A comparative study on primary wound closure by subcuticular suture using different suture materials with emphasis on complications, cosmesis and cost-effectiveness

Background and Purpose

There are different methods and materials for closing a surgical wound by subcuticular stitch but controversy prevails as concerns the appropriate material for this stitch. This study aims to investigate the different suture materials and compare their technical accessibility, usefulness, complication rates, patient satisfaction and, above all, the general outcome.

Methodology

Over a period of 8 months (June 2011–January 2012), 160 patients underwent wound repair by subcuticular stitch in our unit. A prospective analysis of patients’ case notes was performed. Results: Each type of thread has its own and specific type of complications which is distinct from other types of threads. Among patients on whom polyglactin sutures were used, 15.79% and 14.29% (respectively) developed complications in the presence and absence of complicating comorbid factors. Specifically, 20% of <3 cm wounds, 10% of 3–6 cm wounds, and 20% of >6 cm wounds sutured with polyglactin developed complications. The corresponding complication rates for poliglecaprone sutures were less at 9%, 5.9%, and 8.3%, respectively. The number of patients who are very happy and satisfied with poliglecaprone sutures is much greater than that of those on whom polyglactin sutures were used; the difference is statistically significant. In terms of cost, nylon is the cheapest thread whereas polypropylene is the costliest.

Conclusion

Poliglecaprone seems to be the thread of choice with minimal complication rates both in the presence and absence of comorbid factors in < 3 cm and 3–6 cm wounds. However, nylon appears to be more useful for wounds > 6cm since minimal complication rates are reported.     

A rare and interesting case of primary mammary tuberculosis mimicking breast carcinoma

Introduction

Mammary tuberculosis (MT) is an extremely rare form of extrapulmonary tuberculosis (TB), which is uncommon even in countries where TB is considered to be endemic. It can occur in primary and secondary forms, clinically and radiologically, both of which can mimic breast carcinoma or persistent breast abscess.

Case presentation

A 35-year-old multigravida presented with a history of swelling in the right breast and axilla that had begun six months earlier, to be followed three months later by a yellowish dirty discharge, and five months later by blackish discolouration of the overlying skin. Ultrasonography (USG) showed cutaneous oedema and lymphatic dilatation in the right breast with a lump measuring 6 cm × 7 cm, as well as three significantly enlarged pectoral lymph nodes in the right axilla.

Discussion

The most common type of MT is the nodular pattern which may be mistaken for carcinoma or fibroadenoma. MT may present as multiple heterogeneous, hypoechoic masses with irregular margins, or on USG as thickwalled cystic lesions with septa and sinus tracts. It can only be accurately diagnosed by histological identification of typical necrotising granulomas in the tissue sections. Conservative surgery (local excision of the mass) if needed, followed by antitubercular therapy is the standard treatment protocol.

Conclusion

An atypical rare entity, primary MT may mimic adenoma or carcinoma and may often be misdiagnosed without formal histopathology due to its intriguing clinical and radiological features.     

Potentiation of antileukemic therapies by Smac mimetic, LBW242: effects on mutant FLT3-expressing cells

Members of the inhibitor of apoptosis protein (IAP) family play a role in mediating apoptosis. Studies suggest that these proteins may be a viable target in leukemia because they have been found to be variably expressed in acute leukemias and are associated with chemosensitivity, chemoresistance, disease progression, remission, and patient survival. Another promising therapeutic target, FLT3, is mutated in about one third of acute myelogenous leukemia (AML) patients; promising results have recently been achieved in clinical trials investigating the effects of the protein tyrosine kinase inhibitor PKC412 on AML patients harboring mutations in the FLT3 protein. Of growing concern, however, is the development of drug resistance resulting from the emergence of point mutations in targeted tyrosine kinases used for treatment of acute leukemia patients. One approach to overriding resistance is to combine structurally unrelated inhibitors and/or inhibitors of different signaling pathways. The proapoptotic IAP inhibitor, LBW242, was shown in proliferation studies done in vitro to enhance the killing of PKC412-sensitive and PKC412-resistant cell lines expressing mutant FLT3 when combined with either PKC412 or standard cytotoxic agents (doxorubicin and Ara-c). In addition, in an in vivo imaging assay using bioluminescence as a measure of tumor burden, a total of 12 male NCr-nude mice were treated for 10 days with p.o. administration of vehicle, LBW242 (50 mg/kg/day), PKC412 (40 mg/kg/day), or a combination of LBW242 and PKC412; the lowest tumor burden was observed in the drug combination group. Finally, the combination of LBW242 and PKC412 was sufficient to override stromal-mediated viability signaling conferring resistance to PKC412.     

