Snatching: A modified cosmetic technique in pterygium surgery without using scalpel

AIM

To evaluate the cosmetic surgical outcomes of primary corneal pterygia excision using the avulsion (snatching) technique.

METHODS

A prospective, interventional study included twenty-five eyes of 25 patients with primary pterygium underwent excision were followed up for at least 6 months. In all patients, snatching (modified avulsion) technique was utilised to avulse the pterygium head off the corneal surface and remove any residual fibres by Colibri without need for keratectomy with a scalpel.

RESULTS

The study involved 25 eyes of 25 patients with an average age of 42.5±56.5 years. The mean follow-up was 6 months. One-week post-op, 8 patients (32%) reported they can tell which is the operated eye but looked untouched while 17 (68%) patients reported that the operated eye looked red but is accepted. Twenty patients (80%) reported some discomfort while the remaining 5 patients (20%) reported no discomfort. Cornea examination showed a clear cornea in 18 eyes (72%), 6 eyes (24%) had mild keratitis, and 1 eye (4%) had clouding at the surgical site. Over an average of six months post-op follow-up period, all the patients (100%) reported they cannot tell which eye had the surgery and none (0%) of them reported discomfort. Examination of the cornea was clear in 24 (96%) eyes, but 1 (4%) eye had mild keratitis.

CONCLUSION

Snatching (modified avulsion) technique was found to be effective, safe, and presents decent aesthetic appearance for the management of primary corneal pterygia when safety points are firmly followed.

Clinical utility of abbreviated breast MRI based on diffusion tensor imaging in patients underwent breast conservative therapy

PURPOSE

To evaluate the added value of the diffusion tensor imaging (DTI) parameters to abbreviated breast MRI protocol in differentiating recurrent breast cancer from post-operative changes in cases of breast conservative surgery (BCS).

METHODS

This prospective study was approved by our institutional review board. Written informed consent was obtained in all patients. 47 female patients (mean age, 49 years; range, 32-66 years) that previously underwent breast conservative surgery with a palpable mass were included in this study (62 breast lesions). Two abbreviated MRI protocols were compared using 1.5 Tesla MRI, AB-MRI 1 (axial T1, T2, pre-contrast T1, 1st post-contrast and subtracted images) and AB-MRI 2 (same sequences plus adding DTI). In both protocols, the wash-in rate was calculated. Histopathology was used as the standard of reference. Appropriate statistical tests were used to assess sensitivity, specificity, and diagnostic accuracy for each protocol.

RESULTS

The mean total acquisition time was of 6 min for AB-MRI 1 and 10 min for AB-MRI 2 protocols while the mean interpretation time was of 57.5 and 75 s, respectively. Among analyzed DTI parameters, MD (mean diffusivity) showed the highest sensitivity (96.43%) and specificity (91.18%) (P value =  < 0.001). FA (fractional anisotropy), AD (axial diffusivity) and RD (radial diffusivity) showed sensitivity = (78.57%, 82.14% and 85.71%), specificity = (88.24, 85.29% and 79.41%), respectively, P value (< 0.001).

CONCLUSION

DTI may be included in abbreviated MRI protocols without a significant increase in acquisition time and with the advantage of increasing specificity and clinical utility in the characterization of post-conservative breast lesions.

Prediction of local breast cancer recurrence after surgery: the added value of diffusion tensor imaging

Background

There is considerable overlap between benign postoperative changes and recurrent breast cancer imaging features in patients surgically treated for breast cancer. This study aims to evaluate the value of adding multiple diffusion tensor imaging (DTI) parameters, including mean diffusivity (MD), fractional anisotropy (FA), radial diffusivity (RD), axial diffusivity, (AD), and relative anisotropy (RA) in differentiating breast cancer recurrence from postoperative changes in patients who were surgically treated for breast cancer and to also evaluate the role of these parameters in characterizing the different pathologies seen in the postoperative breast.

Results

This is a prospective study that was performed on female patients who were surgically treated for breast cancer. The study was done on 60 cases having 77 breast lesions. (Sixty-two of them were described as mass lesions and 15 of them were described as non-mass enhancement on MRI.) Among analyzed DTI parameters, MD showed the highest sensitivity (97.1%), specificity (88.1%), and accuracy (92.2%) in predicting recurrent breast cancer. FA, AD, and RD showed sensitivity (77.1%, 85.7%, and 88.6%) and specificity (83.3%, 83.3%, and 73.8%) in predicting recurrent breast cancer, respectively. The median MD values were lower in grade III recurrent breast cancers when compared to its values in recurrent grade II breast cancers and recurrent DCIS (0.6 × 10–3 mm2/s vs. 0.8 × 10–3 mm2/s and 0.9 × 10–3 mm2/s), respectively. FA also showed median values in grade III recurrent breast cancer higher than its values in grade II recurrent breast cancer and recurrent DCIS (0.6 vs. 0.5 and 0.39), respectively. The sensitivity, specificity, PPV, NPV, accuracy, F1 score, and MCC of DCE-MRI alone versus DCE-MRI plus combined DTI parameters were 88.6% versus 100%, 88.1% versus 90.5%, 86.1% versus 89.7%, 90.2% versus 100%, 88.3% versus 94.6%, 87.3% versus 94.6%, and 76.5% versus 90.1%, respectively.

