Furthermore, we describes a successful case history for early detection and evolution of reservoir souring due to microbial activity at one of the highest producing reservoirs at GOS fields (Badri field) based on our experience and a set of improved laboratory evaluation tests.

Moreover, paper shows in a systematic way the latest research results for Corrosion inhibition of carbon steel in acidic medium using some natural products and heterocyclic compounds containing nitrogen or sulphur.

Direct comparison of dietary portfolio vs statin on C-reactive protein

BACKGROUND

3-Hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) markedly reduce serum cholesterol and have anti-inflammatory effects. The effect of cholesterol-lowering diets on inflammatory biomarkers is less well known.

OBJECTIVE

To compare the efficacy of a dietary combination (portfolio) of cholesterol-lowering foods vs a statin in reducing C-reactive protein (CRP) as a biomarker of inflammation linked to increased cardiovascular disease risk.

METHODS

In all, 34 hyperlipidemic subjects completed three 1-month treatments as outpatients in random order: a very low-saturated fat diet (control); the same diet with 20 mg lovastatin (statin); and a diet high in plant sterols (1.0 g/1000 kcal), soy protein (21.4 g/1000 kcal), viscous fibers (9.8 g/1000 kcal), and almonds (14 g/1000 kcal) (portfolio). Fasting blood samples were obtained at weeks 0, 2, and 4.

RESULTS

Using the complete data, no treatment reduced serum CRP. However, when subjects with CRP levels above the 75th percentile for previously reported studies (> 3.5 mg/l) were excluded, CRP was reduced similarly on both statin, -16.3 +/- 6.7% (n = 23, P = 0.013) and dietary portfolio, -23.8 +/- 6.9% (n = 25, P = 0.001) but not the control, 15.3 +/- 13.6% (n = 28, P = 0.907). The percentage CRP change from baseline on the portfolio treatment (n = 25) was greater than the control (n = 28, P = 0.004) but similar to statin treatment (n = 23, P = 0.349). Both statin and portfolio treatments were similar in reducing CRP and numerically more effective than control but only the change in portfolio was significant after the Bonferroni adjustment.

CONCLUSIONS

A combination of cholesterol-lowering foods reduced C-reactive protein to a similar extent as the starting dose of a first-generation statin.

Noninvasive vacuum constriction device in the management of erectile dysfunction

The effectiveness of a device designed to overcome erectile impotence was assessed in 21 patients: 5 patients with vasculogenic impotence due to venous leakage, 6 with diabetes mellitus with or without atherosclerotic cardiovascular disease, 2 paraplegic patients after spinal cord injury, 3 severely obese patients and 5 patients with psychogenic impotence. They were instructed how to use the device, which uses suction to induce penile engorgement and maintains erection with a constriction band. A total of 17 patients (81%) achieved an erection or an erection-like state that was satisfactory for intercourse. No serious ill effect from the use of the device has been reported. In selected patients the device is an alternative to either surgical placement of penile prosthesis, intracavernous injection of vasoactive drugs or sexual abstinence.