Can indications for lower limb replantation and revascularization be expanded with simultaneous free-flap transfer for limb salvage?

High-energy trauma from road accidents and work-related injuries is the most common cause of lower-limb traumatic amputations. Many of these cases require extensive debridement and substantial bone shortening for primary closure because of crushing and/or avulsion of the involved parts. Since 1998, the authors have replanted or revascularized five lower limbs in five patients. Free tissue transfers have been used to cover soft-tissue defects during replantation and revascularization in all patients. The numbers and kinds of free flaps include one latissimus dorsi muscle, two transverse rectus abdominis musculocutaneous (TRAM), and two anterolateral thigh fasciocutaneous flaps. Survival of the replanted and revascularized limbs and transferred flaps was obtained in four patients. Below-knee amputation was performed because of flap necrosis and extensive infection in one patient. Simultaneous free-tissue transfers may be used simultaneously with lower limb replantation or revascularization to obtain functional extremities in appropriately selected patients. The indications for lower limb salvage may be enhanced and successful results may be obtained in one stage, with low complication rates and shorter hospital stays. The authors report their experience with simultaneous free tissue transfers and lower limb replantation or revascularization.     

Assessment of linear growth of affluent urban Pakistani adolescents according to CDC 2000 references

BACKGROUND: The appropriateness of using international reference data for assessing growth of children and adolescents from developing countries has been debated. If the growth performance in at least those sections of the society that may be considered affluent has reached the levels represented by the international reference, the case for adoption of the NCHS reference would be strong. Findings from studies in younger children indicate appropriateness of these standards but data from older children are lacking. AIM: The study aimed to compare the linear growth of affluent Pakistani adolescents living in Karachi with the NCHS reference so as to assess the appropriateness of using these standards for assessing the growth status of Pakistani adolescents. SUBJECTS AND METHODS: Data were collected from 876 girls and 819 boys aged 10-15 years studying in well known and established affluent urban public schools in Karachi. A portable stadiometer (Minimeter by CMS, London) was used for measuring heights. Heights were compared using the United States Center for Disease Control (CDC 2000) reference values to assess growth status. RESULTS: The mean ages of boys and girls were 12.82 and 12.63, respectively. Mean Height for Age Z score (HAZ) (-0.02) was very close to CDC 2000 reference values but the growth pattern was not similar. Younger children were relatively taller and the older children were shorter than CDC standards. Mean HAZ scores for 10, 11, 12, 13, 14 and 15-year-old boys and girls were 1.12 and 1.03, 0.54 and 0.55, 0.47 and 0.26, 0.29 and -0.21, -0.08 and -0.64, -0.19 and -0.53, respectively. The mean HAZ for boys (0.12) was slightly higher and that for girls slightly lower (HAZ = -0.14) than the reference population. Even among the relatively affluent group of children studied HAZ scores increased with relative socio-economic status. CONCLUSIONS: Although in terms of averages for 10-15-year-old boys and girls the height status was not very different from CDC standards, the growth curves of Pakistani children was slightly different from CDC 2000 standards. Further studies are needed to assess the appropriateness of using international growth standards for assessing height status of Pakistani adolescents.     

