Challenges of spine surgery in obese patients

Obesity, one of the most common health problems in the United States, is becoming more prevalent. At the same time, because of technological advances, the rate of spine surgeries is on the rise. Given these trends in obesity and spine surgeries, it can be inferred that the number of obese patients who undergo spine surgeries will increase as well. When spine surgeries are planned for obese patients, several factors must be considered. Obesity is closely correlated with additional medical comorbidities including hypertension, coronary artery disease, and diabetes mellitus. Preoperative evaluation may be more difficult, as more extensive medical testing may be needed. Adequate radiographic images can be difficult to obtain because of patient size and equipment limitations. Administering anesthesia becomes more difficult, as does proper patient positioning. After surgery, obese patients are at higher risk for wound infection and deep vein thrombosis. Nevertheless, appropriate clinical outcomes can be achieved in obese patients who undergo spine surgery. Obesity is not a contraindication for spine surgery. Patient selection is key in achieving favorable clinical outcomes.

The effect of sterile versus non-sterile tourniquets on microbiological colonisation in lower limb surgery

INTRODUCTION

Surgical tourniquets are commonplace in lower limb surgery. Several studies have shown that tourniquets can be a potential source of microbial contamination but have not compared the use of sterile versus non-sterile tourniquets in the same procedures.

METHODS

Patients undergoing elective orthopaedic lower limb surgery were randomised prospectively to use of non-sterile pneumatic tourniquet or sterile elastic exsanguination tourniquet (S-MART™, OHK Medical Devices, haifa, Israel). Samples were taken from the ties of the non-sterile tourniquet prior to surgery and from the sterile tourniquets at the end of the operation in a sterile fashion. These were then sealed in universal containers and immediately analysed by the microbiology department on agar plates, cultured and incubated.

RESULTS

Thirty-four non-sterile tourniquets were sampled prior to surgical application, twenty-three of which were contaminated with several different organisms including coagulase-negative Staphylococcus spp, Staphylococcus aureus, Sphingomonas paucimobilis, Bacillus spp, and coliforms. Thirty-six sterile tourniquets were used, with no associated contamination.

CONCLUSIONS

There was significant contamination of 68% of orthopaedic surgical tourniquets. These are used regularly in procedures involving the placement of prosthesis and metalwork, and can act as a potential source of infection. We recommend the use of sterile single-use disposable tourniquets where possible. The availability of an alternative should now set the new standard of care and we recommend adopting this as a current NICE guideline for control of surgical site infection.

Unusual presence of Wormian (sutural) bones in human skulls

Wormian bones are a subset of the small intrasutural bones that lie between the cranial sutures formed by the bones of the skull vault. They are formed due to additional ossification centres in or near sutures. They are usually considered as normal variants and seem to be determined genetically in certain populations. They have been linked with rapid cranial expansion as they appear in great number in hydrocephalic skulls. They are commonly found in the lambdoid suture and fontanelles but are occasionally seen in other sutures especially the coronal, squamosal, and sagittal sutures. We examined 25 dried human skulls with the aim to find out the occurrence and variations of Wormian bones, and surprisingly we found Wormian bones in the coronal, squamosal, and sagittal sutures in 6 skulls. These are uncommon sites of occurrence of sutural bones as reported in the literature. These findings prompted us to report these cases as their presence can lead to confusion in diagnosis in cases of skull fractures.

Parental knowledge, attitude and practice related to blindness of children in some selected Upazilla of Bangladesh

Early detection of blind children at the household and community level is critical in reducing the global burden of visual impairment and childhood blindness. The aim of the study is to identify a range of potential issues relating to parental awareness and perceptions of common eye diseases affecting children. It was a descriptive and cross sectional study. Parents were recruited from four selected Upazillas ('pouroshoba' - 25% and rural - 75%) in the Naogaon district of Bangladesh. The method used in this study to assess parental knowledge and belief was by means of a questionnaire. The selected subjects were interviewed in detail using a structured questionnaire. It is mentionable that among common eye disease, about three-fourth of the parents informed that vitamin-A deficiency was the leading cause of blindness and more than one quarter believed that eye infection was the important cause of childhood blindness. Very few reported that injury in eye was the cause of childhood blindness. Analysis of respondents of this study revealed that half of the parents believed that childhood cataract is untreatable. Approximately 90% those surveyed were unaware of schooling systems for blind children and only 5% sought treatment from an ophthalmologist. This study also demonstrates that the health seeking behavior of parents and their extended families is poor. The mean age of the parents was 32.5±9.3 years, about 75% of parents had education up to primary level, and only 3.7% of them had graduation degree and above. The findings reinforce the necessity of parental awareness of common eye diseases in children and the importance of seeking timely advice including treatment based on informed decisions.

