Coverage of defects over Posterior aspect of Ankle Joint and Heel with Lateral Calcaneal Artery Flap- Experience in Mymensingh Medical College Hospital

Lateral calcaneal artery flap is randomly used by many Plastic Surgeons for covering any defect on the posterior aspect of heel. A prospective observational study was conducted in the Department of Burn and Plastic Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from January 2020 to June 2022, to see the outcome of the flap for coverage of defects over the posterior aspect of ankle joint and heel. A total number of 09 patients, selected by purposive sampling, were included in the study. The age of the patients ranged from 06 years to 70 years. The cause of the defects were post traumatic in 07 cases, electric burn in 01 case and pressure sore in 01 case. The defect sizes varied from 3×2 to 6×3cm. and flap size ranged from 4×2.5 to 7×4.5cm. The follow-up period ranged from 3 to 6 months. All the flaps survived completely without any complications; except in two cases. In one case, there was marginal epidermal necrolysis that healed secondarily without the need of any further surgical intervention. In the other case, there was gangrene of about 0.5 cm area at the flap tip, which was debrided and the resulting wound healed secondarily. The average operating time was 63 minutes. The results were satisfactory on the context of adequate coverage, and flap and donor site morbidity. So, the lateral calcaneal artery flap can be a good and safe option for the coverage of posterior ankle and heel defects.

An outbreak of multi-drug-resistant Acinetobacter baumannii on a burns ICU and its control with multi-faceted containment measures

BACKGROUND

Patients in burns centres are at high risk of acquiring multi-drug-resistant organisms (MDROs) due to the reduced skin barrier and long hospital stay.

METHODS

This study reports the investigation and control of an outbreak of MDR Acinetobacter baumannii in a burns centre. The 27 patients hospitalized in the centre during the outbreak were screened regularly, and a total of 132 environmental samples were analysed to identify a potential source. Fourier-transform infra-red (FT-IR) spectroscopy and multi-locus sequence typing were applied to characterize the outbreak strain.

RESULTS

Between August and November 2022, the outbreak affected eight patients, with 11 infections and three potentially related fatal outcomes. An interdisciplinary and multi-professional outbreak team implemented a bundle strategy with repetitive admission stops, isolation precaution measures, patient screenings, enhanced cleaning and disinfection, and staff education. FT-IR spectroscopy suggested that the outbreak started from a patient who had been repatriated 1 month previously from a country with high prevalence of MDR A. baumannii. Environmental sampling did not identify a common source. Acquisition of the outbreak strain was associated with a higher percentage of body surface area with burn lesions ≥2a [per percent increase: odds ratio (OR) 1.05, 95% confidence interval (CI) 0.99-1.12; P=0.09], and inversely associated with a higher nurse-to-patient ratio (per 0.1 increase: OR 0.34, 95% CI 0.10-1.12; P=0.06).

CONCLUSIONS

Burn patients with a higher percentage of body surface area with burn lesions ≥2a are at high risk of colonization and infection due to MDROs, particularly during periods of high workload. A multi-faceted containment strategy can successfully control outbreaks due to MDR A. baumannii in a burns centre.

Developments in Hand Surgery: Experience from a Tertiary Hospital of Northern Bangladesh

Hand Surgery is a specialized branch of Plastic and Reconstructive surgery. There are many conditions that require hand surgery, for example, congenital deformity, electric or flame burn, mechanical or road traffic injury, and post burn or post traumatic deformity. A retrospective observational study was conducted in the department of Burn and Plastic surgery, Mymensingh Medical College Hospital, Bangladesh during a 2 years period extending from 9th September 2021 to 8th September 2023. The objective of this study was to see the hand surgery status in a tertiary hospital of Bangladesh during the post Covid pandemic period. During this period 236 hand surgery procedures were performed in 176 patients. The age of the patients ranged from 02 to 78 years (Mean 31.14±1.52). One hundred and four (59.0%) were male and 72(41.0%) were female. Thirty-four (19.32%) patients had co-morbidities e.g., Epilepsy, Diabetes Mellitus, Chronic Kidney Diseases and HBsAg +ve. Causes of surgery included, wound due to electric burn 49(27.84%), flame burn 36(20.45%), post traumatic 24(13.64%), post infective 11(06.25%), tumor excision 02(2.24%), Dupuytren's contracture 03(1.70%), congenital anomalies 06(3.41%), post burn scar contractures 41(23.29%), nerve injury 01(00.57%) and carpal tunnel syndrome 01 (00.57%). Procedures were performed: post burn scar contracture release 41(17.37%), syndactly release 06(2.54%), release of post traumatic contracture 06(2.54%), carpal tunnel release 01(00.42%), release of Dupuytren's contracture 03(01.27%), nerve repair 01(00.42%), debridement, amputation and Fillet flap 29(12.29%), split thickness skin graft 46 (19.49%), V-Y advancement flap 06(2.54%), transposition flap 18(07.63%), cross finger flap 16 (06.78%), reverse cross finger flap 02 (00.85%), first dorsal metacarpal artery (FDMA) flap 05 (02.12%), reverse FDMA flap 01 (00.42%), metacarpal artery perforator flap 08(3.39%), radial artery perforator flap 04(01.69%), posterior interosseous artery flap 05(2.12%), abdominal flap 11(04.46%) and flap division and insetting 27(11.44%). Outcome of surgery was satisfactory in 225(95.34%) and 11(04.46%) cases had complications (p value 0.453), which was not significant. So, it can be concluded that the outcome of various types of hand surgery procedures in tertiary hospital of northern Bangladesh during the post Covid period was satisfactory overall.

