Embolization of arteriovenous malformations of head and neck: A systematic review

BACKGROUND

Cervicofacial arteriovenous malformations (AVMs) are a significant source of morbidity. Endovascular embolization has emerged as a promising treatment technique for these lesions. However, current literature on cervicofacial AVM embolization mostly consists of single-agent oriented case series, and to date, no comprehensive study has compared the outcomes of available embolic agents.

PURPOSE

To investigate the performance of different embolic agents in the management of cervicofacial AVMs.

METHODS

We systematically searched Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials Scopus, and Web of Science. Studies providing data for the endovascular treatment of cervicofacial AVMs were included. The data regarding complication and cure rates were collected for each embolic agent. Pooled event rates were presented as descriptive statistics.

RESULTS

Eleven studies comprising 204 patients were included in the review. The overall complete and partial cure rates were 62.2% (127/204) and 36.2% (74/204), respectively. Embolization failed to achieve significant improvement in only 1.6% (3/204) of the patients. The complete cure rates were 87.5% (75-100%) for n-Butyl cyanoacrylate (NBCA, glue), 80.5% (61-100%) for Onyx (Medtronic, MN, USA), and 51.5% (18-85%) for ethanol. The overall complication rate was 30% (61/204). The complication rates were 33% (12.5-53%) for ethanol, 14% (0-28%) for Onyx, and 0% for NBCA.

CONCLUSIONS

Our systematic review supports that endovascular embolization is an effective treatment option for cervicofacial AVMs. In our review, the use of Onyx and NBCA was associated with consistently high complete cure rates and a promising safety profile. However, more research is needed to investigate the use of different embolic agents in the treatment of cervicofacial AVMs.

Incidental diagnosis of presacral ganglioneuroma in a patient with hematuria

Ganglioneuromas are benign neuroblastic tumors seen most in pediatric population. The most common locations are mediastinal, retroperitoneal and adrenal regions. Ganglioneuromas rarely occur in presacral space. We present one such case of an incidentally diagnosed presacral ganglioneuroma in an asymptomatic 71-year-old male who initially presented with hematuria.

Feasibility of telesurgery in the modern era

Telesurgery is not a foreign concept and dates to as early as the 1920s. The use of robots in medicine has had a very positive effect and improved outcomes with little to no adverse effects. Having global access to telemedicine and telesurgery during the COVID-19 pandemic and being able to provide top medical care to gravely ill and contagious patients without compromising the safety of the medical team would be a very big achievement. We explore the hurdles needed to make it a realistic goal and give recommendations to achieve it utilizing the major advancements that have occurred over the past few years in the fields of engineering, communication etc. The biggest issues needed to be addressed are of financial investment, legal concerns, and availability of high-speed uninterrupted data connections.

Endovascular Versus Surgical Arteriovenous Fistulas: A Systematic Review and Meta-analysis

Rationale & Objective

To facilitate the process of dialysis for patients with kidney failure, an arteriovenous fistula (AVF) is created using either a surgical or percutaneous approach. We sought to compare the efficacy and procedural outcomes in creating an AVF percutaneously using Ellipsys (Avenu Medical) or WavelinQ (Becton Dickinson Medical) with surgery in all patients with kidney failure requiring a permanent AVF for dialysis.

Study Design

Systematic review and meta-analysis.

Setting & Study Populations

All patients requiring a permanent AVF for dialysis.

Selection Criteria for Studies

We included studies that compared either the Ellipsys device or WavelinQ directly with surgery to create an AVF for long-term dialysis.

Data Extraction

Two reviewers independently reviewed the studies and extracted the data. Conflicts were resolved with a discussion and approval from the senior author.

Analytical Approach

Fixed-effects or random-effects models were used to pool the fixed sizes and 95% CIs based on the level of heterogeneity.

Results

There was no statistically significant difference observed between surgical AVF and endovascular AVF when comparing the primary outcomes of procedural success (OR = 1.44; 95% CI, 0.35, 5.88; P = 0.61; I2 = 0%), complications (OR = 0.28; 95% CI, 0.06, 1.46; P = 0.13; I2 = 69%), and the secondary outcomes of interest that included follow-up time (mean difference [MD] = -17.71; 95% CI, -189.53, 154.12; P = 0.84; I2 = 94%), failure rate (OR = 1.03; 95% CI, 0.21, 5.13; P = 0.97; I2 = 85%), and time to 2-needle cannulation (MD = -5.40; 95% CI, -38.88, 28.08; P = 0.75; I2 = 0%). However, a statistically significant difference was seen among the 2 groups for procedural time (MD = -54.25; 95% CI, -59.78, -48.71; P < 0.001; I2 = 98%), number of interventions needed to maintain patency (OR = 1.73; 95% CI, 1.22, 2.45; P < 0.01; I2 = 94%), and primary patency rate (OR = 0.34; 95% CI, 0.23,0.52; P < 0.001; I2 = 0%).

