"Labia majora fasciocutaneous flap reconstruction in complex urogynecological fistulas with vaginal deficit - A versatile approach"

OBJECTIVES

To appraise the pivotal points of different modifications of labia majora fasciocutaneous flap in combating the challenges of complex urogynecological fistula repair in the form of seven cases.

METHODS

Seven patients with complex urogynecological fistulas with vaginal deficit were treated over last three years. The challenges associated with them were non-capacious rigid vagina, irradiated and inflamed surrounding tissues, inelasticity, long-standing fistula with radiation-induced vesicovaginal fistula(VVF), an iatrogenic urethrovaginal fistula with anterior vaginal wall loss with vaginal stenosis, and a case of vesicolabial fistula with a history of forceps delivery and transvaginal VVF repair. Transvaginal repair with labia majora fasciocutaneous flap along with fat pad with relevant technical modifications was contemplated in all.

RESULTS

All radiation-induced VVF patients demonstrated no leak in the postoperative period barring one who became dry after transvaginal colpocleisis later. The patient with urethrovaginal fistula and vaginal stenosis was continent, had capacious vagina, and without any leak with regular menstrual periods. The female with vesicolabial fistula remained dry at the end of six-month follow-up.

CONCLUSION

Transvaginal repair using the labia majora fasciocutaneous flap and the demonstrated technical modifications can be a feasible option in repairing complex urogynaecological fistulas associated with vaginal wall deficit.

Clinical and videourodynamic study characteristics in female primary bladder neck obstruction and outcomes of bladder neck resection: A tertiary care center experience in India

Introduction:

Video urodynamic study (VUDS) with clinical correlation helps in diagnosing primary bladder neck obstruction (PBNO) in women. Bladder neck incision/bladder neck resection (BNR) though effective is not commonly practiced for the fear of complications and limited literature available.

Methods:

The records of ten women diagnosed with PBNO between 2017 and 2019 were reviewed and data pertaining to their clinical features, laboratory results, findings on abdominal ultrasonography, uroflowmetry, and VUDS was noted. Type of operative procedure performed and outcomes on follow-up were also assessed.

Results:

Out of ten patients, two presented with lower urinary tract symptoms (LUTS), three with voiding LUTS and chronic retention and five had acute urinary retention. Mean serum creatinine was 3.4 mg/dl. In those able to void, mean maximum flow rate (Q max) was 7 ml/sec, and mean postvoid residual volume (PVR) was 360 ml. On VUDS, mean detrusor pressure at maximum flow (pdet@Qmax) was 54.2 cm of H20. Three patients opted conservative treatment and 7 had a successful surgical outcome with mean Q max of 26.2 ml/s (range: 13.9–41 ml/s), insignificant PVR and resolution of renal failure. Patients with pdet@Qmax <20 cm H₂O (n = 3, mean 18.3 cm H₂O) did equally well as compared to those with pdet@Qmax >20 cm H₂O (n = 4, mean 93 cm H₂O). None of the patients developed any complications on follow-up.

Conclusions:

Clinical assessment supported with VUDS correlation holds a key in identifying patients with PBNO. BNR is a safe and effective treatment of PBNO in women who fail or are not candidates for conservative treatment.

Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Post Radiation Female Urethral Stricture - A Technical Appraisal With Outcomes

INTRODUCTION AND OBJECTIVES

Female urethral stricture following radiation has been reported sparsely in the literature with just a handful of case reports. Radiation to the pelvis affects the genitourinary tracts and afflicts damage by causing periurethral fibrosis, necrosis, and subsequent tissue contraction, posing as a hurdle to the reconstructive surgeon. We studied the technique and outcomes of dorsal onlay buccal mucosal graft (BMG) urethroplasty in patients of radiation-induced female urethral stricture disease (FUSD).

MATERIALS AND METHODS

Three cases of radiation-induced FUSD were reviewed. The preoperative and postoperative parameters like IPSS, Flow rate (Qmax), Postvoid residue (PVR), urethroscopy findings, and Videourodynamics study parameters were analyzed. All patients underwent dorsal onlay BMG urethroplasty. The salient steps of the operative procedure are demonstrated in this video presentation.

RESULTS

The mean duration after the last radiation cycle was 2.33 years. Preoperatively mean IPSS, Qmax, and PVR were 27.33 ± 1.15, 6.46 ± 0.6 mL/s, and 56.67 ± 16.07 mL, respectively. After dorsal onlay BMG urethroplasty the mean IPSS, Qmax, and PVR were 3.33 ± 1.5, 23.33 ± 6.1 mL/s, 15.67 ± 8.14 mL, respectively. None of the patients reported bothersome lower urinary tract symptoms, and stricture recurrence in the 12-month follow-up. However, one patient had transient stress incontinence, which was managed conservatively.

