The anterior approach for the fixation of displaced talar neck fractures—A cadaveric study

BackgroundTalar neck fractures are rare and are associated with high complication rates. Adequate surgical exposure is essential in the operative management of these challenging injuries. The anterior approach is an alternative to the more commonly described and utilized anterolateral and anteromedial approaches.ObjectiveThe main objective was to compare the surface area of talus visible and quality of exposure via the anterior approach, with the anteromedial and anterolateral approaches.Materials and methodsAn anterior approach was performed on five fresh frozen cadaveric specimens. The surface area of talus visible was measured using an Immersion Digital Microscribe and analyzed with the Rhinoceros 3D graphics package. Standard anterolateral and anteromedial approaches were performed in the same specimens and areas visible measured using the same method.ResultsThe talar surface area visible using the anterior approach is significantly greater than that visible using the anterolateral approach or anteromedial, without and with medial malleolar osteotomy, as well as combination approaches.ConclusionThe anterior approach offers excellent visualization in the fixation of displaced talar neck fractures. Greater talar surface area is visible using this approach compared to traditional approaches.     

Evolving instrumentation for endoscopic tumour removal of CNS tumours

Background

Open surgical approaches to intraventricular tumours are complex and challenging. Neuro-endoscopy, however, has enabled us to biopsy and resect small intraventricular tumours with potentially reduced morbidity. Nevertheless, suitable methods/ instrumentation for resection have limited the use of the endoscope. The authors report the utilisation of endoscopic ultrasonic aspirator in the resection of an intraventricular tumour. This technique was compared to another case that utilised conventional endoscopic techniques for removal of an intraventricular tumour.

Methods

Using an endoscope, the third ventricle was entered and visualised, with the tumours clearly seen. Tumours were then either debulked via conventional or novel technique.

Results

Using the conventional technique, tumour was removed with rongeurs via the flexible scope. Irrigation was needed to improve vision due to bleeding. Postoperative magnetic resonance imaging (MRI) confirmed good excision. Histology was reported as anaplastic ependymoma World Health Organization (WHO) Grade III. Utilising the novel technique, the tumour was also debulked uneventfully. Histology confirmed Grade 1 glioneuronal tumour. Postoperative MRI revealed a small residuum.

Conclusions

To date, endoscopic resection of tumours has been limited by suitable tools. The advent of an ultrasonic aspirator that can be used down an endoscope increases the possibilities for such resections. This is the first reported case of endoscopic resection of an intraventricular tumour using this technique.     

Second-line treatment of advanced hepatocellular carcinoma: Time for more individualized treatment options?

Hepatocellular carcinoma (HCC) is the most frequently diagnosed primary tumor of the liver and is usually detected as advanced disease. It is an aggressive disease that often progresses rapidly when it fails to respond to treatment. As such, patients have limited opportunities to try different subsequent-line treatment regimens. In the last 5 years, the number of agents and/or regimens available for the treatment of advanced HCC has significantly increased, which has made treatment choices for this patient population increasingly complex. In the second-line setting, several phase III trials of regorafenib (RESORCE), ramucirumab (REACH/REACH-2), and cabozantinib (CELESTIAL) have demonstrated clinically meaningful survival benefits in patients with the disease. However, the median overall survival of patients with advanced HCC remains unchanged at approximately 12 mo from the start of systemic second-line therapy, with a limited duration of response. Evidence from the REACH/REACH-2 trials demonstrated for the first time that baseline alpha-fetoprotein (AFP) levels can be used as an identification factor to select those who are likely to benefit the most from ramucirumab treatment. Ramucirumab is both well tolerated and efficacious and has a clinically acceptable safety profile. Therefore, it should be considered an option for patients with AFP levels ≥ 400 ng/mL.     

In-silico analysis of 6-hydroxymethyl-7,8-dihydropterin pyrophosphokinase (HPPK): a potential drug target against Salmonella enterica serovar typhi

Salmonella enterica serovar typhi is a gram-negative pathogenic bacterium that inhabits the lymphatic tissues of the small intestine, liver, spleen and bloodstream of infected humans. It spreads mainly through contaminated food and drinks. It is estimated that nearly 16–33 million infections occur annually and cause 216,000 deaths in endemic areas. Its incidence is high in children and young adults between 5 and 19 years of age. 6-Hydroxymethyl-7,8-dihydropterin pyrophosphokinase is one of the key enzymes that play a vital role in folate metabolism which is important for bacterial growth and survival. The absence of this enzyme in higher eukaryotes, including mammals, makes the enzyme an excellent target for designing antimicrobial agents. As the structure of this enzyme has not been experimentally determined, a 3-dimensional model of this target enzyme was generated by comparative modelling programme Modeller. Since the magnesium ions are needed for enzyme activity, Mg²⁺ ions were complexed with the predicted protein model and molecular docking studies were carried out with the possible inhibitors using Schrodinger’s Glide. From this study, it has been shown that the lead molecules chosen bind with the receptor molecule with better binding energy. The top scoring enzyme–lead complex having a Glide energy of ?171.98259 was further validated through simulation studies using Gromacs simulation suite. The simulation study confirms a stable enzyme–ligand complex.     

