Effects of allogenic acellular dermal matrix combined with autologous razor‐thin graft on hand appearance and function of patients with extensive burn combined with deep hand burn

The aim of the study was to observe the effect of allogeneic acellular dermal matrix (ADM) combined with autologous razor‐thin graft on the appearance and function of hands in patients with extremely large area burns combined with deep hand burns. Sixty‐four patients with severe burn combined with deep burn of the hand in our hospital from August 2015 to August 2019 were selected as the study subjects. All patients were randomly divided into the study group (32 cases, given allogeneic ADM combined with autologous razor‐thin graft) and the control group (32 cases, given autologous scar tissue combined with autologous razor‐thin graft). Hand appearance, wound healing, wound contraction, hand function, and quality of life were compared between the two groups at 3 and 6 months after treatment. The vascular distribution, skin thickness, and flexibility scores of the two groups 6 months post operation were lower than those of the 3 months post operation (P < .05). At 6 months after operation, there were significant differences in blood vessel distribution, skin thickness, flexibility, and colour between the two groups (P < .05). The wound healing rate and wound contraction rate of the two groups at 6 months after operation were higher than those at 3 months after operation (P < .05). The wound healing rate of the study group was higher than that of the control group (P < .05), but there was no significant difference in the wound contraction rate between the two groups. Hand function was better in both groups 6 months after operation than 3 months after operation (P < .05). The hand function of the experimental group was better than that of the control group at 3 and 6 months after operation (P < .05). The quality of life in the two groups at 6 months after operation was significantly higher than that at 3 months after operation, and the quality of life in the study group was consistently higher than that in the control group (P < .05). Allogeneic ADM combined with razor‐thin graft in the treatment of patients with extensive burns and deep hand burns can effectively restore the shape and function of the hand, which is conducive to wound healing and improve the quality of life of patients, and it is worthy of wide clinical application.     

‘Nephrostomy-Free’ Percutaneous Nephrolithotomy: Experience in a UK District General Hospital

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. ‘Tubeless’ or ‘nephrostomy-free’ PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of ‘nephrostomy-free’ PCNLs compared to standard PCNL over a 4-year period.

PATIENTS AND METHODS

Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive ‘nephrostomy-free’ PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications.

RESULTS

‘Nephrostomy-free’ PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted ‘nephrostomy-free’ PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the ‘nephrostomy-free’ group developed a delayed perirenal haematoma.

CONCLUSIONS

‘Nephrostomy-free’ percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.     

A Comparative Study of Dermatoscopic Features of Melasma and Hori’s Nevus in Asian Patients

BackgroundDermatoscopy is a noninvasive diagnostic tool for pigmented lesions. However, data regarding dermatoscopic features in melasma and Hori’s nevus, which are commonly found in Asian populations, are still lacking. In addition, melasma coexisting with Hori’s nevus presents a particular diagnostic challenge and they generally require different treatments.ObjectiveWe sought to describe the dermatoscopic features of melasma and Hori’s nevus and to establish diagnostic clues for each condition.MethodsFifty patients with melasma and 46 patients with Hori’s nevus were enrolled in the study. Dermatoscopic pictures were taken with Dermlite DL200 HR (3Gen, San Juan Capistrano, Califorinia) and evaluated by two blinded board-certified dermatologists.ResultsThe dermatoscopic features more prominently seen in melasma compared to Hori’s nevus include light brown pigmentation (98% vs. 10.9%, P<0.001), regular pigment network (38% vs. 2.2%, P<0.001), irregular pigment network (98% vs. 63%, P<0.001), arcuate structure (68% vs. 13%, P<0.001), circles (48% vs. 10.9%, P<0.001), sparing of follicles and sweat gland openings (98% vs. 4.3%, P<0.001), and telangiectasias (52% vs. 19.6%, P=0.001). In contrast, the common features of Hori’s nevus include blue-brown or grey pigmentation (63% vs. 0%, P=0.001) and speckled homogenous pattern (52.2% vs. 0%, P<0.001).ConclusionDermatoscopy is a useful diagnostic tool for distinguishing between melasma and Hori’s nevus. In patients with coexistence of both conditions, dermatoscopy can be used to confirm the diagnosis and aid the proper treatment.     

