Banking a fillet flap to aid in reconstruction following a hindquarter amputation

A hindquarter amputation and hemipelvectomy for recurrent malignancy presents a reconstructive challenge to the plastic surgeon. Tumour resection leaves a considerable defect, with exposure of bone, neurovascular structures, pelvic and abdominal organs. A free lower leg fillet flap is a recognised method of providing soft tissue coverage, but ischaemic time is often lengthy as described in the literature. We present a unique method of providing soft tissue coverage using a free lower leg fillet flap, and minimising ischaemic time by banking the flap on the ulnar artery during the hindquarter amputation and tumour resection.Level of Evidence: Level V, therapeutic study.     

Late-presenting complete heart block after pediatric cardiac surgery

Late presenting complete heart block after pediatric cardiac surgery is a rare complication and its management is well defined once the initial diagnosis in made timely and appropriately. In this report we described a child who underwent atrioventricular septal defect repair with a normal sinus rhythm during the postoperative period, as well as during the first 2 years of follow up.She subsequently developed complete heart block with bradycardia that required insertion of a pacemaker. Here we discuss this unusual late-presenting complication, possible risk factors, and management.     

The use of end-tidal carbon dioxide monitoring in patients with hypotension in the emergency department

Background

The aim of this study was to determine the usefulness of end tidal carbon dioxide (ETCO₂) monitoring in hypotensive shock patients presenting to the ED.

Methods

This was a prospective observational study in a tertiary ED. One hundred three adults in shock with hypotension presenting to the ED were recruited into the study. They were grouped according to different types of shock, hypovolemic, cardiogenic, septic and others. Vital signs and ETCO₂ were measured on presentation and at 30-min intervals up to 120 min. Blood gases and serum lactate levels were obtained on arrival. All patients were managed according to standard protocols and treatment regimes. Patient survival up to hospital admission and at 30 days was recorded.

Results

Mean ETCO₂ for all patients on arrival was 29.07?±?9.96 mmHg. Average ETCO₂ for patients in hypovolemic, cardiogenic and septic shock was 29.64?±?11.49, 28.60?±?9.87 and 27.81?±?7.39 mmHg, respectively. ETCO₂ on arrival was positively correlated with systolic and diastolic BP, MAP, bicarbonate, base excess and lactate when analyzed in all shock patients. Early ETCO₂ measurements were found to be significantly lower in patients who did not survive to hospital admission (p?=?0.005). All patients who had ETCO₂????12mmHg died in the ED. However, normal ETCO₂ does not ensure patient survival.

Conclusion

The use of ETCO₂ in the ED has great potential to be used as a method of non-invasive monitoring of patients in shock.     

Is it safe to use propofol in the emergency department? A randomized controlled trial to compare propofol and midazolam

Background

This study examined the safety and effectiveness of the procedural sedation analgesia (PSA) technique carried out in the emergency department (ED) of a university hospital over a period of 1 year. The research was done to compare the effectiveness and efficacy of moderate sedation of fentanyl combined with either midazolam or propofol for any brief, intense procedure in the ED setting.

Aims

The objectives were to observe the occurrence of adverse events in subjects undergoing PSA for intense and painful procedures in the emergency department and to implement the use of capnography as a method of monitoring the patients when they were under PSA.

Methods

Forty patients were selected for this study. They were randomly divided into two equal groups using the computer-generated random permuted blocks of four patients. Twenty patients were grouped together as group A and the remaining 20 patients as group B. Drugs used were single blinded to prevent any bias. Drug A was propofol and fentanyl, while drug B was midazolam and fentanyl. The procedures involved included orthopedic manipulation such as reduction of fractures, reduction of dislocated joints, abscess drainage, wound debridement, laceration wound repair and cardioversion. All of the subjects were monitored for their vital signs and end tidal carbon dioxide level every 10 min till the PSA was completed. The duration of stay in the ED was documented when the subjects had completed the procedure and were released from the department.

Result

Of the study population, 75.6% were males. The mean age was 37.8 years (95% CI 33.2, 39.8). None of the patients developed any major complications while under PSA. The vital signs pre-, intra- and post-procedure were not significantly different in either the propofol or mizadolam groups (p value >0.05).