Evaluation of Non-vascular Fibula Graft for Mandibular Reconstruction

Introduction

Functional and cosmetic defects in maxillofacial region are caused by various ailments like trauma, neoplasm, developmental, infections and iatrogenic causes. Reconstruction of these defects with free flaps remains the gold standard but demerits like need for surgical expertise and equipment, prolonged duration of surgery, compliance of the patient and increased cost are associated with microvascular reconstruction. Hence reconstruction with nonvascular bone grafts can be considered when defect is nonirradiated and <9 cm and with sufficient soft tissue cover available.

Purpose

To retrospectively evaluate clinical, radiological outcome and complications encountered with mandibular reconstruction using non vascular fibula graft.

Patients and Methods

This retrospective study included 7 patients who were treated in the Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital, Nellore, AP between 2011 and 2013 with histologically proven benign osteolytic lesions of mandible that require a segmental mandibulectomy and primary reconstruction using autogenous non-vascularised fibular graft. The clinical case records of the patients and personal patient assessment forms (Quality of Life Assessment Forms) were analysed. They were recalled every 3rd, 6th and 9th month after surgery for evaluation of clinical, radiological outcome of the graft and complications occurring at recipient and donor sites.

Results

In all the 7 patients, the lower border continuity was maintained except in one where the graft was dislodged. Tongue movements in all the patients were unrestricted. Jaw movements were affected in cases of ramus defects with slight deviation to operated side and reduced mouth opening. Radiological observations revealed no significant changes in 3 months except for slight reduction in graft height. The radioopaque bridging with continuity of lower border of mandible was noticed in 6th month indicating the take of the graft. This was achieved in every case except in one where the graft was lost due to dislodged reconstruction plate. In 9th month the edges of the graft i.e., graft to native mandible junction showed more resorption (3 mm) especially where there is >2 mm of gap. Whereas increase in height of graft in other areas especially in graft to graft junction was seen. Significant graft resorption was seen in two cases. There were no major complications associated with the donor site.

Conclusion

Avascular fibula graft although a second choice to vascularised fibula, is a favourable option for mandible defects of 6–10 cm under optimum conditions especially in developing countries where financial and/or surgical resources are limited. An attempt for primary reconstruction with this is never futile as it prevents aesthetic deformity even in the event of failure and thus makes secondary reconstruction easy. However in order to confirm the results a prospective study with large scale of patients is necessary.

Electronic supplementary material

The online version of this article (doi:10.1007/s12663-014-0657-1) contains supplementary material, which is available to authorized users.     

Adenomatoid odontogenic tumor, an uncommon tumor

Here we report a case of adenomatoid odontogenic tumor (AOT) in the maxilla in a young girl aged 14 years and its surgical management. We also review the literature and variations in the nomenclature and classifications of this interesting tumor. The review of literature gives an interesting picture regarding terminologies in the past and dilemma in classifying this tumor. The introduction of the name adenomatoid odontogenic tumour has resulted in the simpler and fruitful surgical management like enucleation and curettage with no reports of recurrences. In the past, similar lesion with the terminology like adeno ameloblastoma has resulted in unnecessary mutilating surgery. The conflicting views whether the lesion is being neoplasm or an anomalous hamartomatous growth is also being discussed.     

Association of serum triiodothyronine with B-type natriuretic peptide and severe left ventricular diastolic dysfunction in heart failure with preserved ejection fraction

There are well-documented changes in thyroid hormone metabolism that accompany heart failure (HF). However, the frequency of thyroid hormone abnormalities in HF with preserved ejection fraction (HFpEF) is unknown, and no studies have investigated the association between triiodothyronine (T(3)) and markers of HF severity (B-type natriuretic peptide [BNP] and diastolic dysfunction [DD]) in HFpEF. In this study, 89 consecutive patients with HFpEF, defined as symptomatic HF with a left ventricular ejection fraction >50% and a left ventricular end-diastolic volume index <97 ml/m(2), were prospectively studied. Patients were dichotomized into 2 groups on the basis of median T(3) levels, and clinical, laboratory, and echocardiographic data were compared between groups. Univariate and multivariate linear regression analyses were performed to determine whether BNP and DD were independently associated with T(3) level. We found that 22% of patients with HFpEF had reduced T(3). Patients with lower T(3) levels were older, were more symptomatic, more frequently had hyperlipidemia and diabetes, and had higher BNP levels. Severe (grade 3) DD, higher mitral E velocity, shorter deceleration time, and higher pulse pressure/stroke volume ratio were all associated with lower T(3) levels. T(3) was inversely associated with log BNP (p = 0.004) and the severity of DD (p = 0.039). On multivariate analysis, T(3) was independently associated with log BNP (β = -4.7 ng/dl, 95% confidence interval -9.0 to -0.41 ng/dl, p = 0.032) and severe DD (β = -16.3 ng/dl, 95% confidence interval -30.1 to -2.5 ng/dl, p = 0.022). In conclusion, T(3) is inversely associated with markers of HFpEF severity (BNP and DD). Whether reduced T(3) contributes to or is a consequence of increased severity of HFpEF remains to be determined.