Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Pooled-Testing for SARS-CoV-2 Reverse Transcription Polymerase Chain Reaction (RT-PCR) in asymptomatic healthcare workers in EL-Raghy isolation COVID-19 hospital, Assiut University

COVID-19 pandemic is a substantial challenge for healthcare systems. Severe acute respiratory syndrome coronavirus (SARS-CoV-2) reverse transcription-polymerase chain reaction (RT-PCR) tests are considered the gold standard technique for diagnosis of symptomatic and asymptomatic infectious viral carriers and for screening special or at-risk populations. The pooled testing procedure is commonly used to reduce the cost of screening a large number of individuals for infectious diseases. This work was conducted to verify the accuracy of the standard SARS COV-2 RT- real-time PCR kit for detecting a single positive sample in a pool of negative samples. Kit verification using negative and positive samples was performed for the selection of the target pool sizes. RNA extracts from 443 healthcare workers, after 15 days’ rotation in EL-Raghy Isolation COVID-19 Hospital, Assiut University during the first outbreak of COVID-19 pandemic (the period from June to September 2020) were obtained and tested. Sixty-three different pool sizes (2, 3, 4, 5, 6, 7, 8, 9, and 10) were tested for the presence of SARS-CoV-2 using RT-qPCR. Of these, 53 pools (84.1%) were negatives and 10 pools (15.9 %) tested positive. The individual number of SARS- COV 2 RT-PCR tests used in different pool sizes was 40 tests. The total number of SARS- COV 2 RT-PCR test used in this study was 110 tests instead of 443 tests which reflect a decrease in cost up to 75.16%. In conclusion, the suggested pooling strategy can reduce testing loads which enable substantial savings in reagent costs, technical burden, and time to generate laboratory results.

Chlamydia trachomatis Infection: its relation to semen parameters and sperm DNA integrity

The present study was conducted to determine the effect of Chlamydia trachomatis (CT) infection on semen quality and sperm DNA integrity. The study included 60 infertile male patients with CT infection and 25 age matched controls. Diagnosis of patients was based on detection of CT IgA by ELISA in seminal plasma and CT plasmid DNA in the semen sediment. All patients and controls were subjected to the following investigations: history taking, conventional semen analysis, detection of CT IgA, Plasmid DNA in semen samples, reactive oxygen species (ROS) and percentage of DNA fragmentation. There was significant increase in semen ROS levels and the percentage of sperm DNA fragmentation in the CT patient group when compared to the control group (P<0.05) and in those with leukocytospermia when compared to those without leukocytospermia (P<0.05). In the patient group with CT infection there was a positive correlation between the percentage of DNA fragmentation, ROS (r = 0.82 with P<0.0001) and pus cell count. (r = 0.7 with P<0.0001). In patients with leukocytospermia, there was a positive correlation between the percentage of DNA fragmentation, ROS (r = 0.9 with P<0.0001) and pus cell count (r = 0.83 with P<0.0001). In conclusion, sperm concentration, mobility, and viability, are significantly decreased in patients with CT compared to controls. ROS levels and the percentage of sperm DNA fragmentation significantly increased in CT patients especially patients with leukocytospermia.

Glycated hemoglobin versus oral glucose tolerance test in the identification of subjects with prediabetes in Qatari population

BACKGROUND

Subjects with prediabetes are at increased risk of future T2DM and cardiovascular disease (CVD) compared to NGT individuals. The OGTT (FPG = 100-125 and 2 h-PG = 140-199 mg/dl) and HbA1c 5.7-6.4% have been used to diagnose subjects with prediabetes. In the present study, we compared the ability of the OGTT and HbA1c to identify Qatari subjects with prediabetes.

METHODS

Four hundred forty six subjects without a history of T2DM received 75-g OGTT and measurement of HbA1c. The incidence of prediabetes in this cohort according to OGTT criteria was compared to that of HbA1c criteria.