Conclusion

This study had proven that there was no difference in adverse event occurrence between the studied drugs during PSA. Propofol can be recommended for use in PSA if the operator is well trained and familiar with the drug.     

Ruptured saphenous venous graft pseudoaneurysm presenting as a pulsatile chest mass

A 72‐year‐old man with prior history of coronary artery bypass grafting and sternal wire infection presented with non‐ST‐segment elevation myocardial infarction. His coronary angiogram revealed stenosis of the distal left main coronary artery (LMCA) and a pseudoaneurysm of saphenous venous graft (SVG) to right posterior descending artery. Patient developed ventricular fibrillation during admission, and postcardiopulmonary resuscitation, a pulsatile chest mass was observed which was diagnosed with computed tomography as a chest wall collection resulting from rupture of the pseudo‐aneurysm. He underwent percutaneous coronary intervention of the LMCA with drug‐eluting stents followed by successful coil embolization of the SVG pseudoaneurysm. Patient had an uneventful recovery postprocedure.     

Heparin-II domain of fibronectin is a vascular endothelial growth factor-binding domain: enhancement of VEGF biological activity by a singular growth factor/matrix protein synergism

We describe extracellular interactions between fibronectin (Fn) and vascular endothelial growth factor (VEGF) that influence integrin-growth factor receptor crosstalk and cellular responses. In previous work, we found that VEGF bound specifically to fibronectin (Fn) but not vitronectin or collagens. Herein we report that VEGF binds to the heparin-II domain of Fn and that the cell-binding and VEGF-binding domains of Fn, when physically linked, are necessary and sufficient to promote VEGF-induced endothelial cell proliferation, migration, and Erk activation. Using recombinant Fn domains, the C-terminal heparin-II domain of Fn (type III repeats 13 to 14) was identified as a key VEGF-binding site. Mutation of the heparin-binding residues on FnIII(13-14) abolished VEGF binding, and peptides corresponding to the heparin-binding sequences in FnIII(13-14) inhibited VEGF binding to Fn. Fn fragments containing both the alpha5beta1 integrin-binding domain (III 9 to 10) and the VEGF-binding domain (III 13 to 14) significantly enhanced VEGF-induced EC migration and proliferation and induced strong phosphorylation of the VEGF receptor and Erk. Neither the cell-binding or VEGF-binding fragment of Fn alone had comparable VEGF-promoting effects. These results suggest that the mechanism of VEGF/Fn synergism is mediated extracellularly by the formation of a novel VEGF/Fn complex requiring both the cell-binding and VEGF-binding domains linked in a single molecular unit. These data also highlight a new function for the Fn C-terminal heparin-binding domain that may have important implications for angiogenesis and tumor growth.     

Glycosylated hemoglobin levels in Sudanese sickle cell anemia patients

Glycosylated hemoglobin was measured, by a colorimetric method, in 49 patients with sickle cell anemia attending Khartoum Teaching Hospital. The level obtained (4.9%, SD 1.3) was significantly lower than the control value (5.6%, SD 0.2; p less than 0.0025). Expressed as percentage of the control value, the glycosylated hemoglobin level in these patients was 81%. This falls midway between the 90% reported in a benign form of sickle cell anemia in Saudi Arabia and the 58% reported in a severe form in an American Black group, which gives support to the observed heterogeneity of sickle cell anemia. Alternatively, glycosylated hemoglobin level in 27 subjects with sickle cell trait (5.6%, SD 0.2) was identical to that of the controls. The state of hemolysis in the sickle cell anemia patients, as indicated by bilirubin levels, did not correlate with the glycosylated hemoglobin values. Although glycosylated hemoglobin measurement is affected by red cell survival, it does not reflect the state of ongoing hemolysis.     