Multimodality approach: A revolutionary concept in the management of diabetic limb ulcers

Aim

The aim of the study is to evaluate the results of the multimodality approach to diabetic limb ulcers.

Background

Management of diabetic limb ulcers requires a multisystem approach that addresses the component problems of the nervous, vascular, skeletal, immune and integumentary system.

Materials and Method

The study period was from January 2012 to September 2013, and involved 60 patients with both type 1 and type 2 diabetes that also had limb ulcers.

Results

Mean duration of healing in controls was 23.1564 ± 6.7859 weeks and in cases 15.6723 ± 4.0084 weeks. Ulcers converted from grade 2 to grade 1 in 18 cases, from grade 3 to grade 1 in five cases, and from grade 3 to grade 2 in three cases. Five controls and two cases had to undergo amputation.

Discussion

Diabetes is the prime cause of non-traumatic amputations in the United States accounting for 54,000 to 55,000 limbs lost every year [5]. Hunt T K et al found that PDGF gel healed a greater percentage of patients after 10 weeks of application [19]. Edmonds M E et al (1986) observed that the recurrence rate of ulceration was 26% among those with special footwear and 83% among those who returned to using their regular footwear [23].

Conclusion

Although limb problems in diabetics cannot be completely eradicated, it is evident that a number of hospitalizations and health costs directly attributable to such problems can be reduced by adopting a multimodality approach.     

Using a tightRope? to treat a complex fracture of the trapezium

We present the case of a 23-year-old man with a combined scaphoid fracture and comminuted trapezium fracture, treated surgically with percutaneous fixation of the scaphoid fracture and concomitant Arthrex Mini TightRope^® stabilisation of base of thumb metacarpal to base of index finger metacarpal. The patient made a good functional recovery, returning to usual activities within six weeks. We suggest that this technique could be used to treat complex trapezium fractures that cannot be reconstructed with surgery.     

Electrodeposition of atmosphere-sensitive ternary sodium transition metal oxide films for sodium-based electrochemical energy storage

We introduce an intermediate-temperature (350 °C) dry molten sodium hydroxide-mediated binder-free electrodeposition process to grow the previously electrochemically inaccessible air- and moisture-sensitive layered sodium transition metal oxides, Na_xMO₂ (M = Co, Mn, Ni, Fe), in both thin and thick film form, compounds which are conventionally synthesized in powder form by solid-state reactions at temperatures ≥700 °C. As a key motivation for this work, several of these oxides are of interest as cathode materials for emerging sodium-ion–based electrochemical energy storage systems. Despite the low synthesis temperature and short reaction times, our electrodeposited oxides retain the key structural and electrochemical performance observed in high-temperature bulk synthesized materials. We demonstrate that tens of micrometers thick >75% dense Na_xCoO₂ and Na_xMnO₂ can be deposited in under 1 h. When used as cathodes for sodium-ion batteries, these materials exhibit near theoretical gravimetric capacities, chemical diffusion coefficients of Na⁺ ions (∼10⁻¹² cm²⋅s⁻¹), and high reversible areal capacities in the range ∼0.25 to 0.76 mA⋅h⋅cm⁻², values significantly higher than those reported for binder-free sodium cathodes deposited by other techniques. The method described here resolves longstanding intrinsic challenges associated with traditional aqueous solution-based electrodeposition of ceramic oxides and opens a general solution chemistry approach for electrochemical processing of hitherto unexplored air- and moisture-sensitive high valent multinary structures with extended frameworks.