Elevated plasma homocysteine levels in gestational diabetes mellitus

OBJECTIVE: This prospective study investigated the occurrence of hyperhomocysteinemia in a population of patients with gestational diabetes. The aim was to determine whether elevated plasma homocysteine is associated with gestational diabetes in Turkish women. STUDY DESIGN: This prospective controlled study was conducted in the Department of Obstetrics and Gynecology of the Baskent University Faculty of Medicine between April 2002 and June 2003, and involved 304 Turkish women with uncomplicated pregnancies who were at 24-28 weeks gestation. The women in the study were assigned to one of three groups according to the results of the 50-g glucose screening and the oral glucose tolerance test (OGTT): group 1 comprised women who had normal glucose levels (< or = 135 mg/dL) after the 50-g challenge; group 2 comprised women with abnormal screening test results (> 135 mg/dL) but normal OGTT results; and group 3 comprised patients with gestational diabetes mellitus (GDM) according to the OGTT. Levels of fasting glucose, homocysteine, vitamin B(12) and folic acid, total cholesterol, high density lipoprotein (HDL) cholesterol, and triglycerides, low density lipoprotein (LDL) cholesterol and very low density lipoprotein (VLDL) cholesterol levels were measured in the three groups. Levels of insulin sensitivity were calculated using the homeostasis model assessment (HOMA) formula. RESULTS: The mean level of homocysteine in group 1 was significantly lower than the levels in groups 2 and 3 (p < 0.001) The mean triglyceride and VLDL levels in group 3 were significantly higher than the corresponding levels in group 1 (p < 0.05 for both). There were no significant differences among the groups with respect to levels of total cholesterol, vitamin B(12), folic acid, creatinine, fasting glucose or insulin. The mean HOMA value in group 3 was significantly higher than that in group 1 (p < 0.05). Only the blood glucose level after the 50-g glucose screening [p = 0.000, 95% confidence interval (CI) 0.009-0.027] had a significant correlation with homocysteine levels. CONCLUSION: In this prospective study of Turkish women, we found that patients with gestational diabetes and women with abnormal screening test results (> 135 mg/dL) but normal OGTT results have higher homocysteine levels than normal pregnant women. This increased level seems to be related to an abnormal 50-g test but not to insulin resistance. Further investigations are needed to follow up for these patients in the postpartum period and later in their life.     

Visual evoked potential is superior to triple dose magnetic resonance imaging in the diagnosis of optic nerve involvement

The aim of this study was to evaluate whether VEP is sensitive to optic neuritis (ON) when compared with triple dose orbital MRI. Twenty-four relapsing-remitting MS (RRMS) patients were included in the study. Group I (n = 10) patients with acute ON, Group II (n = 8): patients presenting with a current relapse who had the history of ON in the previous relapses. Group III (n = 6): patients presenting with a current relapse but with no history of ON. Neuro-ophtalmological evaluation. VEP investigation and orbital MRI with triple dose (0.3 mmol/kg) gadolinium (Gd) were carried out for all. VEP was found to be 70% sensitive and 12.5% specific to the acute ON, whereas orbital MRI with triple dose Gd was 70% sensitive and 100% specific. In chronic ON, the sensitivity of orbital MRI is 0%, whereas the VEP is still 75% sensitive to chronic optic nerve involvement and can distinguish the pathology 100% specifically. In conclusion, orbital MRI with triple dose Gd is not more sensitive than VEP in determining the acute optic nerve pathologies but it is a 100% specific method. The results suggest that VEP is superior to the orbital MRI in determining the chronic optic nerve involvement.     

Mosaic form (45X/46XX) of Turner's syndrome. A case report

BACKGROUND: Turner's syndrome (TS) is a sex chromosome disorder occurring in 1 in 2,500 female births and in approximately 50 in 100,000 adult females and is characterized by retarded growth, gonadal dysgenesis and infertility. The 45,X/46,XX chromosomal pattern is the most frequent mosaic type of this disease (36%). CASE: The mosaic form of TS was diagnosed in a 25-year-old, nulliparous woman whose major symptoms were menstrual irregularity and menorrhagia. She had normal development of secondary sexual characteristics and spontaneous menarche despite a very low amount (7%) of normal cells. CONCLUSION: Dysfunctional uterine bleeding is very uncommon in TS. Mosaic forms of TS may have very few features of TS despite a very low range of normal cells.     

