Antibacterial diterpenoids from Fabiana densa var. ramulosa

A biologically monitored fractionation of the resinous exudate of Fabiana densa Remy var. ramulosa Wedd. led to the isolation of the two new diterpenes: ent-beyer-15-en-18-O-succinate and ent-beyer-15-en-18-O-oxalate as the unique compounds responsible for the observed antibacterial activity of this extract. Their structures were determined by 1D and 2D NMR spectroscopy.     

Development and descent of the testis

Normal testicular descent is achieved by a residuum of primitive embryonic mesenchyme which is retained through into the fetal period; this is the gubernaculum testis. It forms a medium into which the cremaster muscles and the processus vaginalis can develop in anticipation of testicular descent. At the time of descent the gubernacular mesenchyme dilates, largely due to the uptake of fluid by the interstitial hyaluronic acid. By this means the scrotal sac is dilated and, with concurrent growth of related structures, all under the overall influence of maternal and chorionic gonadotrophic (luteinising) hormones, stimulating the testicular interstitial cells of the fetal testis, testicular descent is permitted.Failure to maintain the undifferentiated gubernacular mesenchyme, as by invasion of differentiating tissues, mechanically prevents the necessary growth to normal descent and may thus produce ectopic testes. Failure of the fetus to respond to luteinising hormones either by testicular interstitial cellular response, or the other tissues' response to normally produced testosterone, leads to an essentially hormonal failure of descent (cryptorchidism). Commonly, the failure to descend is no more than a premature birth, so separating the fetus from its source of luteinising hormone before the descent process is complete. The replacement of that antenatal stimulus of luteinising hormone at an early postnatal stage appears the logical treatment of cryptorchidism. However, if a proper scrotal formation has not occurred, then the indication is that the gubernaculum has not carried out its initial dilating function and probably the testis is deficient in its interstitial cell secreting potential.     

A hairy affair: tarantula setae-induced panuveitis requiring pars plana vitrectomy

Cases of ocular inflammation following penetration by urticating hairs from caterpillars and tarantulas have been previously reported and although rare, the condition is increasingly being recognised as a cause of chronic panuveitis. The long-term outcomes and prognosis of this condition are not well known. This article describes a case of chronic panuveitis as a result of ocular penetration by tarantula setae, and its challenging management that ultimately required pars plana vitrectomy. Interventional case report: A 29-year-old male presented with chronic panuveitis secondary to tarantula-hair penetration. Initial management with mechanical removal of hairs from the cornea and intensive topical steroid therapy for 18 months did not adequately control his symptoms. Pars plana vitrectomy was carried out and at 6-month follow-up the patient was symptom-free without any pharmacological therapy. We propose early pars plana vitrectomy as a management option for treatment-resistant panuveitis in cases of ophthalmia nodosa secondary to setae-related injury.     

Phrynoderma: a rare dermatologic complication of bariatric surgery

Biliopancreatic diversion is a predominantly malabsorptive bariatric procedure that can lead to the development of several nutrition complications, including fat-soluble vitamin deficiencies. Routine supplementation with vitamins and trace elements and a strict medical follow-up are essential to prevent these nutrition risks. Vitamin A deficiency is common after bariatric surgery but rarely causes clinical symptoms. Case reports have described ophthalmological and fetal complications associated with vitamin A deficiency after malabsorptive bariatric surgery. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. The simultaneous occurrence of phrynoderma and ocular symptoms secondary to hypovitaminosis A after bariatric surgery is exceptional. The authors describe a man who presented follicular hyperkeratosis with nyctalopia and xerophthalmia that had appeared 1 year after biliopancreatic diversion. He admitted poor compliance with diet and daily supplementation of vitamins and oligoelements. Serum vitamin A levels were decreased. Treatment with high doses of vitamin A was associated with a clear improvement of cutaneous and ocular lesions with complete resolution after 2 months. The patient was readmitted 2 years later because of the reappearance of cutaneous lesions and micronutrient deficiency. Revisional bariatric surgery was performed. The authors review and discuss the relationship between phrynoderma, malnutrition, and vitamin A deficiency.     