Intra-left ventricular systolic asynchrony in patients with overt hyperthyroidism

Hyperthyroidism causes a variety of adverse effects on the cardiovascular system. Left ventricular (LV) asynchrony is defined as loss of the simultaneous peak contraction of corresponding cardiac segments. The aim of this study was to assess systolic asynchrony in patients with overt hyperthyroidism. Asynchrony was evaluated in 27 patients with overt hyperthyroidism and 21 controls. All the patients and controls were subjected to a tissue synchronization imaging (TSI). The time to regional peak systolic tissue velocity (Ts) in LV by the six-basal-six-mid-segmental model was measured on ejection phase TSI images and four TSI parameters of systolic asynchrony were computed. All TSI parameters of LV asynchrony increased in hyperthyroid patients compared to controls: the standard deviation (SD) of the 12 LV segments Ts (35.7±14.4 vs 20.1±10.1, P<0.0001); the maximal difference in Ts between any 2 of the 12 LV segments (111.9±40.7 vs 65.9±30.7, P<0.0001); the SD of the 6 basal LV segments (31.2±18.2 vs 16.8±9.7, P=0.01); and the maximal difference in Ts between any 2 of the 6 basal LV segments (76.6±42.0 vs 44.4±25.7, P=0.005). Patients with overt hyperthyroidism present evidence of LV asynchrony by TSI.     

An In Vitro Stereomicroscopic Evaluation of Bioactivity between Neo MTA Plus,Pro Root MTA,BIODENTINE & Glass Ionomer Cement Using Dye Penetration Method

The ideal root end filling material should form a tight seal in the root canal by adhering to the cavity walls. Several materials have been used for root end filling. The present study aims to find out and compare the bioactivity of Neo MTA Plus, Pro Root MTA White, BIODENTINE & glass ionomer cement as root end filling materials using 1% methylene blue as tracer. Materials and methods: 80 extracted human permanent maxillary anterior teeth were used in the study. They were divided into four groups. Specimens were sectioned transversely in the cervical area to separate the crown from the root. The root canal was obturated with gutta percha and zinc oxide eugenol sealers. Thereafter, each sample was resected apically by removing 3 mm of the apex and filled with different materials. Samples were kept in buffering solution at 37 °C until the recommended evaluation periods. The specimens were then suspended in 1% methylene blue for 24 h, prior to the analysis. The teeth were then sectioned, and dye penetration was examined, photographed, and evaluated under a stereomicroscope. Results: Vertical dye penetration showed significant differences across different groups. The minimum dye penetration was seen in Neo MTA plus followed by BIODENTINE, Pro Root MTA and maximum in GIC. There was no significant difference in dye penetration between Neo MTA plus and BIODENTINE both at fifteen days and one-month intervals. Conclusion: The present study suggests Neo MTA plus and BIODENTINE should be the preferred material for root end filling.     

Cytokine gene polymorphisms in Turkish patients with inflammatory bowel disease

OBJECTIVE: Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the bowel, the causes of which are not fully known. Ethnic differences in disease prevalence, familial aggregation of the disease and studies of twins provide the most important evidence to suggest that genetic factors play a role in the pathogenesis of inflammatory bowel disease (IBD). The aim of this study was to examine the allelic polymorphisms that can determine the immune response levels in tumor necrosis factor alpha (TNFalpha), interleukin-1beta (IL-1B), interleukin-1 receptor antagonist ( IL-1RN) and interleukin-10 (IL-10) genes and to investigate their roles in the inflammatory pathway in IBD. MATERIAL AND METHODS: The study included 120 patients with UC and 70 patients with CD who were diagnosed either endoscopically or histopathologically. The control group comprised 105 healthy individuals who stated that they had never had any bowel disease during their life span. The polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) method for polymorphisms in the TNFalpha gene at positions -308 and -238, the IL-10 gene at positions -1082 and -627, the IL-1B gene at -511 regions and the variable number of tandem repeat (VNTR) method for polymorphism in the intron 2 of the IL-1RN gene were performed. The results were analyzed on agarose gel electrophoresis. RESULTS: No significant differences were found in the allele and genotype frequencies of the polymorphisms in the IL-1B, IL10, TNFalpha and IL-1RN genes between the patients with UC and CD and controls. CONCLUSIONS: The results suggest that these polymorphisms were not important risk factors in the susceptibility to IBD in Turkish patients.