RESULTS

The agreement between the OGTT and HbA1c in identifying subjects with prediabetes in Qatari subjects was poor, though significant (k = 015, p < 0.0001). Only 56% of participants had prediabetes or NGT according to OGTT and HbA1c. The disagreement between OGTT and HbA1c in diagnosing prediabetes was primarily due to low sensitivity of HbA1c. Moreover, subjects with prediabetes diagnosed with the OGTT have more severe metabolic profile than prediabetic subjects diagnosed with HbA1c. Lastly, more subjects with the metabolic syndrome were identified with OGTT (60%) criteria than with the HbA1c (49%), p < 0.0001.

CONCLUSION

These results demonstrate subjects with prediabetes diagnosed with OGTT have more severe metabolic risk than those diagnosed with HbA1c, and more likely to have greater risk of progression to T2DM.

Insulin secretion predicts the response to therapy with exenatide plus pioglitazone, but not to basal/bolus insulin in poorly controlled T2DM patients: Results from the Qatar study

The present study aims to identify predictors for response to combination therapy with pioglitazone plus exenatide vs basal/bolus insulin therapy in T2DM patients who are poorly controlled with maximum/near-maximum doses of metformin plus a sulfonylurea. Participants in the Qatar study received a 75-g OGTT with measurement of plasma glucose, insulin and C-peptide concentration at baseline and were then randomized to receive either treatment with pioglitazone plus exenatide or basal/bolus insulin therapy for one year. Insulin secretion measured with plasma C-peptide concentration during the OGTT was the strongest predictor of response to combination therapy (HbA1c ≤ 7.0%) with pioglitazone plus exenatide. A 54% increase in 2-hour plasma C-peptide concentration above the fasting level identified subjects who achieved the glycaemic goal (HbA1c < 7.0%) with 82% sensitivity and 79% specificity. Only baseline HbA1c was a predictor of response to basal/bolus insulin therapy. Thus, the increment in 2-hour plasma C-peptide concentration above the fasting level provides a useful tool to identify poorly controlled T2DM patients who can achieve glycaemic control without insulin therapy, and thereby, can be used to individualize antihyperglycaemic therapy in poorly controlled T2DM patients.

The benefits of a comprehensive rehabilitation program in patients diagnosed with spastic quadriplegia

Spastic quadriplegia has as an etiopathogenic substrate, a non-progressive brain lesion; however, the clinical manifestations of the disease evolve over time. Children diagnosed with spastic quadriplegia show a variety of symptoms in different areas: sensorimotor, emotional, cognitive, and social. The purpose of this study was to assess the functional status in patients diagnosed with spastic quadriplegia, who followed a complex medical rehabilitation program, during a year, and highlight the importance of using physical and kinetic techniques in improving their status. A total of 10 children diagnosed with spastic quadriplegia were included in the study and the Gross Motor Function Classification System (GMFCS) and manual ability classification system (MACS) were used to evaluate the functionality status of each patient. Every patient was evaluated initially (T1), after six months of program (T2), and after they completed the study. All the children were originally monitored daily, for 5 days per week for a period of one month, then two times a week for a year. A statistically significant difference regarding the modification of the GMFCS and MACS stage was found, which occurred between the first and the third evaluation. The inverse correlation of the statistical significance between the ages of patients and the decrease in GMFCS or MACS stage was highlighted; the younger the patient, the more the scale decreased. A direct link between the gross motor function and the manual ability was noticed. Applying a complex rehabilitation program has proven efficient by improving both the gross motor functionality and the manual ability.

[Trichoblastic carcinoma]

INTRODUCTION

Trichoblastic carcinoma is a rare malignant adnexal tumor. Its presentation is non-specific and the diagnosis is always histological.

CASE REPORT

A 56-year-old patient presented with a trichoblastic carcinoma of the eyelid and eyebrow. It was located on the lower end of the scar, 7 years after the incomplete excision of a tumor. There was a large subcutaneous extension of the tumor, well beyond the visible margins of the skin lesion. The treatment was a broad surgical excision followed by radiotherapy. There was neither local recurrence nor metastasis 20 months later.

DISCUSSION

This clinical presentation was atypical and had never been reported. We discuss the therapeutic management of this rare tumor.

The lateral tarsal strip in ectropion surgery: is it effective when performed in isolation?

PURPOSE

The lateral tarsal strip (LTS) for involutional ectropion is often performed with a medial spindle (tarsoconjunctival diamond excision). We aimed to evaluate how well the LTS alone can achieve symptomatic relief.