The OpenMolcas Web: A Community-Driven Approach to Advancing Computational Chemistry

The developments of the open-source OpenMolcas chemistry software environment since spring 2020 are described, with a focus on novel functionalities accessible in the stable branch of the package or via interfaces with other packages. These developments span a wide range of topics in computational chemistry and are presented in thematic sections: electronic structure theory, electronic spectroscopy simulations, analytic gradients and molecular structure optimizations, ab initio molecular dynamics, and other new features. This report offers an overview of the chemical phenomena and processes OpenMolcas can address, while showing that OpenMolcas is an attractive platform for state-of-the-art atomistic computer simulations.

Patterns of Locoregional Failure After Ablative 5-Fraction Stereotactic MR-Guided on-Table Adaptive Radiation Therapy for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

SBRT for pancreatic ductal adenocarcinoma (PDAC) is routinely delivered with non-ablative dose to only gross disease resulting in locoregional failure (LRF) rates of >50%, most commonly near the celiac artery (CA) and/or superior mesenteric artery (SMA). It is unclear whether an alternative approach of prescribing ablative dose to gross disease plus elective coverage prevents and/or delays LRF. The study objective was to describe the incidence and anatomic distribution of LRF using this treatment approach.

MATERIALS/METHODS

A single institution retrospective analysis was performed of non-metastatic PDAC patients who received ablative stereotactic MR-guided on-table adaptive radiation therapy (A-SMART) on a 0.35T MR-Linac from 2018-2022. Median prescribed dose was 50 Gy/5 fractions. Elective coverage (EC), including a margin around the primary tumor, CA, and SMA, to 33-35 Gy/5 fractions became routine in 2019 using a simultaneous integrated boost; the porta hepatis was not routinely covered. LRFs were contoured and defined as out-of-field (OOF), marginal (M), or in-field (IF) if >80%, 20-80%, or <20% of it was outside of the most peripheral prescription isodose line.

RESULTS

One hundred four patients were evaluated (87% head tumors). 94% had induction chemotherapy (median 4 months), usually FOLFIRINOX (66%) or gemcitabine/nab-paclitaxel (27%). 88% received EC. Median GTV, CTV, PTVgrosstumor, and PTVelective volumes were 29 cc, 90 cc, 64 cc, and 127 cc, respectively. 16 patients (15%) had LRF after a median of 17 months (range: 2.4-30.8) from A-SMART; 13 had scans available for delineating LRF. Median follow-up from A-SMART for the entire cohort vs. LRF was 12 vs. 24 months. LRF involved the primary tumor (31%), retroperitoneal lymph nodes (25%), SMA (19%), porta hepatis (19%), and CA (6%). LRF was OOF, M, or IF in 30.8% (n = 4), 61.5% (n = 8), and 7.7% (n = 1). Distance from the 3 SMA failures to SMA origin was 10 cm (EC used), 9.3 cm (EC used), and 3 cm (no EC). The 1 CA failure involved the CA origin (no EC). Median mean, maximum, and minimum dose of the contoured LRF region on the original plan was 33.3 Gy (range: 9.7-50.3 Gy), 56 Gy (range: 44.2-71.4 Gy), and 11.4 Gy (range: 1.2-22.7 Gy), respectively. Median V20, V25, V30, V35, and V40 of the contoured LRF was 84.3% (range: 16.1-100%), 69.2% (range: 12.5-99.7%), 57.5% (range: 9.3-95.5%), 41.2% (range: 6.8-84.0%), and 32.7% (range: 4.8-71.8%).