CONCLUSION

Dorsal onlay BMG urethroplasty achieves excellent outcomes in patients with postradiation FUSD. Adequate dorsal urethrotomy should be contemplated in previously irradiated strictures.

Signalling by melanopsin (OPN4) expressing photosensitive retinal ganglion cells

Over the past two decades there have been significant advances in our understanding of both the anatomy and function of the melanopsin system. It has become clear that rather than acting as a simple irradiance detector the melanopsin system is in fact far more complicated. The range of behavioural systems known to be influenced by melanopsin activity is increasing with time, and it is now clear that melanopsin contributes not only to multiple non-image forming systems but also has a role in visual pathways. How melanopsin is capable of driving so many different behaviours is unclear, but recent evidence suggests that the answer may lie in the diversity of melanopsin light responses and the functional specialisation of photosensitive retinal ganglion cell (pRGC) subtypes. In this review, we shall overview the current understanding of the melanopsin system, and evaluate the evidence for the hypothesis that individual pRGC subtypes not only perform specific roles, but are functionally specialised to do so. We conclude that while, currently, the available data somewhat support this hypothesis, we currently lack the necessary detail to fully understand how the functional diversity of pRGC subtypes correlates with different behavioural responses, and ultimately why such complexity is required within the melanopsin system. What we are lacking is a cohesive understanding of how light responses differ between the pRGC subtypes (based not only on anatomical classification but also based on their site of innervation); how these diverse light responses are generated, and most importantly how these responses relate to the physiological functions they underpin.

Validation of a polynomial regression model: the thermal inactivation of Bacillus subtilis spores in milk

AIMS

The predicted survival of Bacillus subtilis 168 spores from a polynomial regression equation was validated in milk.

METHODS AND RESULTS

Bias factor suggested as an index of model performance was used to validate the polynomial model predictions in ultrahigh temperature (UHT) treated and sterilized whole and skim milk. Model predictions were fail safe, predicting higher D-values (decimal reduction times) in buffer than actually noted in milk.

CONCLUSIONS

The D-values for spores were lower in milk as compared with those predicted in potassium phosphate buffer contrary to the popular expectation of better spore survival in complex food systems. The Bias factor, a quantitative measure of the model performance, indicated that on average the model predictions exceed the observations by 40% in the case of whole milk and by 60% in the case of skim milk.

SIGNIFICANCE AND IMPACT OF THE STUDY

The present work is an attempt to ascertain the extent of reliability that one can safely place in polynomial model predictions, without compromising on the safety or palatability of foods where it is eventually intended to be applied. The work has also highlighted the differences in the thermal inactivation pattern of spores in buffer and in milk with a possible influence of the various constituents of milk. The work will assist the dairy industry to better design thermal processes to ensure longer shelf life of dairy foods.

Modelling the combined effects of pH, temperature and sodium chloride stresses on the thermal inactivation of Bacillus subtilis spores in a buffer system

AIMS

The inactivation of Bacillus subtilis 168 spores subjected to the combined stress of pH, temperature and sodium chloride in a buffer system was modelled.

METHODS AND RESULTS

Bacillus subtilis 168 spore suspension in 50 mmol l-1 potassium phosphate buffer was heated in an open system using a block heater. A second order polynomial equation was used to describe the relationship between pH, temperature, sodium chloride concentration and the logarithm of the decimal reduction time (D-value) of the spores. Response surface graphs were constructed to predict the inactivation within the experimental domain. The data obtained were also compared with those reported for B. subtilis in different media and foods included in a large reference-based database of thermal inactivation (ThermoKill Database, TKDB R9100), which was constructed in the laboratory.

CONCLUSIONS

All the variables studied seemed to have a significant effect on the inactivation of B. subtilis 168 spores in potassium phosphate buffer. The coefficient of determination, r2, and an analysis of the residuals from the model indicated the adequacy of the model to predict the inactivation of B. subtilis spores within the range of the experimental variables studied.

SIGNIFICANCE AND IMPACT OF THE STUDY

The findings of this study will enable a better understanding of the inactivation of B. subtilis spores under the influence of the studied environmental variables. The model can be used by food industries to assess and monitor the shelf life of food products in the event of a chance contamination by B. subtilis spores.