Burr-hole Irrigation with Closed-system Drainage for the Treatment of Chronic Subdural Hematoma: A Meta-analysis

There is controversy among neurosurgeons regarding whether irrigation or drainage is necessary for achieving a lower revision rate for the treatment of chronic subdural hematoma (CSDH) using burr-hole craniostomy (BHC). Therefore, we performed a meta-analysis of all available published reports. Multiple electronic health databases were searched to identify all studies published between 1989 and June 2012 that compared irrigation and drainage. Data were processed by using Review Manager 5.1.6. Effect sizes are expressed as pooled odds ratio (OR) estimates. Due to heterogeneity between studies, we used the random effect of the inverse variance weighted method to perform the meta-analysis. Thirteen published reports were selected for this meta-analysis. The comprehensive results indicated that there were no statistically significant differences in mortality or complication rates between drainage and no drainage (P > 0.05). Additionally, there were no differences in recurrence between irrigation and no irrigation (P > 0.05). However, the difference between drainage and no drainage in recurrence rate reached statistical significance (P < 0.01). The results from this meta-analysis suggest that burr-hole surgery with closed-system drainage can reduce the recurrence of CSDH; however, irrigation is not necessary for every patient.     

Ulnar Styloid Fracture Accompanying Distal Radius Fracture Does Not Affect Hand Function,but What About Hand Dexterity?

Introduction  Hand dexterity is not addressed in patients with distal radius fracture (DRF) accompanied with ulnar styloid fracture (USF) in literature. This study aimed to determine whether an associated USF following a DRF has any effect on hand dexterity. Materials and Methods  Patients diagnosed with DRF were included in the study and were divided into two groups according to the USF presence (USF group and non-USF group). Pain, range of motion, Quick-DASH (Quick-Disabilities of the Arm, Shoulder, and Hand), handgrip and pinch strength, Purdue Pegboard test, and Jebsen Taylor Hand Function test were measured in the sixth month. Results  A total of 125 patients, 68 females (54.4%) and 57 males (45.6%) were included in the study. The mean age of the patients was 47.15 ± 13.41 (18–65) years. There were 60 patients (48%) in the USF group and 65 patients (52%) in the non-USF group. No significant difference was found in pain, range of motion, Quick-DASH and handgrip and pinch strength between the groups ( p > 0.05). The hand dexterity tests showed no statistically significant difference between the groups in the sixth month ( p > 0.05). Discussion  Hand function can be determined more accurately by assessing hand dexterity. In this study, it is emphasized that concomitant USF does not lead to poorer hand dexterity.     

Patients’ preferred mode of travel to the orthopaedic theatre

AIM: To determine the preferred mode of travel to the operating theatre for elective orthopaedic patients.METHODS: Data was collected prospectively over a 2-wk period at an elective Orthopaedic Treatment Centre. Patients were asked to complete a patient satisfaction questionnaire following their surgery on their experience and subsequent preferred mode of transport to theatre. The data was then recorded in a tabulated format and analysed with percentages. Fisher’s exact test was used to determine if there was any statistical association between patients’ preference to walk and various groups; in-patient or day case procedures, and whether patients were < 60 years or > 60 years of age.RESULTS: Seventy patients (40 females and 30 males) fully completed the questionnaire. In total there were 33 d-cases and 37 in-patients. The spectrum of orthopaedic sub-specialties included was knee (41%), hip (17%), foot and ankle (24%), spine (13%) and upper limb (4%). Patient satisfaction for overall experience of travelling to theatre was either excellent (77%) or good (23%). Following their experience of travelling to theatre, 87% (95%CI: 79%-95%) of the total cohort would have preferred to walk to the operating theatre. There was a statistically significant association (P = 0.003) between patients’ preference to walk and whether they were day-case or in-patients. Similarly, there was a statistically significance association (P = 0.028) between patients’ preference to walk and whether they were < 60 years or > 60 years of age.CONCLUSION: This study confirms the majority of Orthopaedic elective patients would prefer to walk to theatre, when given the choice and if practically possible.     