CONCLUSION

This study represents the first patterns of LRF analysis after ablative 5-fraction SBRT for PDAC. Although EC is not currently endorsed by published pancreas SBRT guidelines, our low LRF incidence especially involving the CA/SMA demonstrates that EC should be considered, even when delivering ablative dose. Furthermore, given that nearly all LRF were M or OOF we have considered expanding our institutional elective volumes. While the optimal EC dose is uncertain, 33-35 Gy appears effective in limiting IF LRF and therefore has been standardized within ongoing ablative SBRT trials for PDAC at our institution.

Ablative 5-Fraction CT vs. MR-Guided Pancreatic SBRT: Evaluation of Interfraction Anatomic Changes on Dosimetric Constraints

PURPOSE/OBJECTIVE(S)

CT-guided SBRT for locally advanced pancreatic cancer (LAPC) is usually non-ablative (BED < 100 Gy10) to minimize grade 3+ toxicity risks given the concern of interfraction anatomic changes (IACs) in GI anatomy and imaging quality associated with kV-CBCT. Emerging data demonstrate that MR guidance facilitates 5-fraction (fx) dose escalation due to superior soft tissue contrast, continuous intrafraction imaging, automatic beam gating, and on-table adaptive replanning capability. Treatment outcomes for ablative 5-fx CT- vs. MR-guided SBRT are not well characterized, nor are differences in predicted GI OAR doses when accounting for IACs.

MATERIALS/METHODS

Weevaluated 40 plans (20 CT, 20 MR) for 20 LAPC patients (pts) previously treated in breath hold (BH) on a 0.35 T MR-Linac. Prescribed dose was 50 Gy (gross disease) and 33 Gy (elective) in 5 fx using a simultaneous integrated boost technique. CT plans were retrospectively created using 2-3 VMAT arcs with the same prescription dose, target volumes (assuming BH), and constraints (prioritizing OARs over target coverage) as the MR IMRT plans (∼20-40 fields). CT planners were blinded to MR plans. We compared predicted GI OAR dose of CT vs. MR plans across each of the 5 fx for all 20 patients to evaluate the dosimetric impact of IACs by coregistering CT plans to the anatomy of the day based on 0.35T MR scans acquired for GI OAR segmentation and treatment delivery.

RESULTS

MedianV100% of the GTV, CTV, PTV50, and PTV33 across the original CT vs. MR plans were 97.5% vs. 91.3% (p = 0.017), 99.9% vs. 98.2% (p<0.01), 86.2% vs. 79.3% (p = 0.39), and 97.2% vs. 93.0% (p<0.01), respectively. GI OAR constraints were met for all original CT/MR plans although it was predicted that 1+ GI OAR constraint would be violated (most commonly duodenum) for 88/100 CT vs. 85/100 MR fractions. Across the 88 violated CT fractions, the median predicted GI OAR doses were duodenum V35: 3.3 cc (range: 0.16-18.0cc), duodenum V40: 1.2 cc (range: 0.01-11.9cc), small bowel V35: 1.2 cc (range: 0.4-10.9cc), small bowel V40: 0.2 cc (range: 0.04-7.0cc), stomach V35: 1.5 cc (range: 0.52-6.8cc), stomach V40: 0.3 cc (range: 0.05-2.8cc). GI OAR doses across the 85 violated MR fractions were similar. Median fxs per pt with 1+ predicted GI OAR violation was 5 (range: 1-5) for both CT and MR plans.

CONCLUSION

This isthe first evaluation of IAC effects on predicted GI OAR dose for 5-fx CT- vs. MR-guided SBRT. Although VMAT arcs facilitated higher target coverage in the initial CT plans, GI OAR constraint violations were observed in 85-88% of CT/MR plans. Although on-table adaptive replanning is routine on MR-guided Linacs it is not commonly available on CT-guided Linacs. As such, ablative 5-fx SBRT delivered with CT guidance is expected to result in significant toxicity due to exceeding GI OAR constraints for most delivered fractions.

A Multiconfigurational Wave Function Implementation of the Frenkel Exciton Model for Molecular Aggregates

We present an implementation of the Frenkel exciton model into the OpenMolcas program package enabling calculations of collective electronic excited states of molecular aggregates based on a multiconfigurational wave function description of the individual monomers. The computational protocol avoids using diabatization schemes and, thus, supermolecule calculations. Additionally, the use of the Cholesky decomposition of the two-electron integrals entering pair interactions enhances the efficiency of the computational scheme. The application of the method is exemplified for two test systems, that is, a formaldehyde oxime and a bacteriochlorophyll-like dimer. For the sake of comparison with the dipole approximation, we restrict our considerations to situations where intermonomer exchange can be neglected. The protocol is expected to be beneficial for aggregates composed of molecules with extended π systems, unpaired electrons such as radicals or transition metal centers, where it should outperform widely used methods based on time-dependent density functional theory.