METHODS

A retrospective, comparative case series was performed on consecutive patients undergoing LTS alone or with medial spindle for involutional ectropion. Outcomes for LTS alone were clinically derived functional success (improvement in symptoms and aesthetic appearance) and anatomical success (judged by punctal position in the tear lake, punctal movement during blinking and absence of ectropion). We verified if these outcomes compared favourably with those of the patients who had undergone an LTS with medial spindle. Procedure selection was based on pre-operative clinical examination, especially the lateral pinch and twist test (this is described). Complications were also recorded.

RESULTS

Of 67 eyes, 23 had LTS alone and 44 had LTS with a medial spindle. Of those having LTS alone the functional success rate was 87% (95% CI (66.4, 97.2%)). This did not differ significantly from a success rate of 89% (75.4, 96.2%) in LTS with a medial spindle (P=0.99). A total of 78% (56.9, 92.5%) of patients undergoing LTS had a good anatomical result compared with 82% (67.3, 91.8%) of those who had an additional medial spindle (P=0.75). Complication rates were similar between the groups.

CONCLUSION

Where the lateral pinch and twist test returns the eyelid to a good position, the LTS alone can suffice for the management of involutional ectropion.

[Congenital insensitivity to pain: difficulty of management]

INTRODUCTION

Congenital insensitivity to pain with anhidrosis (CIPA) is a very rare disorder, most often of genetic origin.

CASE REPORT

The authors present the case of two siblings, 10 and 13 years old, both followed-up since the age of 2 for CIPA diagnosed after discovering insensitivity to pain during iterative falls, burns, and of severe oro-digital self-mutilating behavior. Sural nerve biopsy and an electromyogram confirmed the diagnosis.

DISCUSSION

CIPA with anhidrosis is a very rare disease. It is characterized by unexplained fever episodes, anhidrosis, pain insensitivity, self-mutilating behavior, and sometimes mental retardation. Complications of this insensitivity (non-treated fractures, burns, and oro-digital mutilation) may be lethal. Treatment remains preventive. The patient must observe a very strict hygiene. Prevention for maxillofacial involvement consists in breaking the cycle of oral self-mutilation.

[Outcome of oral implants after autogenous bone reconstruction]

INTRODUCTION

The purpose of this study was to evaluate the implant placement outcome in edentulous patients prosthetically rehabilitated after autogenous bone graft.

MATERIAL AND METHOD

Between 2002 and 2006, 75 patients underwent graft surgery, only 64 patients (mean age of 53.8 years) had a complete treatment. Calvarial bone grafts were used in 41 cases, mandible bone in 13 cases, and iliac bone in 13 cases. Grafting techniques were onlay and inlay grafts in the maxilla combined or not with LeFort I osteotomies, and onlay or interposed bone graft in the mandible. Twelve patients presented with complications, wound dehiscence in seven cases and infection in five cases. Twenty-two patients presented with perforation of the sinus mucosa in the course of sinus lift.

RESULTS

Three hundred and seventy-nine implants were inserted in 64 patients, 295 in the maxilla and 84 in the mandible. Fifteen implants failed (3.95%), 13 before loading and two after, 10 maxillary implants (3.38%), and five mandibular implants (5.95%). The global implant survival was 96.05% with a mean background of 23.6 months, 88.37% after sinus lift, 83.33% after apposition graft in the mandible and 88.64% in the maxilla.

DISCUSSION

These results correlate to current published data.

[Suprafascial dissection of the radial forearm flap]

INTRODUCTION

The aim of this study was to assess the efficacy of dissection of radial forearm flap in a superficial plan above the deep fascia to prevent donor site problems.

PATIENTS AND METHODS

Eighteen radial forearm flaps were used for orofacial reconstruction: 11 suprafascial flaps and seven infrafascial flaps. We compared in the two groups: flap failure, graft success, tendon adhesions, sensory nerve damage at donor site.

RESULTS

We observed one case of flap failure in the infrafascial group and one case in the suprafascial group. With suprafascial elevation flap technique, we noted 100% of grafts integration without tendon adhesion. In infrafascial elevation flap technique, four out of seven patients had delayed healing.