Electrochemical synthesis of materials has contributed to significant breakthroughs in materials processing by replacing high-temperature, cost- and energy-intensive pyrometallurgical processes (1). Noteworthy examples include aluminum extraction by Bayer’s process (2), electrowinning of copper (3), titanium extraction through the Kroll process (4), electrolytic production of steel (5), and electrochemical synthesis of cement (6). Additional advantages of electrochemical synthesis include controllable access to metastable polymorphs (7), prevention of crystallite coarsening, and generation of asymmetric, highly oriented structures (8). Specific to the work discussed here on transition metal oxides for electrochemical energy storage, electrodeposition allows direct thermodynamic and kinetic control of the phase formation along with the ability to conformally deposit on topologically complex structures, resulting in improved electron and ion transport kinetics (9). Even though electrodeposition as a technology is well developed for reduction of elements and alloys, studies on multicomponent systems grown by electrolytic oxidation are sparse. Finally, synthesis of materials directly using electrons as the energy packet provides the potential of significant reductions in greenhouse gas emissions and enhanced thermodynamic efficiencies (10).We focus on materials for sodium-ion (Na-ion) batteries due to their potential cost advantages over lithium-ion systems and the equitable distribution of raw materials required for the synthesis of the cathodes relative to lithium-based systems (11). Of particular interest for Na-ion battery cathodes is O3-type layered NaMO₂ (M = Co, Mn, Ni, Fe) with an alpha NaFeO₂-type crystal structure and octahedrally coordinated transition metal ion. Along with electrochemical energy storage applications (12), this class of oxides has also been studied for its catalytic (13) and superconducting (14) properties. Fabrication of NaMO₂-based battery cathodes involves first high-temperature (>700 °C) synthesis of NaMO₂ for over 24 h, followed by grinding, mixing with binders and additives, and slurry casting. Throughout the process, water must be rigorously excluded. While vapor-phase deposition of Na-ion cathodes by methods including pulsed laser deposition and radio frequency magnetron sputtering has been attempted, deposition of polytypes of Na_xCoO₂ (15–18), alpha Na_xMnO₂ (19), and polyanion compounds (20) has faced processing challenges, only the first of which is maintaining Na stoichiometry under vacuum during growth on a substrate heated to around 700 °C. Additionally, the vapor-phase methods have been limited to cathodes with thicknesses of ≤750 nm and growth rates of only tens of nanometers per hour. As a result, the areal capacities are only a few microamps per hour per square centimeter even at modest discharge currents of order 10 µA⋅cm⁻². The direct electrochemical synthesis of thick layered sodium transition metal oxides (STMOs) at reasonable growth rates and temperatures would overcome the abovementioned challenges and serve as a potential starting point for the scalable manufacturing for Na-ion cathodes. As we will show, such electrochemically grown cathodes also have higher volumetric and gravimetric capacities than slurry-based electrodes due to the absence of binder and conductive additives.In early work, most ceramic oxides, including binary (21–23) and ternary oxides (24–27), were formed via aqueous electrodeposition. These systems were generally limited to thinner layers (≤5 µm), exhibited slow growth rates (micrometers per day), and exhibited poor crystallinity. An annealing step is often needed to oxygenate and crystallize the deposit. The general mechanism for anodic electrolytic deposition of ceramic oxides (28) involves the complexation of a transition metal ion in an alkaline solution as stable hydroxo-aquo complexes of the type M^(m+)(OH)_x(H₂O)_y (m = 2–3) (details depend on the transition metal ion concentration, charge on the transition metal ion center, pH, and temperature) (29–32). During the anodic oxidation step, M^m+ is electrochemically oxidized and precipitates as a higher valent oxide and/or proton intercalated oxide. The poor kinetics of the reaction and quality of electrodeposits can be traced back to the choice of water as the solvent, the low temperature of synthesis (room temperature to 80 °C), and the low hydrolysis ratio (i.e., OH⁻/M^m+ = 3 to 5 at pH 14 for low transition metal concentrations). Synthesis temperatures of prior electrodeposited oxide/oxyhydroxides by anodic electrolytic deposition and equivalent solid-state synthesis are summarized in SI Appendix, Fig. S1A. A high hydrolysis ratio (>75) (SI Appendix, Fig. S1B) and high temperature of deposition (>250 °C) (SI Appendix, Fig. S1C) synergistically kinetically benefit the growth of thicker (>10 µm) electrodeposits. Moreover, since the O3 and O′3 polytypes of the STMOs most interesting for energy storage applications are air and moisture sensitive (33), aqueous electrodeposition cannot be employed to grow this class of materials.Here we report a dry molten sodium hydroxide-based solvent-mediated electrodeposition of high-quality thick STMOs with controlled crystallography and phase. By using dry hydroxide salts, we overcome the intrinsic limitations imposed by the inclusion of water in the solvent and broaden the temperature range of the growth conditions. Oxides of transition metals (Co₃O₄, Mn₃O₄, Fe₃O₄, Ni(OH)₂) are first solvated as stable hydroxo complexes in molten NaOH at 350 °C. In comparison to water-based anodic electrodeposition, here, electrodeposition is conducted at an extremely high hydrolysis ratio ([OH⁻]/[M²⁺] = 300:1) and high pH (pH₂O = 10 in Lux Flood bascisity scale) and at an elevated temperature of 350 °C. The combination of these factors improves the kinetics of the deposition rate limiting base catalyzed oxolation (inorganic S_N2) process, due to the extremely high nucleophile concentration [OH⁻], catalyzed by the “base” [OH⁻], and removal of the leaving group H₂O from the bath (as vapor at 350 °C) (31). We specifically demonstrate the direct electrochemical deposition of various thick film (>10 µm) thermodynamically and kinetically controlled highly crystalline STMO polymorphs. Fig. 1 outlines the general electrodeposition scheme. We explore the effects of the applied electrode potential, basicity of the hydroxide solvent medium, transition metal precursor concentration, and temperature of synthesis on the resulting phase assemblage, phase distribution, and electrochemical performance of the electrodeposited Na-M-O phases across various transition metal chemistries.Open in a separate windowFig. 1.Reaction conditions for molten hydroxide-mediated anodic electrodeposition of layered STMOs of general form Na-M-O (M = Co, Mn, Ni, Fe) at 350 °C. SEM image below the reaction shows ∼60-µm-thick Na_xCoO₂ on a nickel foil (nickel foil is the brighter band on left side of image).     