Adapter CAR T cells to counteract T-cell exhaustion and enable flexible targeting in AML

Although the landscape for treating acute myeloid leukemia (AML) patients has changed substantially in recent years, the majority of patients will eventually relapse and succumb to their disease. Allogeneic stem cell transplantation provides the best anti-AML treatment strategy, but is only suitable in a minority of patients. In contrast to B-cell neoplasias, chimeric antigen receptor (CAR) T-cell therapy in AML has encountered challenges in target antigen heterogeneity, safety, and T-cell dysfunction. We established a Fab-based adapter CAR (AdCAR) T-cell platform with flexibility of targeting and control of AdCAR T-cell activation. Utilizing AML cell lines and a long-term culture assay for primary AML cells, we were able to demonstrate AML-specific cytotoxicity using anti-CD33, anti-CD123, and anti-CLL1 adapter molecules in vitro and in vivo. Notably, we show for the first time the feasibility of sequential application of adapter molecules of different specificity in primary AML co-cultures. Importantly, using the AML platform, we were able to demonstrate that chronic T-cell stimulation and exhaustion can be counteracted through introduction of treatment-free intervals. As T-cell exhaustion and target antigen heterogeneity are well-known causes of resistance, the AdCAR platform might offer effective strategies to ameliorate these limitations.

Profiles and trajectories of executive functioning in young children with Down syndrome

BACKGROUND

Language acquisition strongly predicts executive functioning (EF) in early childhood in typical development and in children with Down syndrome (DS). Both language and EF are critical contributors to later positive social and academic outcomes yet are often areas of concern in children with DS. Despite the wider availability of interventions targeting language development in DS, no efforts have been made to understand how these interventions may influence the development of EF in this population.

METHODS

This study examined secondary data from 76 preschoolers with DS collected as part of a randomised waitlist control trial of an early social communication intervention (JASPER-EMT). Children's EF skills were measured using the BRIEF-P, at three timepoints over 6 months. Linear regression was used to examine the baseline relationship between child characteristics and the three indices of the BRIEF-P: Emergent Metacognition, Flexibility and Inhibitory Self-Control. Linear mixed effects models were used to estimate change across the three indices of the BRIEF-P and whether that change was moderated by treatment.

RESULTS

Children in this sample exhibited an uneven profile of EF at baseline, with relative strengths in the Flexibility Index and the Inhibitory Self-Control Index, and relative weaknesses in the Emerging Metacognition Index. Chronological age was associated with all indices at baseline (all P < 0.05). Children in the intervention group exhibited improvements in the Flexibility Index from entry to exit (3 months later) compared with the control, although this treatment effect did not maintain at the follow up at 6 months.

CONCLUSIONS

Baseline EF profiles of children were consistent with findings of other studies with children with DS. Longitudinal findings suggest that behavioural interventions targeting language may have positive collateral effects on certain EF skills, however these effects may be transitory without ongoing support. These findings illustrate both the need for further exploration of the impact of early language interventions on EF abilities and the malleability of certain EF domains in young children with DS.

A Comparative Study of Collagen Sheet versus 1% Silver Sulfadiazine Dressing in Superficial Partial Thickness Burns

Burn injury causes a lot of suffering. The goal of burn management is to achieve rapid wound healing, pain relief, rehabilitation with minimum scars and optimal functional ability. Objective of this study was to compare the efficacy of collagen sheets and 1% silver sulfadiazine dressing (SSD) for superficial partial thickness burns. This prospective observational study was conducted among the patients of Department of Plastic surgery, Dhaka Medical College Hospital, and Sheikh Hasina National Institute of Burn and Plastic Surgery, Dhaka, from 1st April 2020 to 31st March 2021. Total 60 patients with superficial partial thickness burns by purposive sampling 30 patients of them were treated with collagen sheet dressing (Group A) and 30 patients with 1.0% silver sulfadiazine dressing (Group B). First case was selected by tossing a coin. Then every alternate patient was provided the same kind of dressing material (either collagen sheet or 1.0% silver sulfadiazine). Data were collected by semi structured data collection sheets. Pearson's chi-square test and student's 't' test were used for data analysis (p value was significant at <0.05). It was observed that a total of 18(60.0%) patients belonged to age <10 years in Group A and 17(56.7%) patients in Group B. The mean age was 14.9±14.2 years in Group A and 11.6±10.2 years in Group B. Good quality of healing was significantly higher in the collagen group compared to the SSD group (<0.05). The mean complete healing time in the collagen group was 10.47±2.21 days and in the 1.0% SSD group were 13.07±2.33 days. The mean healing time was significantly lower in the collagen group compared to the 1.0% SSD group (p<0.001). There was no significant difference in infection rate between the two groups (p>0.05). Considering the overall outcome, Collagen sheet dressing decreases pain, reduces the need for analgesics, aids in early healing as compared to the patients treated with 1% silver sulfadiazine.