Hypotensive Anesthesia Combined with Tranexamic Acid Reduces Perioperative Blood Loss in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Cohort Study

ObjectiveTo assess the efficacy and safety of hypotensive anesthesia (HA) combined with tranexamic acid (TXA) for reducing perioperative blood loss in simultaneous bilateral total hip arthroplasty (SBTHA).MethodsIn this retrospective cohort study, a total of 183 eligible patients (15 females and 168 males, 44.01 ± 9.29 years old) who underwent SBTHA from January 2015 to September 2020 at our medical center were enrolled for analysis. Fifty‐nine patients received standard general anesthesia (Std‐GA group), the other 85 and 39 patients received HA with an intraoperative mean arterial pressure between 70 and 80 mmHg (70–80 HA group) and below 70 mmHg (<70 HA group), respectively. TXA was administrated to all patients. Perioperative blood loss (total, dominant, and hidden), transfusion rate and volume, hemoglobin and hematocrit reduction, duration of operation and anesthesia, length of hospitalization, range of hip motion as well as postoperative complications were collected from hospital''s electronic records and compared between groups.ResultsAll patients were followed for more than 3 months. Total blood loss in the two HA groups (1390.25 ± 595.67 ml and 1377.74 ± 423.46 ml, respectively) was significantly reduced compared with that in Std‐GA group (1850.83 ± 800.73 ml, P < 0.001). Both dominant and hidden blood loss were dramatically decreased when HA was applied (both P < 0.001). Accordingly, the transfusion rate along with volume in 70–80 HA group (14.1%, 425.00 ± 128.81 ml) and <70 HA group (12.8%, 340.00 ± 134.16 ml) were reduced in comparison with those in Std‐GA group (37.3%, 690.91 ± 370.21ml; P = 0.001 and P = 0.014, respectively). The maximal hemoglobin and hematocrit reduction in both HA groups were significantly less than those in Std‐GA group (both P < 0.001). Of note, 70–80 and <70 HA groups exhibited comparable efficacy with no significant differences between them. Besides, significant difference in duration of surgery was found among groups (P = 0.044 and P < 0.001), while no differences in anesthesia time and postoperative range of hip motion were observed. Regarding complications, the incidence of both acute kidney injury and postoperative hypotension in <70 HA group was significantly higher than that in 70–80 HA and Std‐GA groups (P = 0.014 and P < 0.001). Incidence of acute myocardial injury was similar among groups (P = 0.099) and no other severe complications or mortality were recorded.ConclusionThe combination of HA with a mean arterial pressure (MAP) of 70–80 mmHg and TXA could significantly reduce blood loss and transfusion during SBTHA, in addition to shortening operation time and length of hospitalization, and with no increase in complications.     

Predictors of Hand Function Following Digit Replantation: Quantitative Review and Meta-Analysis

Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores (P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level (P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation (P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.     