Predicting the behavior of Escherichia coli introduced as a postprocessing contaminant in shrikhand, a traditional sweetened lactic fermented milk product

The increasing popularity of traditional milk-based foods has placed emphasis on the need for microbial safety in food-chain establishments, as there are ample possibilities for foodborne pathogens to occur as postprocessing contaminants. The behavioral pattern of an enterotoxigenic strain of Escherichia coli D 21 introduced as a postprocessing contaminant in shrikhand, a traditional sweetened lactic fermented milk product, was studied with variables of initial inoculum (4.3, 5.3, and 6.3 log10 CFU/g), storage temperature (4, 10, and 16 degrees C), and storage period (4, 9, and 14 days). During storage of shrikhand prepared individually with Lactobacillus delbruecki ssp. bulgaricus CFR 2028 and Lactococcus lactis ssp. cremoris B-634, there was a steady decrease in the viable count of E. coli that was proportional to the initial inoculum of E. coli introduced into shrikhand. The data were subjected to multivariate analysis, and equations were derived to predict the behavior of E. coli in shrikhand. The predicted values for the probable survival of E. coli showed good agreement with the experimental values with a majority of these predictions being fail-safe. The values of statistical indices showed that the model fits ranged between extremely good and satisfactory. Response surface plots were generated to describe the behavioral pattern of E. coli. The derived models and response surface plots enabled prediction of the survival of E. coli in shrikhand as a function of initial inoculum levels, storage temperatures, and storage periods of shrikhand. These predictions were valid within the limits of the experimental variables used to develop the model.

Adrenal hemorrhage and renal vein thrombosis in the newborn: MR imaging

Three newborn infants with flank masses underwent magnetic resonance (MR) imaging after ultrasound (US) indicated adrenal hemorrhage and/or renal vein and inferior vena cava thrombosis. MR imaging was valuable in defining the hemorrhagic nature of echogenic and hypoechoic suprarenal masses and in delineating thrombi within the renal veins and inferior vena cava. Two infants with renal parenchymal damage had abnormal radionuclide scans and abnormal corticomedullary distinction on MR images. The major role of MR imaging may be in the early course of these conditions, when added diagnostic specificity is likely to affect patient management. In most instances, size of hemorrhage and intravenous clots, as well as renal size, may be accurately followed with US, while radionuclide scanning remains necessary for evaluation of renal functional impairment.

Hemopericardium resulting from attempted internal jugular vein catheterization: a case report and review of complications of central venous catheterization

An unusual case of hemopericardium and presumed fatal cardiac tamponade complicating attempted right internal jugular vein catheterization by the posterior approach is reported. Reports of complications in a series of internal jugular vein catheterizations using various approaches (posterior, central, anterior, supraclavicular) and subclavian vein catheterizations are reviewed. Internal jugular vein catheterization is not necessarily safer than subclavian vein catheterization: numerous factors determine success rate and complication rate in central venous catheterizations.

Addison's disease due to tuberculosis in a 13-year-old girl

A 13-year-old girl developed Addison's disease during antituberculous therapy for presumed tuberculous ventriculitis. CT of the abdomen showed diffusely enlarged hypodense adrenals and a hypodense lesion in the lower pole of the left kidney. Biopsy of the renal lesion revealed caseating and noncaseating granulomas.

The morphology of the calcification front in articular cartilage. Its significance in joint function

Biochemical and histochemical studies have indicated that there is specific cellular activity in the region of the calcification front of articular cartilage implying that a regulation process takes place there. Using scanning and transmission electron microscopy and light microscopy to examine tissue sections of both undecalcified and decalcified articular cartilage in the region of the calcification front, we have looked at its morphology with particular reference to its cellular control. Our observations show that physiological calcification is an active process under cellular control and is related to the presence of extracellular membrane-bound matrix vesicles.

Stability of muscarinic-cholinergic receptor activity in the deafferented retinotectal pathway

The high-affinity antagonist, 3-quinuclidinyl benzilidate (QNB), was used to analyze muscarinic-cholinergic receptor activity in the optic tectum of goldfish and optic lobe of developing chicks and adult pigeons after deafferentation. After deafferentation no significant loss of total or specific muscarinic receptor binding activity was observed in contrast to prior experiments where there was a marked and rapid loss of nictonic-cholinergic receptor binding activity, as measured by alphabungarotoxin binding. The relative stability of the muscarinic site as opposed to the instability of the nicotinic site in these experiments is discussed.