Aspects of transition cow metabolomics-Part I: Effects of a metaphylactic butaphosphan and cyanocobalamin treatment on the metabolome in liver, blood, and urine in cows with different liver metabotypes

Dairy cows in modern production systems are at risk to develop metabolic disorders during the transition period. Reasons for individual differences in susceptibility, as well as the underlying pathomechanisms, are still only partially understood. The development of metaphylactic treatment protocols is needed. In this context, an on-farm prospective 3-fold blinded randomized study involving 80 German Holstein cows was performed throughout 1 yr. The trial involved a thorough recording of the production and clinical traits, clinical chemistry, and liver biopsies and blood and urine sampling at d 14 (mean: 12 d, range: 1-26 d) antepartum (AP), and d 7 (7, 4-13) and 28 (28, 23-34) postpartum (PP) for metabolomics analyses. Two groups received a treatment with butaphosphan and cyanocobalamin (BCC) at either the dosage recommended by the manufacturer or the double dosage (5 or 10 mL/100 kg of body weight 10% butaphosphan and 0.005% cyanocobalamin (Catosal, Bayer Animal Health), n = 20 in each group, parity: 4.2 ± 2.0 and 3.4 ± 1.3, respectively (mean ± SD)] and one group a placebo treatment (NaCl 0.9%, n = 40, parity: 4.0 ± 1.9). The animals were treated at 6 time points (7, 6, and 5 d AP, and 1, 2, and 3 d PP) via intravenous injection. Mass spectroscopy-based targeted metabolomics analysis of blood plasma and liver samples were performed using the AbsoluteIDQ p180 kit (Biocrates Life Sciences), whereas the urine samples were analyzed by nuclear magnetic resonance spectroscopy. Statistical analysis was performed using multivariate [partial least squares discriminant analysis (PLS-DA)] and univariate methods (linear mixed model). Multivariate data analysis (PLS-DA plots) of the liver metabolome revealed 3 different metabotypes (A = medium, B = minor, C = large alterations in liver metabolome profile between AP and PP status). Metabotype B animals were characterized by higher PP lipomobilization (stronger PP body condition decrease and higher blood bilirubin, fatty acids, gamma-glutamyltransferase, and triglyceride levels) and a higher occurrence of transition cow diseases, compared with the animals in metabotype C. Analysis of the feeding data showed that the period of metabotype B animals (calving in a distinct time frame) was characterized by a decreased grass silage quality. The PP liver metabolome of the metabotype C animals was characterized by higher concentrations of AA, acylcarnitines, lysoPC and sphingomyelins compared with metabotype B. For the metaphylactic treatment with BCC a dose-dependent effect was confirmed, differing between the metabotypes. In all matrices and metabotypes at various time points significant treatment effects were observed, with different profiles in clinical chemistry and as well in metabolomics data. The most clear-cut treatment effect was observed in metabotype B in the liver at 7 d PP, characterized by an increase in several acylcarnitines and phosphatidylcholines, indicating a more efficient influx and oxidation of fatty acids in mitochondria and thereby an increase in energy supply and more efficient triglyceride export in the liver. The results from the liver metabolomics analysis support the application of an indication-based metaphylactic treatment with BCC.

Aspects of transition cow metabolomics-Part II: Histomorphologic changes in the liver parenchyma throughout the transition period, in cows with different liver metabotypes and effects of a metaphylactic butaphosphan and cyanocobalamin treatment