Identification of BCR-ABL point mutations conferring resistance to the Abl kinase inhibitor AMN107 (nilotinib) by a random mutagenesis study

Patients with advanced stages of chronic myeloid leukemia (CML) often manifest imatinib mesylate resistance associated with point mutations in BCR-ABL. AMN107 is a new higher-potency inhibitor of BCR-ABL. To identify mutations in BCR-ABL that could result in resistance to AMN107, a cDNA library of BCR-ABL mutants was introduced into Ba/F3 cells followed by selection in AMN107 (0.125-0.5 microM). A total of 86 individual, drug-resistant colonies were recovered, and the SH3, SH2, and kinase domains of BCR-ABL were sequenced. A total of 46 colonies had single point mutations in BCR-ABL, with a total of 17 different mutations, all within the kinase domain. The other 40 colonies had multiple point mutations and were not analyzed further. Each of the 17 single point mutants were reconstructed by site-directed mutagenesis of native BCR-ABL and found to be approximately 2.5- to 800-fold more resistant to AMN107 than native BCR-ABL. The mutations included 6 known imatinib mesylate-resistant mutations, including T315I, which showed complete resistance to AMN107. Interestingly, most AMN107-resistant mutants were also resistant to imatinib mesylate. These results may predict some of the resistance mutations that will be detected in clinical trials with this kinase inhibitor.     

Effect of hemoglobin levels on cardiovascular outcomes in patients with isolated systolic hypertension and left ventricular hypertrophy (from the LIFE study)

The optimal hemoglobin level in patients with hypertension or heart failure is not yet defined. The aim of the present investigation was to examine the relation of hemoglobin with cardiovascular outcomes in high-risk patients with isolated systolic hypertension (ISH) and left ventricular hypertrophy (LVH). In 1,326 patients with ISH in the Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) study, hemoglobin and cardiovascular outcomes were examined using Cox proportional hazard models. Baseline hemoglobin was negatively related to rate of cardiovascular death (hazard ratio 0.81 per 1 g/dl, 95% confidence interval [CI] 0.67 to 0.98, p = 0.032) after adjusting for baseline Framingham risk score, LVH, treatment, and estimated glomerular filtration rate. Hemoglobin decreased slightly during the study and the decrease was more pronounced in the losartan group (13.9 +/- 1.3 to 13.6 +/- 1.4 g/dl) than in the atenolol group (13.9 +/- 1.2 to 13.8 +/- 1.4 g/dl). Hemoglobin as a time-varying covariate was negatively associated with rate of cardiovascular death (hazard ratio 0.75, 95% CI 0.63 to 0.90, p <0.001) and stroke (hazard ratio 0.84, 95% CI 0.72 to 0.99, p = 0.040) after adjusting for baseline Framingham risk score, LVH, treatment, and estimated glomerular filtration rate. In conclusion, in this high-risk population with ISH and LVH, lower hemoglobin at baseline was associated with higher probability of cardiovascular death, and decrease in hemoglobin over time was associated with higher probability of cardiovascular death or stroke; this effect was attenuated by treatment with losartan.     

A psychological study of male,female related and unexplained infertility in Indian urban couples

Objective: The study intended to see the impact of infertility on experience of emotional trauma, belief pattern and formation of psychopathology and also to explore the psychopathology with respect to degree of infertility related stress impact among male, female and unexplained factor infertility in couples suffering from primary infertility.

Design: This was a clinic-based, cross-sectional comparative study based on a consecutive sampling method.

Subjects: Sixty couples were studied of whom 10 couples had male-related infertility (MF), 10 had female-related infertility (FF) and 10 unexplained infertility (UF). Another 30 fertile couples were also included as comparative group (CG) after matching on certain sociodemographic variables with the clinical groups.

Measures: Impact of Event Scale, Symptom Checklist-90 Revised and Irrational Belief Scale were used.

Results: The impact of emotional trauma and irrational belief was greatest in the male-related infertility couples, and somatisation in the unexplained group, whereas depression and interpersonal sensitivity were higher in the female-related infertility couples. An impact of moderate to severe infertility-related stress on depression and irrational beliefs was also observed. Gender difference was evident with respect to psychopathology and types of infertility.

Conclusion: The impact of infertility is evident with respect to psychopathology with differential impact of various types of infertility groups among Indian couples.