Conclusions

DTI may play an important role as a complementary method to discriminate recurrent breast cancer from postoperative changes in patients surgically treated for previous breast cancer.

Primary Epstein-Barr virus infection, seroconversion, and post-transplant lymphoproliferative disorder in seronegative renal allograft recipients: a prospective cohort study

BACKGROUND

Epstein-Barr virus (EBV)-seronegative renal transplant recipients are at risk of post-transplant lymphoproliferative disorder (PTLD). We compared primary EBV infection, seroconversion, and PTLD in EBV-seronegative patients who received renal allograft from seropositive or seronegative donors (D+/R- and D-/R-, respectively).

METHODS

We prospectively followed 25 D+/R- and 8 D-/R- recipients. We followed patients from January 1999 to June 2009 with clinical visits, monthly EBV polymerase chain reaction tests, and serologic tests for a period of 1 year after kidney transplantation and on an individual basis thereafter.

RESULTS

Three patients (9%) developed PTLD including 2 early-onset (<12 months) and 1 late-onset (>12 months) disease. In D+/R- and D-/R- patients, the frequencies of PTLD (8% vs. 12.5%, P = 0.7), EBV seroconversion (64% vs. 50%, P = 0.4), and EBV viremia (40% vs. 25%, P = 0.6) were not significantly different. Clinical, serologic, and virologic surveillance as well as reduction in immunosuppression after evidence of primary EBV infection resulted in a PTLD rate of 9%, despite a seroconversion rate of 60.6%. Rate of graft loss after reduction in immunosuppression was 10% (2 of 20), which was not significantly different from 13 patients without EBV seroconversion (no graft loss, P = 0.5). Rates of viremia, seroconversion, and PTLD in D+/R- and D-/R- patients appear to be similar.

CONCLUSIONS

The incidence of PTLD in renal transplants ranges from 0.5% to 2.9%. Our data show a significantly higher rate in EBV-seronegative renal allograft recipients, suggesting the need for close surveillance. Our data also suggest that donors for EBV-seronegative recipients may be accepted irrespective of positive or negative serostatus, with ongoing surveillance important in either circumstance.

Pregnancy following gastric bypass surgery (Roux-en-Y) for morbid obesity

Morbidly obese women are at increased risk of obstetric complications and poor neonatal outcomes. Gastric bypass surgery is being performed with increased frequency in reproductive-aged women to treat morbid obesity. Both maternal and fetal complications have been reported in women who underwent gastric bypass surgery.

Current recommendations advise delaying pregnancy for at least 1 year following bariatric surgery. This guideline is meant to discourage women from becoming pregnant during the rapid weight loss phase of the first post-surgical year. Pregnancy during this time could lead to a malnourished fetus, due to some protein malnutrition, possibly resulting in complications such as low birth weight or malformation. However, data validating this concern are lacking.

We report a case of 37-year-old woman who had laparoscopic bypass surgery, as treatment for morbid obesity, 6 months prior to her pregnancy with good outcome despite the short duration between gastric bypass surgery and pregnancy.

Apparent diffusion coefficient values of mediastinal masses in children

OBJECTIVE

Compare apparent diffusion coefficient (ADC) values between benign and malignant mass lesions in a cohort of children referred for imaging of a mediastinal mass.

MATERIAL AND METHODS

Prospective study including 24 consecutive children (11 boys, 13 girls aged 5 months to 16 years). All underwent echo planar diffusion weighted MR imaging of the mediastinum with b-factors of 0 and 600 s/mm(2). Apparent diffusion coefficient (ADC) values were calculated and correlated with the surgical finding or biopsy.

RESULTS

The mean ADC value of malignant mediastinal tumors was 0.91 (S.D., 0.17) × 10(-3) mm(2)/s and of benign lesions 1.8 (S.D., 0.33) × 10(-3) mm(2)/s. There was significant different in the ADC value between malignant tumors and benign mediastinal tumors (P<0.001). Selection of 1.2 × 10(-3) mm(2)/s as a threshold value for differentiating malignant from benign mediastinal masses has an accuracy of 93%, sensitivity of 92%, specificity of 94%, positive predictive value of 94%, negative predictive value of 92% and area under the curve of 0.962.

CONCLUSION

Apparent diffusion coefficient value is a promising non-invasive parameter for assessment of mediastinal mass in children.

