Foreign Bodies in Facial Trauma-Report of 3 Cases

Background

Foreign bodies embedded deep in facial tissues presents a challenge to maxillofacial surgeons. Approximately one third of all foreign bodies are missed during initial examination. After facial trauma foreign bodies like grit particles, wooden pieces, thorns, pebbles, glass particles may get embedded into deeper facial tissues which are detected only accidently either with the help of radiographs or at a later stage when patient presents with some signs & symptoms like pain, pus discharge, sinus formation etc. Trauma to maxillofacial region especially after road traffic accidents is one of major cause of embedment of foreign body, but many of these cases go unnoticed. This article contains 3 cases of foreign bodies embedded in facial tissues.

Conclusion

Proper initial examination of facial lacerations with thorough debridement is very essential for finding embedded foreign bodies. Foreign bodies embedded in deeper tissues are missed by surgeon eyes, so whenever in doubt radiographs must be advised to rule out presence of foreign bodies.     

Does Femoral Rotation Influence Anteroposterior Alpha Angle,Lateral Center-edge Angle,and Medial Proximal Femoral Angle? A Pilot Study

Background

Femoral rotation on AP radiographs affects several parameters used to assess morphologic features of the proximal femur but its effect on femoroacetabular impingement parameters remains unknown.

Question/purposes

We therefore evaluated and characterized the potential effect of femoral rotation on (1) AP alpha angle, (2) lateral-center edge angle (LCEA), and (3) medial proximal femoral angle (MPFA) on AP hip radiographs.

Methods

We took seven AP hip radiographs at intervals of successive femoral rotation on a single dry, cadaveric specimen: 60°, 40°, and 20° internal rotation; 0° neutral/anatomic rotation; and 20°, 40°, and 50° external rotation. The AP alpha angle, LCEA, and MPFA were measured on all radiographs by two independent evaluators.

Results

Within the range of femoral rotation studied, the AP alpha angle ranged from 39° to 62°, the LCEA from 25° to 35°, and the MPFA from 70° to 115°. MPFA and AP alpha angle showed a linear relationship with femoral rotation. Each additional degree of internal rotation produced a reciprocal reduction of the MPFA by 0.36° and the AP alpha angle by 0.18° and vice versa in external rotation. The LCEA, especially within the internal rotation range, showed minimal variation.

Conclusions

These changes in radiographic parameters emphasize the importance of femoral rotation and patient positioning. We recommend radiographs be evaluated for excessive femoral rotation or nonstandardized positioning before interpretation for diagnostic and treatment implications. It may be prudent to repeat radiographs in these circumstances or, when standardized positioning is not feasible, proceed toward advance imaging.     

Telmisartan in the management of diabetic nephropathy: a contemporary view

Diabetic nephropathy, a complex disorder with heterogeneous etiologies, remains one of the most threatening diseases worldwide. There were around 177 million people with diabetes mellitus worldwide, and it has been estimated to be increased to 360 million by 2030. Given that about 20-30% of these people develop diabetic nephropathy, the present treatment protocols primarily aim for an efficient glucose and blood pressure control to arrest the initiation and progression of diabetic nephropathy. The treatment of diabetic nephropathy near the beginning at microalbuminuria stage with angiotensin-II-AT1 receptor blockers (ARBs) improves blood pressure control and halts disease progression of diabetic nephropathy. In fact, ARBs exert renoprotective effects independently of their blood pressure lowering effect, as they have direct defensive action on the diabetic kidney. Indubitably, it would be better if an ARB has both glucose-lowering and blood pressure controlling potentials efficiently. Intriguingly, telmisartan has such possessions considering its dual role of AT1 receptor blocking action and peroxisome proliferator-activated receptor gamma (PPARγ) partial agonistic property. The additional PPARγ agonistic potential of telmisartan could make it a distinctive intervention in the ARB class to prevent the progression of diabetic nephropathy through activation of PPARγ-mediated insulin sensitization, and renal anti-inflammatory and anti-oxidant actions. Indeed, telmisartan reduced insulin resistance and glucose intolerance, and halted the progressive renal dysfunction associated with diabetic nephropathy by inhibiting the incidence of albuminuria, and preventing the progression of glomerulosclerosis, renal interstitial inflammation and fibrosis. This review will discuss the current status of therapeutic potentials of telmisartan in treating diabetic nephropathy.     

