The Outcome Of Pedicled Medial Sural Artery Perforating Flap For Proximal Leg Reconstruction

BACKGROUND

Reconstruction of defects around the knee and proximal leg are difficult to reconstruct. Out of the multiple flaps described for reconstruction, the pedicled Medial Sural Artery Perforating Flap (MSAP) has recently gained popularity. We conducted this study to assess the clinical outcomes of pedicled MSAP for this purpose at our hospital.

METHODS

A descriptive case series was conducted from April 2022 to March 2023. All patients above 18 years with defects around the knee and proximal leg were included. Patients with tissue loss in the calf area were excluded.

RESULTS

A total of 14 patients were included. Twelve (86%) were males, while only 2 were females (14%). The mean age was 33.5 years (±8.76). The most common cause of the defect was trauma (n=11, 85%). The Mean distance of the distal-most perforator from the popliteal crease was 12.714 (±1.990) cm (range 9-16 cm). It was observed that the most distal perforator is usually present in a 2 cm radius of the medial musculo-tendinous junction of the gastrocnemius. Complications were seen in 2 (14%) patients. The mean duration of hospital stay was 4.2 (±0.96) days. Patients were followed up weekly for the first two weeks and then at 1, 3 and 6 months.

CONCLUSIONS

MSAP Flap is a reliable thin, long pedicled fasciocutaneous flap with low donor site morbidity and aesthetically good results for reconstruction around the knee and proximal leg.

Serum Vitamin D status in full term neonates with severe perinatal depression

BACKGROUND

Severe perinatal depression is a significant cause of mortality and morbidity in neonates. Vitamin D levels were observed to be low in mothers and their neonates with hypoxic ischemic encephalopathy in some studies, owing to its neuroprotective properties.

OBJECTIVE

Primary objective was to compare vitamin D deficiency state in full term neonates with severe perinatal depression and healthy term controls. Secondary objectives were to determine sensitivity and specificity of serum 25(OH)D<12 ng/mL in predicting mortality, development of hypoxic ischemic encephalopathy, abnormal neurological examination at discharge, and developmental outcome at 12 weeks of age.

MATERIAL AND METHODS

Serum 25(OH)D levels in full term neonates with severe perinatal depression and healthy controls were compared.

RESULTS

Serum 25(OH)D levels in severe perinatal depression and controls (n = 55 each group) were significantly different (7.50 ± 3.53 ng/mL vs 20.23 ± 12.70 ng/mL). At cut-off of <  12 ng/mL, serum 25(OH)D could predict mortality with 100% sensitivity and 17% specificity and poor developmental outcomes with sensitivity of 100% and specificity of 50% .

CONCLUSION

Vitamin D deficiency status at birth can serve as an effective screening tool and poor prognostic markers in term neonates with severe perinatal depression.

Comparison of Results After Facial Fat Grafting with Filtered and Washed Fat Versus Centrifuged Fat

Objectives: To compare the centrifuged fat versus filtered and washed fat for facial fat grafting in terms of patient satisfaction and subjective/objective appearance. Study Design: Comparative prospective study. Setting/Duration of Study: Department of Plastic Surgery, CMH, Rawalpindi Pakistan, from Aug 2017 to Jan 2020. Methodology: A total of 64 patients (32 in each group) requiring facial fat grafting who fulfilled the sample selection criteria were included in the study. Patients who had received facial cosmetic surgery previously had systemic comorbid or were suffering from active infections were excluded. Group-A patients received centrifuged fat grafts, while Group-B patients received filtered and washed fat grafts. All patients were followed for patient satisfaction and subjective/objective appearance. Results: In Group-A, 23 (71.9%), 3 (9.4%), and 6 (18.7%) patients were happy, just satisfied and unhappy with the overall results of the procedure, respectively, while these numbers were 25 (78.1%), 3 (9.4%), and 4 (12.5%) in Group-B (p=0.785). Patients’ evaluation of their general appearance post-procedure (scored out of 10) showed a mean score of 6.53 ± 2.46 in Group-A and 6.72 ± 2.19 in Group-B (p=0.749). Scoring for a general appearance by an expert panel showed a mean score of 6.72 ± 2.16 in Group-A and a mean score of 7.13 ± 1.81 in Group-B (p=0.418). Conclusion: There is no difference between centrifugation and filtration/washing of fat grafts for facial grafting regarding patient satisfaction and subjective/objective appearance.