State of the art in myeloid sarcoma

INTRODUCTION

Myeloid sarcomas are extramedullary lesions composed of myeloid lineage blasts that typically form tumorous masses and may precede, follow, or occur in the absence of systemic acute myeloid leukemia. They most commonly involve the skin and soft tissues, lymph nodes, and gastrointestinal tract and are particularly challenging to diagnose in patients without an antecedent history of acute myeloid leukemia.

METHODS

We conducted a search of the English language medical literature for recent studies of interest to individuals involved in the diagnosis of myeloid sarcoma.

RESULTS

The differential diagnosis includes non-Hodgkin lymphoma, blastic plasmacytoid dendritic cell neoplasm, histiocytic sarcoma, melanoma, carcinoma, and (in children) small round blue cell tumors. The sensitivity and specificity of immunohistochemical markers must be considered when evaluating a suspected case of myeloid sarcoma. A high percentage of tested cases have cytogenetic abnormalities.

CONCLUSION

A minimal panel of immunohistochemical markers should include anti-CD43 or anti-lysozyme as a lack of immunoreactivity for either of these sensitive markers would be inconsistent with a diagnosis of myeloid sarcoma. Use of more specific markers of myeloid disease, such as CD33, myeloperoxidase, CD34 and CD117 is necessary to establish the diagnosis. Other antibodies may be added depending on the differential diagnosis. Identification of acute myeloid leukemia-associated genetic lesions may be helpful in arriving at the correct diagnosis.

Seminal fibronectin in fertile and infertile males

This study aimed to assess seminal plasma fibronectin in fertile and infertile males. Ninety infertile males were investigated; asthenozoospermia (n = 27), asthenoteratozoospermia (n = 30), oligoasthenoteratozoospermia (n = 33) compared with 20 healthy fertile controls. They were subjected to semen analysis, seminal plasma fibronectin estimation by radial immune diffusion, serum testosterone (T) and follicle stimulating hormone (FSH) estimation by ELISA. There was significant increase of seminal plasma fibronectin among different infertile groups compared with the controls. Significant negative correlation was elicited between seminal fibronectin and sperm count, sperm motility grades A, B, A + B, sperm velocity, linear velocity, linearity index, sperm normal forms and serum T. Seminal fibronectin showed significant positive correlation with grade D sperm motility and serum FSH. ROC curve analysis discriminating controls and other infertile groups demonstrated criteria value of < 674 mg l(-1) (sensitivity 100% and specificity 96.4%). It is concluded that increased seminal fibronectin is associated with decreased sperm count and sperm motility.

Development of a kidney TeleUltrasound consultation system

This paper presents the development of kidney TeleUltrasound consultation system. The TeleUltrasound system provides an innovative design that aids the acquisition, archiving, and dissemination of medical data and information over the internet as its backbone. The system provides data sharing to allow remote collaboration, viewing, consultation, and diagnosis of medical data. The design is layered upon a standard known as Digital Imaging and Communication in Medicine (DICOM). The DICOM standard defines protocols for exchanging medical images and their associated data. The TeleUltrasound system is an integrated solution for retrieving, processing, and archiving images and providing data storage management using Structured Query Language (SQL) database. Creating a web-based interface is an additional advantage to achieve global accessibility of experts that will widely open the opportunity of greater examination and multiple consultations. This system is equipped with a high level of data security and its performance has been tested with white, black, and gray box techniques. And the result was satisfactory. The overall system has been evaluated by several radiologists in Malaysia, United Arab Emirates, and Sudan, the result is shown within this paper.