The PROMIS Upper Extremity Computer Adaptive Test Correlates With Previously Validated Metrics in Patients With Carpal Tunnel Syndrome

Background: The Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) computer adaptive test was developed to improve precision and reduce question burden. We hypothesized that in patients with carpal tunnel syndrome (CTS): (1) PROMIS UE would correlate with established patient-reported outcome measures (PROs); (2) the time and number of questions required would be lower than current metrics; (3) there would be no floor or ceiling effects; and (4) PROMIS UE would not correlate with disease severity. Methods: Patients undergoing electrodiagnostic evaluation found to have a primary diagnosis of unilateral CTS prospectively completed PROMIS UE, Quick Disabilities of the Arm, Shoulder and Hand (qDASH), and Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Electrophysiologic and clinical severity was recorded. The relationships among PROs were described with Spearman coefficients. A floor or ceiling effect was confirmed if >15% of patients achieved the lowest or highest possible score, respectively. Results: Fifty-one patients (average, 53.9 years) were enrolled. An excellent correlation was identified between PROMIS UE and qDASH (R = −0.76, P < .001). There was a good correlation between PROMIS UE and BCTQ (R = −0.58, P < 0.001). The PROMIS UE required less time and fewer questions than qDASH and BCTQ (P = .02 and P < .001). There were no floor or ceiling effects. Neither neurophysiologic nor clinical severity correlated with PROMIS UE (R = 0.24, P > .05 and R = −0.18, P > .05). Conclusions: The PROMIS UE has an excellent correlation with qDASH and a good correlation with BCTQ in patients with CTS. Furthermore, PROMIS UE required less time and fewer questions than established PROs. Used as a single PRO, PROMIS UE represents a practical alternative to current metrics in patients with CTS.     

Clinical Research and Technique Note of TLIF by Wiltse Approach for the Treatment of Degenerative Lumbar

ObjectiveTo assess the clinical efficacy and share the technique notes of Wiltse Approach TLIF for the treating single segment degenerative lumbar spinal disease.MethodIn this retrospective controlled study, 780 patients with single segment degenerative lumbar disease who were operated in our hospital from January 2016 to December 2020 were analyzed retrospectively. The patients were randomly assigned to Wiltse approach group (group A, 410 cases) and conventional open approach group (group B, 370 cases). Patient''s assessment of pain and disability were evaluated by the visual analogue scale (VAS) and the Oswestry disability index (ODI) before and after surgery. The incision length, operative time, exposure time, intraoperative blood loss, hidden blood loss, time to ambulation, total length of hospitalization, serum creatine kinase, X‐rays, CT and MRI were also evaluated.ResultsThere were no differences in sex, age, pre‐operative ODI score, VAS score between the two groups (P > 0.05). The Wiltse approach group had a shorter incision length with 7.69 ± 0.44 cm compared to the conventional group with 11.13 ± 0.36 cm (P < 0.01). The average operative time was 119.20 ± 14.64 min with exposure time of 16.20 ± 3.42 min in the Wiltse approach group and 145.65 ± 16.98 min with 29.20 ± 3.42 min in the conventional group (P < 0.05, P < 0.01). Comparing the intraoperative blood loss, hidden blood loss, serum creatine kinase, time to ambulation, total length of hospitalization, the Wiltse approach group was less than the conventional open approach group (P < 0.05). The VAS score of the two groups decreased significantly with time, and the VAS score of the Wiltse group was significantly lower than that of the conventional open approach group (P < 0.05). At last investigation after operation, ODI scores of the two groups were significantly decreased compared with that before operation. Wiltse approach group was significantly lower than that of the conventional open approach group (P < 0.05). The multifidus of the two groups of patients had a certain degree of atrophy. But the Wiltse approach group multifidus muscle atrophy rate is significantly lower than the conventional open approach group.ConclusionThe Wiltse approach TLIF significantly reduces the damage to the paravertebral muscles and the postoperative incidence of chronic low back pain.     