The accuracy and reproducibility of rhinospirometry in detecting flow asymmetry in a nasal cavity model

The objective of this study is to investigate the appropriateness of the NV1 rhinospirometer in the assessment of asymmetrical nasal airflow using a nasal cavity model. The Study is a laboratory-based basic-science study using an artificial model of nasal airflow. It is conducted in Medical Physics Department, Singleton Hospital, Swansea, Wales. A nasal cavity model was created with a series of parallel flow symmetry/asymmetries that were each assessed using standard flow volume measurements. The results were converted into Nasal Partition Ratios (NPRs) for each trial scenario and were examined against a mathematically calculated NPR derived using Pouseille’s law. Experimental scenario results were assessed for correlation, accuracy and precision against the mathematically derived result. In this study 300 individual test scenarios were completed using 2 different flow volumes and 15 different symmetry/asymmetry combinations. Correlation of the attained results against the mathematically derived figure gave a very strong correlation, using Spearman’s Rho = 0.975. Accuracy was excellent within one Standard deviation of the expected results. It was concluded that the NV1 rhinospirometer is an accurate and precise objective marker of airflow symmetry in the nasal cavity model giving strong correlation, accuracy, precision and reproducibility. The rhinospirometer, as a precision tool, has displayed potential to become an effective objective marker of nasal airflow in the assessment of nasal obstruction; however, clinical trials are required to examine whether the accurate results of this laboratory study are transferable to clinical practice.     

Reliability of slice-encoding for metal artefact correction (SEMAC) MRI to identify prosthesis loosening in patients with painful total hip arthroplasty – a single centre,prospective, surgical validation study

Objectives:To validate reliability of slice-encoding for metal artefact correction (SEMAC)-MRI findings in prosthesis loosening detection by comparing them to surgical outcomes (gold standard) in symptomatic patients following hip arthroplasties. To evaluate periprosthetic anatomical structures in symptomatic patients to identify an alternative cause of hip symptoms.Methods:We prospectively followed 47 symptomatic patients (55 hips, 39 painful hips – group P and 16 control hips – group C) at our institution from 2011 to 2016. We acquired 1.5 T MRI conventional and SEMAC-MRI images for all patients. Two consultants scored MRI for osteolysis and marrow oedema zone-wise using predefined signal characteristics and settled scoring variations by consensus. We used Spearman Rank-Order Correlation for correlation analysis and used OMERACT (Outcome Measures in Rheumatology) filter pillars to validate SEMAC-MRI findings.Results:Eleven patients needed revision surgery, all from group P. None from group C required revision surgery. Remaining 28 hips in the group P were managed conservatively pain completely resolved in 21 hips, eight hips had trochanteric bursitis, eight had extraarticular cause and the remaining five hips had spontaneous pain resolution. We found moderate-to-weak correlation between SEMAC-MRI findings for prosthesis loosening and revision surgery outcomes. Sensitivity, Specificity, PPV and NPV in Group P were (72.7, 64.3, 44.4, 85.7%) in T1W-SEMAC, (90.9, 46.4, 40.0, 92.9%) in STIR-SEMAC and (36.3, 78.5, 40.0, 75.8%) in PDW-SEMAC.Conclusion:Negative SEMAC-MRI results can effectively exclude prosthesis loosening confirmed on revision surgery and SEMAC-MRI can detect alternative cause of hip pain accurately.Advances in knowledge:Negative SEMAC-MRI in painful THA patients can effectively exclude prosthesis loosening as a cause.     

The management of pelvic ring fractures in low-resource environments: review

Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more “old-fashioned” protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.

     

Physiological correction of hereditary mild hypofibrinogenemia during pregnancy

Introduction

Hereditary hypofibrinogenemia is a rare fibrinogen disorder characterised by decreased levels of fibrinogen. Pregnant women with hypofibrinogenemia are at risk of adverse obstetrical outcomes, depending on the fibrinogen level.

Aim

We investigated how the physiological changes of hemostasis throughout the pregnancy impact the hemostatic balance in a woman with hereditary mild hypofibrinogenemia.

Methods

Fibrin clot properties were analyzed by turbidimetry and scanning electron microscopy, clot weight and red blood cells retention were measured by whole clot contraction, and in vitro thrombin generation was assessed by calibrated automated thrombogram and ex vivo by TAT.

Results

Throughout the pregnancy, the fibrinogen levels increased reaching normal values in the third trimester (activity 3.1 g/L, antigen 3.2 g/L). In parallel, the fibrin polymerisation increased, the fibrinolysis decreased, the fibrin clot network became denser with thicker fibrin fibers, and the fibrin clot weight and red blood cells retention increased, reaching control's value at the third trimester. Similarly, in vitro and ex vitro thrombin generation increased, reaching maximum values at the delivery.

Conclusion

In this case of hereditary mild hypofibrinogenemia we observed a physiological increase of fibrinogen and thrombin generation. Future studies should focus on moderate and severe hypofibrinogenemia, to assess fibrinogen variation and the overall impact of increased TG on the hemostasis balance.