High resolution array comparative genomic hybridization identifies copy number alterations in diffuse large B-cell lymphoma that predict response to immuno-chemotherapy

Despite recent attempts at sub-categorization, including gene expression profiling into prognostically different groups of "germinal center B-cell type" and "activated B-cell type," diffuse large B-cell lymphoma (DLBCL) remains a biologically heterogenous tumor with no clear prognostic biomarkers to guide therapy. Whole genome, high resolution array comparative genomic hybridization (aCGH) was performed on four cases of chemoresistant DLBCL and four cases of chemo-responsive DLBCL to identify genetic differences that may correlate with response to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) therapy. Array CGH analysis identified seven DNA copy number alteration (CNA) regions exclusive to the chemoresistant group, consisting of amplifications at 1p36.13, 1q42.3, 3p21.31, 7q11.23, and 16p13.3, as well as loss at 9p21.3 and 14p21.31. Copy number loss of the tumor suppressor genes CDKN2A (p16, p14) and CDKN2B (p15) at 9p21.3 was validated by fluorescence in situ hybridization and immunohistochemistry as independent techniques. In the chemo-sensitive group, 12 CNAs were detected consisting of segment gains on 1p36.11, 1p36.22, 2q11.2, 8q24.3, 12p13.33, and 22q13.2, as well as segment loss on 6p21.32. RUNX3, a tumor suppressor gene located on 1p36.11 and MTHFR, which encodes for the enzyme methylenetetrahydrofolate reductase, located on 1p36.22, are the only known genes in this group associated with lymphoma. Whole genome aCGH analysis has detected copy number alterations exclusive to either chemoresistant or chemoresponsive DLBCL that may represent consistent clonal changes predictive for prognosis and outcome of chemotherapy.

Predictors of large volume paracantesis induced circulatory dysfunction in patients with massive hepatic ascites

PURPOSE

In patients with massive ascites, large volume paracentesis may be associated with complications as circulatory dysfunction. Selection of appropriate patients might reduce such side effects.

PATIENTS AND METHODS

Forty-five patients known to have liver cirrhosis and presenting with massive ascites were included. There were 27 males and 18 females, with age (mean 51.2+10.64). All patients were subjected to full history, clinical examination, complete blood picture, prothrombin time, serum albumin, total plasma protein, serum bilirubin, serum creatinine, serum electrolytes and plasma renin activity measured by radioimmunoassay. Echocardiographic evaluation for cardiac output, pulmonary artery pressure, diastolic and systolic function before and after paracentesis. Large-volume paracentesis (LVP) ranging 8-18 liters with a mean 9.9 L was performed to all patients. Paracentesis induced circulatory dysfunction (PICD) was defined as increase in plasma renin activity (PRA) of more than 50% of pretreatment value to a level greater than 7.5ng /ml/ hour on the 6th day after paracentesis.

RESULTS

The incidence of PICD in patients with massive hepatic ascites was 73.3% (87.5% with Dextran and 38.5% with albumin). There were no serious systemic or local side effects one week following LVP. Type of plasma expander and younger ages were the only independent predictors (odd ratio OR with 95% confidence interval CI, 3.01<21.79<157.58 and 0.80<.88<.97 respectively) Gender and other clinical and laboratory parameters had no influence. Neither electrolytes levels nor hematocrite value had an influence. Ascitic patients showed higher heart rate and cardiac output and lower arterial pressure that was accentuated after LVP (P < 0.01). Echocardiographic diastolic function, A wave velocity and deceleration time of the E wave were markedly increased in cirrhotic patients with tense ascites and the E/A ratio was markedly reduced (0.9 ± 0.3) but was not significantly affected by LVP. Ejection fraction had similar values of the normal patients with a tendency to increase after paracentesis. There were no changes in the left ventricular wall thickness.

CONCLUSION

LVP is a safe and effective procedure for treatment of tense/refractory ascites. PICD is a frequently occurring silent complication following LVP. Salt free human albumin should be the plasma expander of choice especially if at least 8 liters are evacuated. Left ventricular diastolic function is altered in cirrhosis with tense ascites. This may represent an early stage of hepatic cardiomyopathy but was not affected by LVP and this was not reflected on the occurrence of PICD.

Respiratory gated simultaneous integrated boost-intensity modulated radiotherapy (SIB-IMRT) after breast conservative surgery for carcinoma of the breast: The Salmaniya Medical complex experience

PURPOSE

To present our clinical experience using SIB-IMRT Technique for Intact Breast cancer.