The Outcomes and Quality of Life of Patients with Achalasia after Peroral Endoscopic Myotomy in the Short-Term

Purpose: To assess the short-term efficacy and quality of life (QOL) of patients with achalasia after peroral endoscopic myotomy (POEM).Methods: Thirty-five achalasia patients underwent POEM from May 2013 to December 2013. The data on clinical evaluation and QOL before therapy, at 1 month and 6 months postoperation were collected and analyzed.Results: All the thirty-five patients underwent POEM successfully. By comparing the data of the preoperative with that of 1 month and 6 months after POEM respectively, we found that: mean Eckardt score decreased (6.83 vs 0.51, 6.83 vs 0.46, all P <0.05), esophagus diameter reduced (47.97 mm vs 32.00 mm, 47.97 mm vs 28.50 mm, all P <0.05), and esophageal manometry declined (29.5 mmHg vs 11.5 mmHg, 29.5 mmHg vs 10.3 mmHg, all P <0.05). Complications occurred in 14.3% (5/35) of the cases, and no recurrence was observed. At each time point, postoperative QOL scores were higher than those of preoperative (P <0.05).Conclusions: POEM is safe and effective for treating achalasia in the short-term, it can relieve clinic symptoms as well as improve patients’ QOL.     

ICSI treatment of severe male infertility can achieve prospective embryo quality compared with IVF of fertile donor sperm on sibling oocytes

Azoospermia, cryptozoospermia and necrospermia can markedly decrease the ability of males to achieve pregnancy in fertile females. However, patients with these severe conditions still have the option to be treated by intracytoplasmic sperm injection (ICSI) to become biological fathers. This study analyzed the fertilization ability and the developmental viabilities of the derived embryos after ICSI treatment of the sperm from these patients compared with in vitro fertilization (IVF) treatment of the proven-fertile donor sperm on sibling oocytes as a control. On the day of oocyte retrieval, the number of sperm suitable for ICSI collected from two ejaculates or testicular sperm extraction was lower than the oocytes, and therefore, excess sibling oocytes were treated by IVF with donor sperm. From 72 couples (73 cycles), 1117 metaphase II oocytes were divided into 512 for ICSI and 605 for IVF. Compared with the control, husbands’ sperm produced a lower fertilization rate in nonobstructive azoospermia (65.4% vs 83.2%; P < 0.001), crytozoospermia (68.8% vs 75.5%; P < 0.05) and necrospermia (65.0% vs 85.2%; P < 0.05). The zygotes derived in nonobstructive azoospermia had a lower cleavage rate (96.4% vs 99.4%; P < 0.05), but the rate of resultant good-quality embryos was not different. Analysis of the rates of cleaved and good-quality embryos in crytozoospermia and necrospermia did not exhibit a significant difference from the control. In conclusion, although the sperm from severe male infertility reduced the fertilization ability, the derived embryos had potential developmental viabilities that might be predictive for the expected clinical outcomes.     

A new way to use transit-time flow measurement for coronary artery bypass grafting

 Open in a separate windowOBJECTIVESTransit-time flow measurement is a recognized method for graft evaluation in coronary surgery. However, single flow measurement has been associated with a low specificity for detecting graft dysfunction. The goal of this study was to assess the value of transit-time flow measurement for assessing in situ internal mammary artery grafts during non-existent native coronary circulation and the relevance of collateral blood flow in target vessels.METHODSBetween 2014 and 2018, a total of 134 patients undergoing on-pump coronary artery bypass grafting were evaluated using transit-time flow measurement. We analysed 111 single left internal mammary artery and 57 single right internal mammary artery bypasses. Correlations between coronary relevant parameters were calculated using Spearman’s ρ coefficient. Risk factors for decreased flow with an arrested heart (FAH) <30 ml/min and an increased pulsatility index (PI) >3.0 as well as flow reduction >30% were calculated.RESULTSFAH correlated with the diameter of the target vessel (Spearman’s ρ = 0.32; P < 0.001), the amount of blood distribution (Spearman’s ρ = 0.34; P < 0.001), the PI (Spearman’s ρ = 0.19; P = 0.019) and the degree of stenosis (Spearman’s ρ = −0.17; P = 0.042). The percentage of flow change was found to correlate with the PI (Spearman’s ρ = −0.47; P < 0.0001), the degree of stenosis (Spearman’s ρ = 0.42; P < 0.001), the diameter of the target vessel (Spearman’s ρ = −0.22; P = 0.008) and the area of blood distribution (Spearman’s ρ = −0.19; P = 0.018). A small blood distribution area was the only risk factor for decreased FAH [odds ratio (OR) 8.43, confidence interval (CI) 95% (3.04–23.41); P < 0.001]. Binary logistic regression identified PI [OR 2.05, CI 95% (1.36–3.10); P = 0.001], FAH [OR 0.98, CI 95% (0.97–0.99); P = 0.005] and degree of stenosis [OR 0.95, CI 95% (0.92–0.99); P = 0.011] as risk factors for decreased flow after cardiopulmonary bypass (<30 ml/min). An increased PI (>3) was mainly influenced by percentage of flow change [OR 0.99, CI 95% (0.98–1.00); P = 0.031].CONCLUSIONSFAH and percentage of flow change are related to the dimensions of the target vessel and the degree of stenosis. The addition of flow measurements with the heart arrested provides additional information about the bypass graft, the quality of the anastomosis and the physiology of the coronary circulation.     