The value of sex hormone binding globulin (SHBG) in predicting treatment response in polycystic ovary syndrome (PCOS)

BACKGROUND

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterised by chronic anovulation, hyperandrogenism and polycystic ovaries on ultrasound. Patients commonly show features of the metabolic syndrome and insulin resistance. It has been shown that treatment with the insulin sensitising agent metformin can lead to improvements in symptoms in some but not all patients. The aim of the study was to assess whether sex hormone binding globulin (SHBG) (a surrogate marker of insulin resistance) could predict a positive response to metformin treatment in women with PCOS.

METHODS

Medical notes of patients who presented to the gynaecology clinic at Southmead Hospital, Bristol with suspected PCOS were reviewed. Data collected included clinical symptoms and signs of hyperandrogenism, markers of PCOS in the family and obstetric history, biochemical markers and outcome of any treatment.

RESULTS

A total of 66 patients were included in the study; 45 were classified as PCOS positive. In this group, patients who responded to metformin treatment had significantly lower SHBG levels compared to those who did not (median SHBG 37.5 nmol/L compared to 56.0 nmol/L) (p = 0.016, Mann-Whitney U-test). Patients with lower SHBG tended to have a better treatment outcome than those with higher values (odds ratio 0.983, 95% confidence interval 0.963-1.002, p = 0.079).

CONCLUSIONS

Patients with a positive response to metformin treatment had significantly lower pre-treatment SHBG levels. For every unit increase in SHBG, the odds of a patient having a positive outcome to metformin treatment fell by a factor of 0.983.

Role of diffusion-weighted echo-planar MR imaging in differentiation of residual or recurrent head and neck tumors and posttreatment changes

BACKGROUND AND PURPOSE

The purpose of this work was to evaluate whether diffusion-weighted MR imaging can be used in differentiating residual or recurrent head and neck tumors from postoperative or postradiation changes.

MATERIALS AND METHODS

This study included 32 patients clinically suspected for recurrent head and neck tumor after surgery (n=3), radiation therapy (n=13), or both (n=16). Diffusion-weighted MR imaging was done by using a single-shot spin-echo echo-planar sequence. The apparent diffusion coefficient (ADC) value of the suspected lesion was calculated and correlated with pathologic results.

RESULTS

Adequate diffusion-weighted MR images and ADC maps were obtained in 30 patients (93.8%). The mean ADC value of residual or recurrent lesions (1.17 +/- 0.33 x 10(-3) mm(2)/s) was less than that of posttherapeutic changes (2.07 +/- 0.25 x 10(-3) mm(2)/s), and the difference was statistically significant (P<.001). When an ADC value of 1.30 x 10(-3) mm(2)/s was used as a threshold value for differentiation, the best results were obtained with an accuracy of 87%, sensitivity of 84%, specificity of 90%, positive predictive value of 94%, and negative predictive value of 76%.

CONCLUSIONS

Diffusion-weighted MR imaging with ADC measurement has promising results for differentiating residual or recurrent head and neck tumors from postoperative or postradiation changes.

Oral health and nutritional status in Egyptian elderly

A cross-sectional sample of 253 ambulatory elderly Egyptians (99 males and 154 females) of minimal age, 60 y, living in the metropolitan Cairo area was investigated. Nutritional status assessment was based on body weight, mid-upper arm circumference and skinfold thickness. Additionally, three nutritional indices, namely body mass index, index of adiposity and index of muscularity, were computed. The oral cavity was examined clinically to evaluate the number and health condition of teeth present. Results showed that the anthropometric nutritional indicators were higher than expected, however, they decreased by age in both sexes. In addition, the values of body mass index and index of adiposity in females were significantly higher than in males, while the reverse was observed in regards to muscularity index (p < 0.05). The three nutritional indices in dentate subjects were slightly higher than those in edentulous ones. Moreover, within the dentate groups there was a tendency for increased values of these indices by the increasing number of healthy teeth.

Auricular acupuncture and auricular medicine

Auricular acupuncture is a treatment system based on normalizing the body's pain and dysfunction through stimulation of points on the ear. Resulting amelioration of pain and illness is believed to be through the reticular formation through the sympathetic and parasympathetic nervous systems. Scalp acupuncture is one of the newest systems of microacupuncture therapy and anesthesia developed in the People's Republic of China; here the needle is inserted and stimulated in the areas directly above the corresponding nerve center. Hand acupuncture is a recently developed type of microreflex system that can be used exclusively or in addition to body acupuncture. Hand acupuncture is indicated to treat all ailments for which acupuncture is traditionally recommended.