Regio- and diastereoselective synthesis of spiropyrroloquinoxaline grafted indole heterocyclic hybrids and evaluation of their anti-Mycobacterium tuberculosis activity

An efficient and eco compatible approach for the regio- and stereoselective synthesis of structurally diverse novel hybrid heterocycles comprising spiropyrrolidine, indenoquinoxaline and indole structural units in excellent yields, has been achieved through a one-pot multicomponent process involving 1,3-dipolar cycloaddition as a key step. The 1,3-dipolar component is the azomethine ylide generated in situ from indenoquinoxaline and l-tryptophan and reacts with various substituted β-nitrostyrenes affording the spiroheterocyclic hybrids. The ring system thus created possesses two C–C and three C–N bonds and four adjacent stereogenic carbons, one of which is quaternary and the reaction proceeded with full diastereomeric control. All the synthesized compounds were assayed for their in vitro activity against Mycobacterium tuberculosis H37Rv using MABA assay. Interestingly, the compound bearing a 2-fluoro substituent on the aryl ring displayed an equipotent activity (MIC 1.56 μg mL⁻¹) to ethambutol against Mycobacterium tuberculosis H37Rv.

An efficient and eco compatible approach for the regio- and stereoselective synthesis of structurally diverse novel spiropyrrolidine tethered indole hybrids in excellent yields employing a one-pot multicomponent 1,3-dipolar cycloaddition strategy.     

A Rare Case of Benign Multicystic Peritoneal Mesothelioma: A Clinical Dilemma

A middle aged housewife presented with an anterior abdominal wall mass which was slowly growing over a period of 1 years over the midline scar of previous caesarean section with cystic degeneration in a part of the tumor. Fine needle aspiration cytology revealed a papillary serous cystadenoma. At exploratory laparotomy tumor was seen arising from the ventral surface of the parietal peritoneum with normal viscera, omentum and ovaries. The pathologist reported the tumor as Benign Multicystic Peritoneal Mesothelioma. It is a rare but clinically favourable neoplasm with wide excision as the definitive treatment. Of the 130 cases reported in the literature, it has the least incidence in the Indian Subcontinent.     

Defining Treatment and Outcomes of Hepaticojejunostomy Failure Following Pancreaticoduodenectomy

Background

The overall complication rate after pancreaticoduodenectomy (PD) approaches 50 %, with anastomotic failure being the most frequent cause of serious postoperative morbidity. Hepaticojejunostomy leaks (also called bile leaks) are the second most common type of leak, behind pancreaticojejunostomy leaks, yet have been the focus of only a single study as reported by Suzuki et al. (Hepatogastroenterology 50:254–257, 12).

Methods

We reviewed the recent experience with bile leaks at a single, high-volume pancreatic surgery center over a six-year time period.

Results

Bile leaks were identified in 16 out of 715 patients (2.2 %). Low preoperative albumin was associated with an increased risk. Bile leaks typically manifested within the first week after surgery as bilious drainage in a surgically placed drain. Associated warning signs included fever and leukocytosis. Patients with a bile leak frequently developed other complications, including a pancreatic fistula, wound infection, delayed gastric emptying, and sepsis. The impact on perioperative outcomes was comparable to patients with a pancreatic leak. A grading system is proposed based on the International Study Group on Pancreatic Fistula model. Grade A bile leaks were classified as those managed with prolonged drainage by operatively placed drains, grade B bile leaks with percutaneous abdominal drainage, and grade C bile leaks with insertion of a percutaneous transhepatic biliary drainage.

Conclusions

Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening and is comparable overall to pancreaticojejunostomy leaks. Surgical intervention is rarely, if ever, required. With prompt and aggressive management, a full recovery can be expected.     

Preoperative Imaging for Resectable Periampullary Cancer: Clinicopathologic Implications of Reported Radiographic Findings

Background

High-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown.

Methods

We identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated.

Results

There were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6).

Discussion

While dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.     

Current concepts in the treatment of adolescent femoroacetabular impingement

There is growing evidence that symptomatic femoroacetabular impingement leads to intra-articular damage and the development of early-onset osteoarthritis. Symptoms of femoroacetabular impingement often do not manifest until adulthood, but have been increasingly recognised in the paediatric and adolescent population. The surgical treatment of femoroacetabular impingement is aimed at restoring a more normal femoral head–neck offset in order to increase the clearance and prevent femoral abutment against the acetabular edge. Current methods include open and arthroscopic techniques. The latter has been combined with an open approach to gain access to the head–neck junction for osteochondroplasty. Proximal femoral and/or periacetabular osteotomies are used to treat femoroacetabular impingement associated with deformity secondary to childhood hip conditions, such as slipped capital femoral epiphysis and Legg–Calvé–Perthes disease. Some adolescents have severe degenerative joint disease at the time of presentation and may require arthroplasty or arthrodesis. The aim of this review is to identify the major trends and advancements in the management of femoroacetabular impingement in adolescents, including the outcome of studies of the surgical treatment modalities used.