Plasma levels of tumor necrosis factor-α and its receptors in patients with mitral stenosis and sinus rhythm undergoing percutaneous balloon valvuloplasty

This study aimed to determine whether plasma levels of tumor necrosis factor-α (TNF-α) and soluble TNF receptor (sTNF-R) increases in rheumatic mitral stenosis (MS) patients with sinus rhythm and to examine the effect of percutaneous mitral balloon valvuloplasty (PMBV) on these parameters. Twenty-six patients with MS and sinus rhythm (study group, 20 female, mean age 33 ± 8 years), who were scheduled for PMBV, and a well-matched control group consisting of 21 healthy volunteers (15 female, mean age 35 ± 6 years) were enrolled in the study. Tumor necrosis factor-α and sTNF-R levels were compared between study patients and controls, and between peripheral and left atrium (LA) blood. Changes in TNF α and sTNF-R levels 24 h and 4 weeks after PMBV were analyzed. Significantly higher baseline TNF-α and sTNF-R levels were noted in the study group. In the study group, TNF-α and its receptors were also found to be higher in LA blood than in baseline peripheral blood. After PMBV, mitral valve area (MVA) increased and transmitral pressure gradient decreased significantly. At the 24th hour after PMBV, the TNF-α level decreased from 29.61 ± 12.22 pg/ml to 22.42 ± 8.81 pg/ml (P < 0.0001) and at the 4th week, from 22.42 ± 8.81 pg/ml to 18.92 ± 7.37 pg/ml (P < 0.0001). Similar reductions were observed in the sTNF-R level. Regression analysis between the difference in sTNF-R level measured 24 h after and before PMBV and the difference in MVA measured 24 h after and before PMBV showed a significant direct relationship between these variables. This study suggests that isolated rheumatic MS without atrial fibrillation is accompanied by increased TNF-α and sTNF-R level. The successful PMBV establishes a significant reduction in TNF-α and its receptors, probably due to improved postprocedural hemodynamic parameters.     

Effects of angle and laminectomy on triangulated pedicle screws

We aimed to demonstrate the effect of angle and laminectomy on paired pedicle screws to determine whether a 90 degrees screw angle is optimal as has been previously suggested. According to the angle between right and left screws, 28 calf vertebrae were divided into three groups and instrumented as follows: Group I: 60 degrees screw angle; Group II: 90 degrees angle; Group III: 60 degrees angle with laminectomy. The screws were connected using rods and cross-fixators and tested to peak pullout force. Triangulated pedicle screws provided 76.5% more pullout strength than single screws. Most of the specimens failed through loss of convergence angle (toggling of screws on the rods) and subsequent uni- or bilateral screw pullout. Mean+/-SD peak loads were: Group I: 2071+/-622 N; Group II: 1753+/-497 N; Group III: 2186+/-587 N. The differences were not significant (p>0.05). 90 degrees triangulation was not associated with a superior pullout performance versus conventional 60 degrees triangulation, suggesting that achieving additional triangulation angle is not necessary to obtain increased pullout strength. Laminectomy did not alter the effect of triangulation on fixation strength.     

Effect of lower extremity amputation on caregiving burden in caregivers of patients with diabetic foot: Prospective cohort study

Lower extremity amputation as a treatment of diabetic foot ulcer is probably a major burden for the patient's family and friends, who typically act as caregivers and support the patient in coping with the physical disabilities and emotional distress. In the present prospective study, we investigated the effects of different lower extremity amputation levels for diabetic foot ulcer treatment on caregivers of patients with diabetes using the Zarit Burden Interview (ZBI‐12) scale. Patients with diabetic foot ulcers who underwent unilateral major amputation (above‐below knee) and minor amputation of foot (heel sparing) and their caregivers were requested to volunteer to participate in this study from June 2016 to December 2018. The ZBI‐12 form was completed immediately preoperatively and 3 and 6 months after postoperatively. In the minor amputation group, the mean age of the 51 patients was 72.1 years. In the major amputation group, the mean age of the 88 patients was 73.7 years. Both groups of caregivers of patients with minor amputation and major amputations showed a significant improvement in ZBI‐12 score when compared preoperatively and at 3‐ and 6‐month follow‐up visits. The mean ZBI‐12 score was significantly higher in the major than in the minor amputation group in preoperative and all postoperative visits. The absence of the ankle joint in the below‐ or above‐knee amputation renders it more difficult for the amputee to quickly learn the use of prosthesis, thereby increasing the burden of the patient and caregivers. We found that lower extremity amputation for the treatment of chronic diabetic foot ulcers has significantly favourable effect on the caregiver burden, and thereby heel sparing was considerably more effective for the caregiver burden.     