DREZ coagulations for deafferentation pain related to spinal and peripheral nerve lesions: indication and results of 79 consecutive procedures

During a 16 years' period, a total of 79 dorsal root entry zone coagulations were performed in 68 patients for deafferentation pain. Of the 23 patients who underwent surgery for pain due to cervical root avulsion, 18 (82%) had a good (12) or fair (6) pain relief (mean follow-up period 51 months). Twelve (57%) patients with spinal cord injuries noted continuous pain reduction (10 good, 2 fair; mean follow-up 52 months). Continuous marked improvement for longer periods was reported only by 2 out of 10 patients with postherpetic neuralgia and 1 out of 7 patients with painful states due to other brachial plexus lesions and none out of 5 with spinal cord lesions (3) and phantom limb pain (2).

Results of DREZ coagulations for pain related to plexus lesions, spinal cord injuries and postherpetic neuralgia

The results of 58 dorsal root entry zone (DREZ) thermocoagulation procedures in 51 patients are reported. The postoperative analgesic effect was judged by the patients as being good (more than 75% pain reduction), fair (25-75% pain reduction) or poor (less than 25% pain reduction). Of the 14 patients who underwent surgery for pain due to cervical root avulsion, 10 (77%) had permanently good (8) or fair (2) pain relief after a mean follow up period of 76 months, another 2 (15%) experienced recurrence to the preoperative level (initially 1 good, 1 fair) after more than 2 and 4 years, respectively. Twenty two paraplegics were operated upon, 3 of whom twice, for intractable pain. After a mean observation time of 54 months, continuing pain relief was reported by 12 (55%) patients (11 good, 1 fair), and one (initially fair) had recurrent pain after 8 months. All 3 (early) re-operations remain successful for an average period of 75 months. Poor results were seen especially in cases of associated spinal cord cysts (5 out of 7), despite combined drainage, and in patients with diffuse pain distribution (5 out of 6). Continuous marked improvement for longer periods (mean follow up: 52 months) after DREZ lesions was reported only by 2 out of 10 patients with postherpetic neuralgia (12 procedures) and by 1 out of 5 with painful states due to radiation-induced brachial plexopathy (2), previous surgery (2) and malignant tumour infiltration of the brachial plexus (1). Three patients died postoperatively due to acute cardiac failure (2) and pulmonary embolism (1). Major complications, especially permanent gait disturbances were observed in 6 patients (12%) following primary procedures and in 2 out of 7 patients after re-operations, most of them suffering from postherpetic neuralgia. Minor neurological deficits were noted in 9 cases (18%). DREZ lesions revealed to be an effective procedure in patients with pain related to root avulsion and paraplegia. In contrast, it seems to be less successful for painful states due to other plexus lesions or postherpetic neuralgia.

Transcriptional polarity enhances the contribution of the internal promoter, ilvEp, in the expression of the ilvGMEDA operon in wild-type Escherichia coli K12

The ilvG gene of Escherichia coli K12 produces a cryptic peptide as a result of a frameshift mutation located approximately halfway through the coding sequence of the gene. This mutation is polar on expression of the downstream genes (ilvEDA) because transcription terminates within the translationally barren region that results from the mutation. Contrary to this, Salmonella typhimurium produces a full-length functional ilvG protein and is therefore unlikely to manifest this polarity event. E. coli K12 strains with mutations either in the ilvG gene (which restores a full-length protein) or in the rho gene, relieve this polarity suggesting that this event couples transcription and translation in a manner analogous to attenuation. This paper describes experiments designed to determine the molecular nature and location of the polarity event. Most significantly, this work establishes the contribution of the internal promoter (ilvEp, located downstream of the polar site) to the expression of the downstream genes in E. coli K12 wild-type and mutant strains (ilvG) and by extension to the role of this promoter in S. typhimurium. This analysis suggests that ilvEp contributes as much as 90% of ilvEDA expression in wild-type E. coli K12 and only 15% in wild-type S. typhimurium when grown under non-repressing conditions.

Spacing in the human deciduous dentition in relation to tooth size and dental arch size

Dental casts of 243 preschool children, 129 males and 114 females, aged 2.5-5.5 years, were analysed for the presence of interdental spaces, mesiodistal crown diameters, intercanine width, intermolar width and arch length (circumference). The prevalence of primate spaces (diastemata mesial to the upper canines and distal to the lowers) varied from 65 to 90% by arch and sex; it was lowest in the lower arch especially in females, and highest in the upper. These prevalences did not increase with age; however, other spaces which usually occur between incisors may develop towards the end of the deciduous dentition, commonly in arches with primate spaces. Generally, spacing of the deciduous anterior teeth was significantly related to mesiodistal crown diameter and intercanine arch width. The crowns were significantly broader and the arches significantly narrower in cases with no spaces than in those where spaces existed. As the genetic programming for tooth size also normally affects arch size, greater discrepancies between mesiodistal crown diameters of the deciduous anterior teeth and their permanent successors are probably associated with more deciduous arch spacing.