The aims of this study were to evaluate histopathologic changes during the transition period, describe the histopathological features of the metabotypes identified in Part I (Schären et al., 2021b), and investigate effects of a metaphylactic treatment with butaphosphan and cyanocobalamin (BCC) on the liver parenchyma. Eighty German Holstein cows (mean 305-d production: 10,957 kg, range: 6,480-15,193 kg; mean lactation number: 3.9, range: 2-9) from a commercial dairy farm in Saxony, Germany, were enrolled in a randomized, prospective, triple-blinded study. Two groups received a treatment with BCC (5 or 10 mL/100 kg of body weight 10% butaphosphan and 0.005% cyanocobalamin, Catosal, Bayer Animal Health, n = 20 each) and one group a placebo treatment (NaCl 0.9%, n = 40). Liver biopsy specimens were collected 14 d antepartum (AP) and 7, 28, and 42 d postpartum (PP), routinely processed for histologic examination, and stained with hematoxylin and eosin, Sudan III, periodic acid-Schiff, and picrosirius red stains. The sections were assessed for fat and glycogen content and degenerative, inflammatory, fibrotic, and proliferative changes. The statistical analysis included the effects of the sampling day, the lactation number, the treatment, and the metabotype (A = medium, B = minor, C = large alterations in the liver metabolome profile between AP and PP status). There was mild to moderate fat infiltration in the liver of 37% of cows in the last 2 wk AP, and moderate to severe fat infiltration in 66% of cows in the first days PP. The degree of fat infiltration increased from 2 wk AP until the end of the first week PP, and then decreased until the end of the study period, at which time about 25% of cows had moderate to severe fatty infiltration. Lipidosis was positively correlated with the severity of liver cell degeneration, and negatively correlated with the degree of glycogen deposits. Complete glycogen depletion of hepatocytes was not observed in cows, even in the presence of severe hepatic lipidosis. Moderate to severe lymphocytic hepatitis was seen in 39% of cows throughout the study period, and cows with lactation numbers 5 or greater had perisinusoidal fibrosis more often than younger cows. Severe fibrosis and cirrhosis of the liver did not occur. Metabotype B animals exhibited a higher chance of fatty infiltration, lower glycogen storage, and perisinusoidal fibrosis and for this metabotype positive correlations were calculated between increased fat deposition in the liver and marked glycogen depletion, and increased degenerative, inflammatory, fibrotic, and proliferative changes of hepatic tissue. For the treatment with BCC, no significant effect was observed. In summary, during the transition period, the liver of dairy cows is characterized by fat accumulation and glycogen depletion and histologic signs of hepatitis and hepatocyte degeneration. These histomorphologic changes were accentuated in animals exhibiting little alterations in their liver metabolome profile across the transition period (metabotype B) and support the assumption of a decreased grass silage quality as a causative factor.

Crane Principle in Plastic Surgery- Experience in Mymensingh Medical College Hospital

The crane principle is a Plastic surgical technique whereby, a pedicled flap can be used as an engineering crane to lift and transport subcutaneous tissue from one area and deposit it in another. The flap can be returned later to its original bed. It takes only one week for the conveyance. Here we present a case of 25 year old female patient with degloving injury of scalp with exposed skull bone was initially managed with transposition flap for coverage of the scalp defect in Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh on 07 December 2017. After 8 months the scalp flap was returned to its original site following the crane principle and the new wound was covered by split-thickness skin graft. The flap survived completely and patient was satisfied.

Genetic diversity and population structure of Culex modestus across Europe: does recent appearance in the United Kingdom reveal a tendency for geographical spread?

In mainland Europe, the mosquito species Culex modestus Ficalbi (1890) is a bridge vector for West Nile virus (WNV) from its natural bird-mosquito cycle to mammals. The present study assessed the genetic diversity of Cx. modestus, as well as related Culex species, using the mitochondrial COI DNA barcoding region and compared this with the population structure across Europe. A haplotype network was mapped to determine genealogical relationships among specimens. The intraspecific genetic diversity within individual Culex species was below 2%, whereas the interspecific genetic divergence varied from 2.99% to 13.74%. In total, 76 haplotypes were identified among 198 sequences. A median-joining network determined from 198 COI sequences identified two major lineages that were separated by at least four mutation steps. A high level of intraspecific genetic diversity was not detected in Cx. modestus in samples submitted from different European populations, which indicates that morphologically identified specimens represent a single species and not a species complex. Therefore, it is deduced that different populations of Cx. modestus will show a similar potential to transmit WNV, lending support to concerns that the population present in southeast England represents a risk of transmission to humans.

Establishment of a clinically relevant large animal model to assess the healing of metaphyseal bone

Despite the high incidence of metaphyseal bone fractures in patients, the mechanisms underlying the healing processes are poorly understood due to the lack of suitable experimental animal models. Hence, the present study was conducted to establish and characterise a clinically relevant large-animal model for metaphyseal bone healing. Six female adult Merino sheep underwent full wedge-shaped osteotomy at the distal left femur metaphysis. The osteotomy was stabilised internally with a customised anatomical locking titanium plate that allowed immediate post-operative full-weight bearing. Bone healing was evaluated at 12 weeks post-fracture relative to the untouched right femur. Histological and quantitative micro-computed tomography results revealed an increased mineralised bone mass with a rich bone microarchitecture. New trabeculae healed by direct intramembranous ossification, without callus and cartilaginous tissue formation. Stiffness at the cortical and trabecular regions was comparable in both groups. Functional morphological analysis of the osteocyte lacunae revealed regularly arranged spherically shaped lacunae along with the canalicular network. Bone surface biochemical analysis using time-of-flight secondary-ion mass spectrometry showed high and homogeneously distributed levels of calcium and collagenous components. Ultrastructure imaging of the new trabeculae revealed a characteristic parallel arrangement of the collagen fibrils, evenly mineralised by the dense mineral substance. The specialised bone cells were also characterised by their unique structural features. Bone remodelling in the fractured femur was evident in the higher expression levels of prominent bone formation and resorption genes. In conclusion, the novel metaphyseal fracture model is beneficial for studying healing and treatment options for the enhancement of metaphyseal bone defects.