Limitations

The total number of studies included in this review was limited, with 3 of the 4 included studies being retrospective and only 1 being prospective. There was a lack of heterogeneity and randomization.

Conclusions

Percutaneous fistula creation using Ellipsys or WavelinQ is a unique and safe alternative with outcomes comparable to surgery. Future studies are needed, including observational studies in current clinical practice, to evaluate the efficacy and outcomes of endovascular AVF creation in clinical populations.

Optimization of the acetic acid method for microfossil extraction from lithified carbonate rocks: Examples from the Jurassic and Miocene limestones of Saudi Arabia

An optimization experiment with different acid concentrations was carried out to assess the use of acid to minimum sustainable limits for the extraction of microfossils from indurated limestones. Two different limestone formations of Jurassic and Miocene ages were tested. Different concentrations of acid ranging from 50 to 100% and processing times varying from 2 to 10 h were tested for optimal recoveries. The acid residue recoveries show a similar trend for both formations. The weight percentage of residue with particle size >1 mm decreased as the acid concentration increased, especially in the 50–80% acid concentration range. On the other hand, the weight percentage of the smallest size particles > 0.063 mm increased as acid concentration increased. This means that the higher concentrations of acid dissolve more of the unnecessary large particles while the foraminifera, which comprise the sand fraction size, are left in the residue. Although higher acid concentrations with longer reaction times yielded better recoveries than with less reaction time, we recommended a 60% concentration of acetic acid and a reaction time of 10 h for optimal recovery of micropaleontological samples in Saudi Arabian carbonate rocks. By lowering the recommended concentration, the consumption of acid is reduced without compromising the recovery of microfossils.•

Acetic acid leaching method is applied on two different age limestone samples to extract foraminifera.

•

Different concentrations of acetic acid are tried and tested, and consensus is made on an optimum concentration of 60% for a submersion time of 10 h.

•

The sample recoveries are optimal while using this concentration for a time of 10 h.

Radiofrequency Ablation and Concomitant Sclerotherapy for the Treatment of Varicose Veins (VV): Perspectives from a Developing Country

Objectives/Background: With decreased patient downtime and reduction in health expenditures, endovascular treatments have become popular for the treatment of venous insufficiency. In this study, we assessed the outcomes of using radiofrequency ablation (RFA) and sclerotherapy for refluxing veins and incompetent perforators in a developing country.

Materials and Methods: Subjects were selected from an ongoing registry from October 15, 2015 to April 5, 2018. Patients were followed up until 6 months. Pre- and post-procedural Clinical, Etiologic, Anatomic, and Pathophysiologic (CEAP) scores were compared, and complications were documented and treated accordingly.

Results: In total, 102 limbs (n=97) with 76 great saphenous veins (GSVs) and 26 small saphenous veins (SSVs) underwent RFA, with 79% undergoing concomitant sclerotherapy. Mean follow-up time was 188 days (±33.16). Moreover, 59% were males and 41% females. At the end of follow-up, 99% of the legs had complete occlusion. Pre- and post-procedural CEAP scores were 4.21±1.5 and 3.36±1.7, respectively (p-value <0.001). Endovenous heat-induced thrombosis (EHIT) types 1, 2, 3, and 4 were found in 8.8%, 3.9%, 1.9%, and 0% of the legs, respectively. Most common complications were pain and tenderness (51%), bruising (18%), and paresthesia (7%).

Conclusion: RFA and sclerotherapy have proved to be safe and efficacious. Computed tomography (CT) venous mapping aids in delineating complex venous anatomy and in ruling out deep vein thrombosis (DVT) in cases with discrepancy on Doppler ultrasound. Strict compliance of procedural and post-procedural protocol can assure promising results and futuristic value.

2D:4D digit ratios in males and females and its correlation with simple reaction time: A cross sectional Study at Combined Military Hospital (CMH), Lahore, Pakistan

A cross-sectional study was conducted on 86 medical students between the ages of 18 to 25 years studying at the Combined Military Hospital (CMH) in Lahore, Pakistan. They were assessed for height, weight, digit length of the 2nd and 4th fingers of both hands and reaction time (response time to auditory stimulus as measured by BIOPAC). Of the 86 students, 42 (49%) were male and 44 (51%) were female, with a mean age of 19.55±1.017 and 19.86±0.905 years, respectively. There was a significant difference in the height, weight and Body Mass Index (BMI) of the students. The mean 2D:4D ratio for males on the left hand was 0.958±0.029 and for females it was 0.979±0.363 (p=0.004). The ratio for the right hand for males was 0.958±0.031 and for the females it was 0.977±0.035 (p=0.011). There was a significant correlation between the 2D: 4D ratio in the left hand with the reaction time in the dominant hand at random intervals (r= -0.240, p= 0.027) and with reaction time in the non-dominant hand at fixed intervals (r= -0.232, p= 0.03). Our results concluded that there is a negative correlation between the digit ratio and the reaction time. Those individuals who had lower digit ratios had faster reaction times than those who had higher digit ratios.