MATERIALS AND METHODS

A retrospective review of 45 cases of Stage I-IV breast cancer patients treated with SIB-IMRT with respiratory gating after Conservative treatments from 25th November 2008 to 16th February 2010. The most common fractionation was 1.8 Gy to Ipsilateral Breast tissue and 2.2 Gy to the lumpectomy cavity giving whole breast dose as 50.4 Gy and Lumpectomy cavity dose as 61.6 Gy over 28 fractions concomitantly. Respiratory gating was done and CT-images were taken in inspiratory breath hold position.

RESULTS

A total of 45 patients with breast cancer - stage I (17.7%), II (71%), III (8.9%), IV (2.2%) were treated with SIB- IMRT with respiratory gated radiotherapy. Out of 45 patients, 24 are of left sided breast cancer and 21 are of right sided breast cancer patients. The median, Dose maximum (D-max) in SIB-IMRT is 106.2% of prescribed lumpectomy site dose. The median isodose line prescribed to PTV-2 is 100%. The Conformity index (CI) is 0.9688 (median value) and Homogeneity index (HI) 1.06 (median). The median ipsilateral lung, mean dose is 21.66 Gy and V-20 is 37.4%. For left sided cases the median value of mean heart dose, V-30 and V-40 are 22.98 Gy, 23.45% and 9.45 % respectively. Acute skin toxicity was of Grade-I in 2.2 %, Grade-II in 64.4 %, Grade-III in 31.1 %, and Grade-IV in 2.2 %. The global Breast cosmoses were seen excellent in majority (93%) of case at median follow up of 8 months duration.

CONCLUSIONS

Breast SIB-IMRT Technique is feasible and comparable with other treatment techniques with reduced treatment duration by six fractions. At median follow up of 8 months the skin toxicity and cosmoses are excellent in high percentage of cases.

Evaluation of the current trend of nalidixic acid susceptibility in typhoidal Salmonellae; a marker of therapeutic failure for the fluoroquinolones

BACKGROUND AND OBJECTIVES

Typhoid is a major health problem faced by the developing countries like Pakistan. More than 20 million cases are reported annually worldwide. Currently fluoroquinolones are the drugs of choice to treat typhoid fever. In vivo resistance to fluoroquinolones leading to therapeutic failure is developing rapidly and is becoming a major concern for the clinicians. The objective of this study was to determine the sensitivity pattern of Nalidixic acid over the last four years

MATERIAL AND METHODS

A descriptive cross sectional study was carried out at the Microbiology Department of the Army Medical College, National University of Sciences and Technology, Rawalpindi from January 2006 to December 2009. All the isolates were dealt with standard microbiological procedures. The antimicrobial sensitivity of Nalidixic acid and Ciprofloxacin was determined using Kirby-Bauer disc diffusion method as per the guidelines of Clinical and Laboratory Standard Institute (CLSI).

RESULTS

Out of 240 isolates, 111 were Salmonella typhi and 129 were Salmonella paratyphi A. The resistance of the typhoidal Salmonella to Nalidixic acid has reached significant levels and it seems only a matter of time when hundred percent resistance will be encountered. All isolates were sensitive to Ciprofloxacin on disc diffusion method.

CONCLUSION

Resistance to Nalidixic acid predicting therapeutic failure with fluoroquinolones is on a steady rise.

Radiologically assessed testicular changes in infertile males with varicocele

The aim of this study was to assess vascular disturbances in the testis of infertile males associated with varicocele. In total, 124 consecutive male subjects were divided into the following groups: healthy fertile controls (n = 10), Gp1 (n = 28); infertile males with subclinical varicocele, Gp2 (n = 26); infertile males with grade I left varicocele, Gp3 (n = 28); infertile males with grade II left varicocele and Gp4 (n = 32); infertile males with grade III left varicocele. They were subjected to colour duplex for pampiniform plexus and scrotal scintigraphy. There was significant decrease in arterial blood velocity, testicular arterial diameters and testicular perfusion especially in high grade varicocele compared with healthy controls. The mean vein diameter demonstrated significant negative correlation with arterial diameter, arterial blood velocity, perfusion index, testicular size and significant positive correlation with perfusion index. The mean testicular size demonstrated significant positive correlation with arterial blood velocity, perfusion index and nonsignificant correlation with arterial diameter. It is concluded that there are significant decreases in testicular volume, testicular perfusion, blood velocity and testicular artery diameter in infertile males with varicocele.