DISCUSSION

The suprafascial dissection of free radial forearm flap creates a superior graft recipient bed ensuring early and complete successful graft.

Study on the physico chemical properties of water of Mouri River, Khulna, Bangladesh

Water sample were collected from six different point of the Mouri River Khulna, Bangladesh with a regular intervals in the months of January-March 2002 for the analyzing different physicochemical parameters of the water. Total 22 different physicochemical parameters were investigated. Correlation and the t value among the parameters were also determined. In the present investigation the minimum and maximum value of water temperature, Transparency, Turbidity, TSS, TDS, Electric Conductivity, water pH, dissolve oxygen, free Carbon dioxide, Alkalinity, Acidity, Hardness, BOD, COD, Sulphate, Phosphate, Nitrite, Sodium, Calcium, Potassium, Manganese and Iron were noted as 21.6 and 32.2 degrees C; 15 and 66 cm; 16 and 22 NTU; 74 and 125 mg L(-1); 255 and 305 mg L(-1); 159 and 275 microS cm(-1); 1.10 mg L(-1) 8.18 mg L(-1); 7.5 and 8.3; 1.1 and 8.3 mg L(-1); 27.5 and 35.5 mg L(-1); 350 and 610 mg L(-1); 32.4 and 171 mg L(-1); 310 and 529 mg L(-1); 13 and 31 mg L(-1); 290 and 365 mg L(-1); 42046 and 57.35 mg L(-1); 4.89 and 11.46 mg L(-1); 0.54 and 1.82 mg L(-1); 16.8 and 33.9 mg L(-1); 1.5 and 6.9 mg L(-1); 49 and 94 mg L(-1); 31 and 59 mg L(-1); 2.6 and 3.8 mg L(-1), respectively. River water did not show any significant pollution during the present study. During the study period dissolved oxygen show direct relation with water temperature but inverse with BOD and COD.

Biochemical composition of some small indigenous fresh water fishes from the River Mouri, Khulna, Bangladesh

Biochemical composition of seven small indigenous fresh water fishes namely Magur (Clarias batrachus), Shingi (Heteropneustes fossilis), Koi (Anabas testudineus), Foli (Notopterus notopterus), Royna (Nandas nandas), Taki (Channa punctatus) and Tangra (Mystus vittatus) from the Mouri river Khulna, Bangladesh was studied in order to evaluate their nutritional values. The mean value of protein, fat, moisture and ash content was found as 14.87 +/- 0.63, 7.90 +/- 1.91, 73.49 +/- 0.69 and 3.74 +/- 0.46% in C. batrachus; 17.34 +/- 0.51, 3.45 +/- 0.92, 76.06 +/- 2.24 and 3.15 +/- 0.25% in H. fossilis; 19.63 +/- 0.5, 7.79 +/- 2.73, 69.27 +/- 1.04 and 3.31 +/- 0.83% in A. testudineus; 18.30 +/- 0.79, 4.98 +/- 1.71, 72.68 +/- 1.08 and 5.82 +/- 0.82% in N. notopterus; 16.09 +/- 2.66, 7.34 +/- 0.49, 75.75 +/- 0.78 and 5.19 +/- .029% in N. nandas; 19.13 +/- 2.40, 4.55 +/- 1.18, 70.55 +/- 1.89 and 6.81 +/- 0.94% in C. punctatus and 15.62 +/- 0.32, 7.53 +/- 1.10, 73.99 +/- 3.13 and 6.50 +/- 0.63% in M. vittatus. Considering the result of the present study, it can be concluded that all the species are rich in food value.

Interobserver agreement on visual field progression in glaucoma: a comparison of methods

AIM

To examine the level of agreement between clinicians in assessing progressive deterioration in visual field series using two different methods of analysis.

METHODS

Each visual field series satisfied the following criteria: more than 19 reliable fields, patient age over 40 years, macular threshold at least 30 dB. The first three fields in each series were excluded to minimise learning effects: the following 16 were studied. Five expert clinicians assessed the progression status of each series using both standard Humphrey printouts and pointwise linear regression (PROGRESSOR). The level of agreement between the clinicians was evaluated using a weighted kappa statistic.