Comparison of the Traditional,Swing, and Chicken Wing Volleyball Blocking Techniques in NCAA Division I Female Athletes

In volleyball, blocking is highly correlated with team success. The identification of specific techniques that produce a more successful block would be helpful knowledge for coaches and players. This study compared the traditional, swing, and “chicken wing” blocking techniques in combination with the running step footwork pattern in order to determine which technique enabled athletes to perform a more effective block. High-speed videography (7 cameras, Vicon Motion Analysis System) was used to capture the blocking movements of thirteen female NCAA Division I athletes (age = 19.4 ± 1.19 years, height = 1.82 ± 0.08 m, mass = 70.63 ± 7.96 kg, and years of participation at the collegiate level = 2.23 ± 1.17 years). Each player was familiar with each blocking technique. Reflective markers were placed on the players and in randomized order the players performed 3 blocking trials of each technique. The following dependent variables were assessed: The time it took the athletes to get off the ground and get their hands above (vertically) the net was calculated. The distance the hand reached over the net or hand penetration (displacement between the net and finger in the anterior and vertical planes) was also measured. Lastly, jump height was calculated. Repeated measures ANOVA and post-hoc comparisons were done (α = 0.05). There was no significant difference in the main effect for time to get off the ground (p > 0.05). There was a significant difference in the time to get the hands above the net (p < 0.05). The swing block was best for jump height (p <.001) and hand penetration (p < 0.05). These results can help coaches and players decide which blocking technique will benefit them most as a blocking team and as individual blockers.

Key points

• The swing blocking technique resulted in greater jump heights and increased hand penetration, relative to the traditional and chicken wing blocking techniques.
• The chicken wing blocking technique resulted in greater jump heights and increased hand penetration, relative to the traditional blocking technique.
• The traditional blocking technique does not appear to provide any competitive advantage related to the variables observed during this study: (1) duration spent getting off of the ground and placing hands over the net, (2) jump height, and (3) hand penetration magnitude.

Key words: Motion analysis, counter- movement, volleyball defense.     

The da Vinci Robot System Eliminates Multispecialty Surgical Trainees' Hand Dominance in Open and Robotic Surgical Settings

Background and Objectives:

Handedness, or the inherent dominance of one hand''s dexterity over the other''s, is a factor in open surgery but has an unknown importance in robot-assisted surgery. We sought to examine whether the robotic surgery platform could eliminate the effect of inherent hand preference.

Methods:

Residents from the Urology and Obstetrics/Gynecology departments were enrolled. Ambidextrous and left-handed subjects were excluded. After completing a questionnaire, subjects performed three tasks modified from the Fundamentals of Laparoscopic Surgery curriculum. Tasks were performed by hand and then with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, California). Participants were randomized to begin with using either the left or the right hand, and then switch. Left:right ratios were calculated from scores based on time to task completion. Linear regression analysis was used to determine the significance of the impact of surgical technique on hand dominance.