Posterior Tibial Artery Perforator Based Propeller Flap for Lower Leg and Ankle Defect Coverage: A Prospective Observational Study

Reconstruction of lower leg and ankle defect with exposed bone or tendon is a challenging task for a Plastic Surgeon. There are various options, among them perforator based propeller flap is a very good option though this is a microsurgical procedure but no need of microvascular anastomosis. This study was designed to see the clinical results of Posterior tibial artery perforator based propeller flap for lower leg and ankle defect coverage. The study was a prospective observational study. It was conducted in the Department of Burn and Plastic Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2017 to June 2018. Sample size was 9. Sampling was carried out purposively. Postoperative follow up period was up to 6 weeks. Among the 9 cases, 8 flaps completely survived, 1 case developed marginal necrosis which was secondarily healed. There were total 2 complications among 9 cases i.e. transient venous congestion and superficial epidermonecrolysis which were resolved spontaneously. Regarding the cause of the defect, maximum cases were post traumatic wound (66.7%), others were post infective, post malignancy excision and post electric burn wound. Defect size was 2cm×2cm to 7cm×5cm. Maximum dimension of the flap was 19cm×6cm and minimum size was 7cm×3cm. Posterior tibial artery perforator location was 4cm to 9cm from lowest level of medial malleolous (mean 6.2±1.6cm). Rotation of the flap was 145°-180° (mean 163°±1.39°). In all cases donor site was covered with split thickness skin graft. Operation time was 120 minutes to 180 minutes; mean operative time was 143.3±2.38 minutes. After operation hospital stay was 10 days to 21 days, mean 11.44±3.64 days. So, posterior tibial artery perforator based propeller flap for lower leg and ankle defect coverage is a very good option.

Variability in space and time: contrasting fruit distribution patterns in the deceptive orchid Orchis militaris

In angiosperms, a decrease in fruit production towards the apex of individual inflorescences is usually observed. Orchids are thought to be primarily pollination-limited species, and non-uniform pollination could cause this decrease pattern in several species. Fruit production was investigated in relation to flower position and floral display size in Orchis militaris (Orchidaceae), a deceptive species. Over 2 years, eight populations of O. militaris were studied and fruit position along the inflorescence was recorded. Generalised linear models were performed to examine the effect of population, year, flower position and floral display size on fruit production. The dominant pattern was characterised by a higher fruit set in the middle part of the inflorescence (parabolic pattern). A non-directional pattern of fruit production was also detected in some populations. Within a given population, patterns were generally consistent among years. In one of the two study years and in one of the eight populations specifically, the proximal-to-distal decrease in fruit production was dramatic in plants with a large floral display but weak or absent in small displays. Our study demonstrates the intraspecific diversity of fruit distribution patterns in O. militaris. Non-uniform pollination along the inflorescence is likely to be responsible for the parabolic pattern, while irregular visitation could explain the non-directional pattern of fruit production. Pattern variation among years and between populations could arise from spatiotemporal variation in pollinator assemblages. Resource competition effects could explain the interaction effect between display size and flower position.