RESULTS

A total of 432 tests comprising 27 visual field series of 16 tests each were assessed by the clinicians. The level of agreement on progression status between the clinicians was always higher when they used PROGRESSOR (median kappa = 0.59) than when they used Humphrey printouts (median kappa = 0.32). This was statistically significant (p = 0.006, Wilcoxon matched pairs signed rank sum test).

CONCLUSIONS

Agreement between expert clinicians about visual field progression status is poor when standard Humphrey printouts are used, even when the field series studied are long and consist solely of reliable fields. Under these ideal conditions, clinicians agree more closely about patients' visual field progression status when using PROGRESSOR than when inspecting series of Humphrey printouts.

Use of high spatial resolution perimetry to identify scotomata not apparent with conventional perimetry in the nasal field of glaucomatous subjects

AIM

To examine whether high spatial resolution perimetry (HSRP) could identify fine scale scotomata which may not be apparent with conventional perimetry. The HSRP was performed in the nasal field, as this location is a recognised site for the early occurrence of glaucomatous defects.

METHOD

16 early glaucoma eyes, 17 glaucoma suspect eyes, and 20 age matched healthy control eyes underwent conventional automated perimetry using the 24-2 program of the Humphrey field analyser (HFA) and HSRP. The HSRP was performed in the nasal field by testing 9 x 9 degrees of 100 tested points separated by 1 degree and the results compared with the HFA 24-2 program.

RESULTS

Mean HSRP thresholds were significantly abnormal in the suspect and glaucoma eyes, with elevated levels of asymmetry between the superior and inferior nasal field. Overall, 7/17 (41%) suspect eyes (95% confidence interval 5/17 (29%) to 7/17 (41%)) had nasal scotomata on HSRP, although their HFA 24-2 fields failed to identify any defects. In glaucomatous eyes, 15/16 (94%) eyes had HSRP scotomata (95% CI 14/16 (88%) to 15/16 (94%)). In 12 these coexisted with HFA 24-2 defects at the same location, while in three eyes only HSRP identified scotomata in the nasal field.

CONCLUSION

HSRP can identify scotoma in glaucomatous eyes in the nasal field which may be missed with the lower spatial resolution of conventional perimetry.

Inter- and intraobserver variation in the analysis of optic disc images: comparison of the Heidelberg retina tomograph and computer assisted planimetry

AIMS

The development of imaging and measurement techniques has brought the prospect of greater objectivity in the measurement of optic disc features, and therefore better agreement between observers. The purpose of this study was to quantify and compare the variation between observers using two measurement devices.

METHODS

Optic disc photographs and images from the Heidelberg retina tomograph (HRT) of 30 eyes of 30 subjects were presented to six observers for analysis, and to one observer on five separate occasions. Agreement between observers was studied by comparing the analysis of each observer with the median result of the other five, and expressed as the mean difference and standard deviation of differences between the observer and the median. Inter- and intraobserver variation was calculated as a coefficient of variation (mean SD/mean x 100).

RESULTS

For planimetry, agreement between observers was dependent on observer experience, for the HRT it was independent. Agreement between observers (SD of differences as a percentage of the median) for optic disc area was 4.0% to 7.2% (planimetry) and 3.3% to 6.0% (HRT), for neuroretinal rim area it was 10.8% to 21.0% (planimetry) and 5.2% to 9.6% (HRT). The mean interobserver coefficient of variation for optic disc area was 8.1% (planimetry) and 4.4% (HRT), for neuroretinal rim area it was 16.3% (planimetry) and 8.1% (HRT), and (HRT only) for rim volume was 16.3%, and reference height 9.1%. HRT variability was greater for the software version 1.11 reference plane than for version 1.10. The intraobserver coefficient of variation for optic disc area was 1.5% (planimetry) and 2.4% (HRT), for neuroretinal rim area it was 4.0% (planimetry) and 4.5% (HRT).

CONCLUSIONS

Variation between observers is greatly reduced by the HRT when compared with planimetry. However, levels of variation, which may be clinically significant, remain for variables that depend on the subjective drawing of the disc margin.