Results:

Ten subjects were enrolled. The mean difference in raw score performance between the right and left hands was 12.5 seconds for open tasks and 8 seconds for robotic tasks (P < .05). Overall left-right ratios were found to be 1.45 versus 1.12 for the open and robot tasks, respectively (P < .05). Handedness significantly differed between robotic and open approaches for raw time scores (P < .0001) and left-right ratio (P = .03) when controlling for the prior tasks completed, starting hand, prior robotic experience, and comfort level. These findings remain to be validated in larger cohorts.

Conclusion:

The robotic technique reduces hand dominance in surgical trainees across all task domains. This finding contributes to the known advantages of robotic surgery.     

Arthroscopic Distal Scaphoid Resection for Scapho-Trapezium-Trapezoid Arthritis

Background: The purpose of this study was to describe the technique of arthroscopic resection of the scaphoid head and evaluate both the clinical and radiographic results of scapho-trapezium-trapezoid osteoarthritis cases. Methods: Seventeen cases (13 men and 4 women) with a mean age of 57 years (24-74 years) were operated on from 2002 to 2015. Inclusion criteria were nontraumatic radial-sided wrist pain without improvement after 4 months of conservative treatment and positive radiographic images demonstrating the presence of osteoarthritis. All cases were evaluated preoperatively and postoperatively using visual analog scale, wrist range of motion (ROM), grip strength, and patient’s work status (Mayo Wrist Score). Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) questionnaires were also administered. The technique consisted of performing a 3- to 4-mm round-shaped scaphoid head resection via arthroscopy while preserving the scaphotrapezial and scaphocapitate ligament insertions. Results: At an average follow-up of 24 months, all the patients were satisfied. The results showed statistically significant improvement in pain at rest (P = .001), under maximal load (P = .0001), and in Mayo Wrist Score (MWS) (P = .0001). Wrist ROM, grip strength, DASH, and PRWHE showed an improvement without reaching statistical significance. The mean preoperative radiolunate (RL) X-ray measurement angle was 17° (–10° to 35°). The postoperative mean value was 25° (0°-45°). In the preoperative radiographic evaluation, 11 cases exceeded the “critical” 15° RL angle. At follow-up, the RL angle increased in 10 cases and remained unchanged in 7 cases. None of these cases became symptomatic. Transitory neurapraxia of the dorsal superficial branch of the radial nerve was observed in 1 case. Damage of the dorsal branch of the radial artery was immediately fixed. Conclusions: Arthroscopic resection of the distal portion of the scaphoid due to scapho-trapezium-trapezoid osteoarthritis demonstrated an effective and safe technique with less complications than open surgery.     

Successful Topical Application of Botulinum Toxin After Microneedling Versus Microneedling Alone for the Treatment of Atrophic Post Acne Scars: A Prospective,Split-face,Controlled Study

BackgroundAcne scars are a source of cosmetic concern for most of the patients.ObjectiveWe sought to compare the clinical efficacy and safety of topical botulinum toxin A (BTX-A) application immediately after microneedling (Mn) versus Mn with saline in the treatment of atrophic acne scars.MethodsForty patients with atrophic acne scars (rolling, boxcar, and mixed types) were enrolled in a split-face study; microneedling was performed on both sides of the face followed by an application of topically diluted botulinum toxin on one side (Side A) and saline on the other (Side B) for two sessions both two weeks apart. Evaluation was done at baseline, two and four weeks after the session. Follow-up was performed after six months. The assessments included blinded clinical assessment and patient’s satisfaction.ResultsAfter the treatment, acne scars in (Side A) showed 70 percent overall improvement versus zero percent in Side B (P<0.0001). A statistically highly significant reduction of acne scars severity occurred in (Side A) (P=0.0008). Patient’s satisfaction was higher in (Side A) (P<0.0001). No serious side effects were reported.ConclusionMicroneedling delivery of BTX-A could be simple, safe, and innovative modality improving the appearance and decrease the depth of atrophic acne scars.     