Fetomaternal Outcome in Eclampsia in Relationship with Gravidity

Eclampsia is a well-recognized major cause of maternal and perinatal morbidity and mortality. Patient's age, occupational status, socioeconomic status, educational status, regular ANC (antenatal care) and gravidity may affect the outcome of mother and foetus. The purpose of this study is to see the fetomaternal outcome in eclampsia in relationship with gravidity. This prospective observational cross-sectional study carried out among the alternate cases of primigravid and multigravid eclamptic patients. Total number of patients was 100 eclamptic patients among them, 50 patients were primigravida and 50 patients were multigravida. The study was conducted in Eclampsia unit of Department of Gynaecology and Obstetrics, Dhaka Medical College Hospital, Dhaka, Bangladesh from 21 November 2011 to 20 May 2012. In this study, it was observed that ARF (acute renal failure) occurred in 6%, of these 4 cases of multigravida and 2 cases of primigravida. Cerebro vascular accident (CVA) was reported in 16 patients and 26% in multigravida and 6% in primigravid patients. HELLP (Haemolysis, Elevated liver enzymes and low platelets) syndrome developed in 25 cases of multigravida and 6 cases of primigravida. Heart failure occurred in 7% cases, out of these 6 cases were multigravida and 1 case was primigravida. Pulmonary edema was observed in 41%, among were 21 cases of multigravida and 20 cases of primigravida. Incidence of DIC (disseminated intravascular coagulation) was noted in 2 cases of multigravida and 1 case of primigravida. PPH (postpartum haemorrhage) occurred in 10 cases of multigravida and 3 cases of primigravid patients. Puerperal psychosis was reported in 8% of multigravida and 4% of primigravida. Total 4% of patients expired, among them 3 cases were multigravida and 1 case was primigravida. Perinatal mortality was 21 cases in multigravida and 8 cases in primigravida. The incidence of live birth, in case of multigravida was 39 cases and primigravida 45 cases. Data were analyzed by paired student's 't' test. There was no statistically significant difference between primi and multigravida in feto-maternal outcome. This study reveals that gravidity does not alter the feto-maternal outcome in eclampsia.

First-in-man-proof of concept study with molidustat: a novel selective oral HIF-prolyl hydroxylase inhibitor for the treatment of renal anaemia

AIMS

Insufficient erythropoietin (EPO) synthesis is a relevant cause of renal anaemia in patients with chronic kidney disease. Molidustat, a selective hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitor, increases endogenous EPO levels dose dependently in preclinical models. We examined the pharmacokinetics, safety, tolerability and effect on EPO levels of single oral doses of molidustat in healthy male volunteers.

METHODS

This was a single-centre, randomized, single-blind, placebo-controlled, group-comparison, dose-escalation study. Molidustat was administered at doses of 5, 12.5, 25, 37.5 or 50 mg as a polyethylene glycol-based solution.

RESULTS

In total, 45 volunteers received molidustat and 14 received placebo. Molidustat was absorbed rapidly, and the mean maximum plasma concentration and area under the concentration-time curve increased dose dependently. The mean terminal half-life was 4.64-10.40 h. A significant increase in endogenous EPO was observed following single oral doses of molidustat of 12.5 mg and above. Geometric mean peak EPO levels were 14.8 IU l^-1 (90% confidence interval 13.0, 16.9) for volunteers who received placebo and 39.8 IU l^-1 (90% confidence interval: 29.4, 53.8) for those who received molidustat 50 mg. The time course of EPO levels resembled the normal diurnal variation in EPO. Maximum EPO levels were observed approximately 12 h postdose and returned to baseline after approximately 24-48 h. All doses of molidustat were well tolerated and there were no significant changes in vital signs or laboratory safety parameters.

CONCLUSIONS

Oral administration of molidustat to healthy volunteers elicited a dose-dependent increase in endogenous EPO. These results support the ongoing development of molidustat as a potential new treatment for patients with renal anaemia.

[Otorhinolaryngology in the field of demography, growing outpatient care and regionalization]

BACKGROUND

Otorhinolaryngology (ENT) departments are strongly affected by current changes in the reimbursement schemes for inpatients. The study was designed to investigate these effects on the ENT Department in Rostock and selected comparison clinics, as well as to outline solutions.

METHODS

We analyzed diagnosis-related group (DRG) reports of the ENT Clinic at Rostock University Medical Center from 2013 to 2015, according to the size of the outpatient potential. Comparisons were made with other surgical departments such as maxillofacial surgery and ophthalmology in terms of average length of stay and the resulting deductibles. We also compared billing as day surgery and complete outpatient surgery for the main small surgical procedures such as tonsillectomy and septum surgery. Finally, we compared the discounts with 22 ENT departments in other maximum care hospitals.

RESULTS

The average case mix index of an ENT department in Germany is 0.75, case load average of 2,500 patients and common length of stay 4.1 days. In a typical academic ENT department as in Rostock, health plans usually discount around 500 T€ (thousand euro), which is considerably higher than comparable departments, e.g., oral and maxillofacial surgery or ophthalmology departments. However, discounts on a DRG for inpatient surgery is still approximately 1,000 € more revenue than surgery in an outpatient setting. The benchmark analysis shows that health plans in rural areas are more likely to accept inpatient surgery with discounts for small procedures than strict billing according to outpatient reimbursement schemes.

CONCLUSION

These effects can result in an insufficient cost effectiveness of ENT departments in Germany. As a consequence, substantial restructuring of the in- and outpatient treatment seems necessary, also for academic ENT departments, e.g., in the form of day surgery or ambulatory surgical centers, outpatient clinics with special contracts and specialized inpatient surgery. However, this results in greater demands on the training of young physicians and management of patient flows within the department.