Using Patient Feedback to Optimize the Design of a Certolizumab Pegol Electromechanical Self-Injection Device: Insights from Human Factors Studies

Introduction

We incorporated patient feedback from human factors studies (HFS) in the patient-centric design and validation of ava^®, an electromechanical device (e-Device) for self-injecting the anti-tumor necrosis factor certolizumab pegol (CZP).

Methods

Healthcare professionals, caregivers, healthy volunteers, and patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, or Crohn’s disease participated in 11 formative HFS to optimize the e-Device design through intended user feedback; nine studies involved simulated injections. Formative participant questionnaire feedback was collected following e-Device prototype handling. Validation HFS (one EU study and one US study) assessed the safe and effective setup and use of the e-Device using 22 predefined critical tasks. Task outcomes were categorized as “failures” if participants did not succeed within three attempts.

Results

Two hundred eighty-three participants entered formative (163) and validation (120) HFS; 260 participants performed one or more simulated e-Device self-injections. Design changes following formative HFS included alterations to buttons and the graphical user interface screen. All validation HFS participants completed critical tasks necessary for CZP dose delivery, with minimal critical task failures (12 of 572 critical tasks, 2.1%, in the EU study, and 2 of 5310 critical tasks, less than 0.1%, in the US study).

Conclusion

CZP e-Device development was guided by intended user feedback through HFS, ensuring the final design addressed patients’ needs. In both validation studies, participants successfully performed all critical tasks, demonstrating safe and effective e-Device self-injections.

Funding

UCB Pharma.

Plain Language Summary

Plain language summary available on the journal website.

     

Influence of Heavy Cigarette Smoking on Heart Rate Variability and Heart Rate Turbulence Parameters

Background: Cigarette smoking increases the risk of cardiovascular events related with several mechanisms. The most suggested mechanism is increased activity of sympathetic nervous system. Heart rate variability (HRV) and heart rate turbulence (HRT) has been shown to be independent and powerful predictors of mortality in a specific group of cardiac patients. The goal of this study was to assess the effect of heavy cigarette smoking on cardiac autonomic function using HRV and HRT analyses. Methods: Heavy cigarette smoking was defined as more than 20 cigarettes smoked per day. Heavy cigarette smokers, 69 subjects and nonsmokers 74 subjects (control group) were enrolled in this study. HRV and HRT analyses [turbulence onset (TO) and turbulence slope (TS)] were assessed from 24‐hour Holter recordings. Results: The values of TO were significantly higher in heavy cigarette smokers than control group (?1.150 ± 4.007 vs ?2.454 ± 2.796, P = 0.025, respectively), but values of TS were not statistically different between two groups (10.352 ± 7.670 vs 9.613 ± 7.245, P = 0.555, respectively). Also, the number of patients who had abnormal TO was significantly higher in heavy cigarette smokers than control group (23 vs 10, P = 0.006). TO was correlated with the number of cigarettes smoked per day (r = 0.235, P = 0.004). While LF and LF/HF ratio were significantly higher, standard deviation of all NN intervals (SDNN), standard deviation of the 5‐minute mean RR intervals (SDANN), root mean square of successive differences (RMSSD), and high‐frequency (HF) values were significantly lower in heavy smokers. While, there was significant correlation between TO and SDNN, SDANN, RMSSD, LF, and high frequency (HF), only HF was correlated with TS. Conclusion: Heavy cigarette smoking has negative effect on autonomic function. HRT is an appropriate noninvasive method to evaluate the effect of cigarette on autonomic function. Simultaneous abnormal HRT and HRV values may explain increased cardiovascular event risk in heavy cigarette smokers.