Proteinuria as a Noninvasive Marker for Renal Allograft Histology and Failure: An Observational Cohort Study

Proteinuria is routinely measured to assess renal allograft status, but the diagnostic and prognostic values of this measurement for renal transplant pathology and outcome remain unclear. We included 1518 renal allograft recipients in this prospective, observational cohort study. All renal allograft biopsy samples with concomitant data on 24-hour proteinuria were included in the analyses (n=2274). Patients were followed for ≥7 years post-transplantation. Compared with proteinuria <0.3 g/24 h, the hazard ratios for graft failure were 1.14 (95% confidence interval [95% CI], 0.81 to 1.60; P=0.50), for proteinuria 0.3–1.0 g/24 h, 2.17 (95% CI, 1.49 to 3.18; P<0.001), for proteinuria 1.0–3.0 g/24 h, and 3.01 (95% CI, 1.75 to 5.18; P<0.001), for proteinuria >3.0 g/24 h, independent of GFR and allograft histology. The predictive performance of proteinuria for graft failure was lower at 3 months after transplant (area under the receiver-operating characteristic curve [AUC] 0.64, P<0.001) than at 1, 2, and 5 years after transplant (AUC 0.73, 0.71, and 0.77, respectively, all P<0.001). Independent determinants of proteinuria were repeat transplantation, mean arterial pressure, transplant glomerulopathy, microcirculation inflammation, and de novo/recurrent glomerular disease. The discriminatory power of proteinuria for these intragraft injury processes was better in biopsy samples obtained >3 months after transplant (AUC 0.73, P<0.001) than in those obtained earlier (AUC 0.56, P<0.01), with 85% specificity but lower sensitivity (47.8%) for proteinuria >1.0 g/24 h. These data support current clinical guidelines to routinely measure proteinuria after transplant, but illustrate the need for more sensitive biomarkers of allograft injury and prognosis.     

Acute effects of static stretching on peak and end-range hamstring-to-quadriceps functional ratios

AIM: To evaluate if static stretching influences peak and end-range functional hamstring-to-quadriceps (H/Q) strength ratios in elite women athletes.METHODS: Eleven healthy female athletes in an elite competitive level participated to the study. All the participants fulfilled the static stretching or non-stretching (control) intervention protocol in a randomized design on different days. Two static unassisted stretching exercises, one in standing and one in sitting position, were used to stretch both the hamstring and quadriceps muscles during these protocols. The total time for the static stretching was 6 ± 1 min. The isokinetic peak torque measurements for the hamstring and quadriceps muscles in eccentric and concentric modes and the calculations for the functional H/Q strength ratios at angular velocities of 60°/s and 180°/s were made before (pre) and after (post) the control or stretching intervention. The strength measurements and functional strength ratio calculations were based during the entire- and end-range of knee extension.RESULTS: The pre-test scores for quadriceps and hamstring peak torque and end range values were not significantly different between the groups (P > 0.05). Subsequently, although the control group did not exhibit significant changes in quadriceps and hamstring muscle strength (P > 0.05), static stretching decreased eccentric and concentric quadriceps muscle strength at both the 60°/s and 180°/s test speeds (P < 0.01). Similarly, static stretching also decreased eccentric and concentric hamstring muscle strength at both the 60°/s and 180°/s test speeds (P < 0.01). On the other hand, when the functional H/Q strength ratios were taken into consideration, the pre-intervention values were not significant different between the groups both during the entire and end range of knee extension (P > 0.05). Furthermore, the functional H/Q strength ratios exhibited no significant alterations during the entire and end ranges of knee extension both in the static stretching or the control intervention (P > 0.05).CONCLUSION: According to our results, static stretching routine does not influence functional H/Q ratio. Athletes can confidently perform static stretching during their warm-up routines.