Injury and injury rates in Muay Thai kick boxing

OBJECTIVE

To determine the type and number of injuries that occur during the training and practice of Muay Thai kick boxing and to compare the data obtained with those from previous studies of karate and taekwondo.

METHODS

One to one interviews using a standard questionnaire on injuries incurred during training and practice of Muay Thai kick boxing were conducted at various gyms and competitions in the United Kingdom and a Muay Thai gala in Holland.

RESULTS

A total of 152 people were questioned, 132 men and 20 women. There were 19 beginners, 82 amateurs, and 51 professionals. Injuries to the lower extremities were the most common in all groups. Head injuries were the second most common in professionals and amateurs. Trunk injuries were the next most common in beginners. The difference in injury distribution among the three groups was significant (p< or =0.01). Soft tissue trauma was the most common type of injury in the three groups. Fractures were the second most common in professionals, and in amateurs and beginners it was sprains and strains (p< or =0.05). Annual injury rates were: beginners, 13.5/1000 participants; amateurs, 2.43/1000 participants; professionals, 2.79/1000 participants. For beginners, 7% of injuries resulted in seven or more days off training; for amateurs and professionals, these values were 4% and 5.8% respectively.

CONCLUSIONS

The results are similar to those found for karate and taekwondo with regard to injury distribution, type, and rate. The percentage of injuries resulting in time off training is less.

A safe and reliable method of intra-operative limb positioning

Images

An atypical presentation of spontaneous pneumomediastinum

Spontaneous pneumomediastinum is a rare condition and a most uncommon complication of sporting activity. We describe a case of spontaneous pneumomediastinum in a 17-year-old boy while playing football with no history of blunt trauma to the chest. The patient presented with symptoms and signs suggestive of an oesophageal perforation. The importance of correct investigations and subsequent management are discussed.

Orthopod or orthogod? A prospective questionnaire study of post-operative patients' impressions of orthopaedic surgeons

A questionnaire that challenged various stereotypes within the medical profession that are attached to orthopaedic surgeons was distributed to two groups of post-operative trauma in-patients: those with osteoporotic fractures and a much younger and active group. The results are presented here in a format that allows the reader to draw his/her own conclusions as to how 'orthopods' are perceived by their patients.

Blood pool SPECT and planar imaging in hepatic hemangioma

To determine the role of blood pool SPECT in hepatic hemangioma, 13 patients with suspected biliary disease but no prior history of neoplasm, in whom ultrasound examinations revealed one or more hepatic lesions, had blood pool SPECT followed by planar imaging of the liver. All 13 patients also had hepatic flow studies and early planar images. The 13 patients had 18 hemangiomas. The sensitivity for planar and SPECT for all hemangiomas was 12/18 (67%) and 17/18 (94%), respectively. All lesions greater than 3 cm were seen in the planar and SPECT images. For lesions 3 cm or smaller the sensitivity was 6/12 (50%) for planar and 11/12 (92%) for SPECT. This study suggests that blood pool SPECT of the liver may be the nuclear medicine study of choice in the diagnosis of hepatic hemangioma and that it has a considerably higher sensitivity than planar imaging in the detection of hemangiomas 3 cm or less in size.

A dynamic quality control phantom for radionuclide cardiology

A three-dimensional dynamic cardiac phantom suitable for quality control of equilibrium gated nuclear cardiographic procedures is described. Its flexible microprocessor based design provides an absolute standard for ejection fraction determination, ventricular volume quantitation, and physiologically gated single photon emission computed tomography. The cost of the phantom is comparable to that of commercially available phantoms suitable for ejection fraction quality control alone.

Simultaneous dual isotope studies in the diagnosis of infection

A simultaneous dual isotope technique incorporating computer subtraction for the diagnosis of bone, joint, or soft-tissue infection using [67Ga]citrate and [99mTc]MDP or sulfur colloid is described. Comparison of this technique with visual congruence or noncongruence of the two radionuclide images in 41 patients shows that the two techniques have identical sensitivity (93%) and specificity (92%) but the computer technique gave additional information in 17% of all cases (44% of abnormals) concerning the anatomic location of the infective focus which aided in the subsequent surgical management of the patient.