Comparison of Outcomes Following Syndactyly Release with Grafts and Without Grafts

Objective: To compare the results of syndactyly release with or without graft in patients with simple syndactyly of hand. Study Design: Prospective comparative study. Place and Duration of Study: Department of Plastic Surgery, Combined Military Hospital Rawalpindi Pakistan, from Jul 2017 to Jun 2019 Methodology: Forty-five patients with simple syndactyly were included in this study. Group-1 had 20 patients whose syndactyly was released without using a skin graft. Group-2 had 25 patients whose soft tissue was covered with a fullthickness skin graft between the flaps post syndactyly release. Both groups were compared based on operative time, wound healing time, and when physiotherapy was started post operatively. Results: The results of our study showed that the mean operative time for the first group was 47.1 ± 4.5 minutes (range 35-60 minutes) and for the second group 90.5 ± 10.0 minutes (range 72-108 minutes) with a p-value <0.001. The wound healing time for the first group was 15.2 ± 1.3 days (12-18 days’ range) and for the second group was 22.5 ± 5.1 days (range 14-30 days) with a p-value <0.001. Post-operative physiotherapy was started earlier in the first group with an average of 20.6 ± 1.3 days (18-22 days’ range) as compared to the second group whose average time of the start of physiotherapy was 27.7 ± 4.4 days (range 20- 35 days) with p-value <0.001. Conclusion: Syndactyly release without a skin graft has a lesser operative time, early wound healing and an earlier start of physiotherapy than syndactyly release with......

Role of Magnetic Resonance Neurography on 3-Tesla in Brachial Plexus Injury Management

Objective: To study the effect of magnetic resonance neurography on 3 Tesla (MRN-3T) on the outcome of brachial plexus injury management. Study Design: Prospective comparative study.Place and Duration of Study: Department of Plastic Surgery, Combined Military Hospital Rawalpindi Pakistan, from Apr 2017 to Mar 2019. Methodology: Two groups of brachial plexus injury (BPI) were studied over two years. Group-A (n=29) cases whose operative intervention was decided based on history, examination, NCS/EMG and CT scan. Second group-B included (n=33) patients in which MRN-3T (magnetic resonance neurography on 3 Tesla) was the critical diagnostic tool. The comparison of preoperative diagnosis with intraoperative findings and outcome of surgery were made. Results: Out of 29 cases in group-A, 11 (37.93%) were explored. In these 11, neurolysis was done in one case, direct repair in one case, nerve grafting in 4 patients, nerve transfers with bridging grafts in 2 cases, whereas three patients had negative exploration. Of 33 cases in group-B, 21(63.64%) were explored. From these 21 cases, neurolysis was done in four patients; the direct repair was possible in 7 and in 10 cases bridging nerve grafts were used along with primary nerve transfers. Conclusion: MRN-3T brachial plexus has significantly improved the diagnosis, preoperative planning and surgical outcome of patients with brachial plexus injury.

Reconstruction Of Segmental Mandibular Loss With Vascularized Free Fibula Flapsn

BACKGROUND

Various methods for mandibular reconstruction have been demonstrated in literature from autogenous bone graft to free flaps and more recently tissue engineered materials. We share our experience of mandibular reconstruction with free fibular flap and evaluate its efficiency as a viable option for mandibular reconstruction.

METHODS

It was a cross-sectional study, conducted at Plastic surgery department combined military hospital, Rawalpindi. Study was carried out over a period of two years from November 2016 to November 2018. The data of demography, mode of presentation, pattern of reconstruction and procedural complications of the patients who underwent free fibula flap for segmental mandibular loss, were collected and analysed. Patients with segmental loss of mandible ranging from 6 to 15 cm and those who could sustain surgery were included in the study, while the patients with metastatic malignancy and recurrent disease were excluded from the study. Each patient was called for first follow up after 2 weeks then subsequent follow up after 1 month. Descriptive statistics were done with the help of SPSS-20.

RESULTS

A total of 57 patients with segmental mandibular loss treated with free fibula flap, fulfilling inclusion and exclusion criteria were included in this study. Thirtyeight patients were male while 19 were female with mean age 56±3 years. Cause of mandibular loss was malignancy in 52 (91.2%), trauma in 3 (5.2%), and ameloblastoma in 2 (3.5%) patients. Major complications like flap failure was seen in one (1.75%), bone exposure in 1 (1.75%) and recurrence was observed in 1 (1.75%) patient. Minor complications like hematoma, wound dehiscence and oro-cutaneous fistula were seen in 2, 1 and 3 patients respectively.

CONCLUSIONS

Free fibular flap shows good functional results with a high degree of consistency, and acceptable complications rate, so it should be the first choice for mandibular reconstruction.

Use of vascularised free fibula in limb reconstruction (for non-malignant defects)

The case series was conducted at the Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from June 2009 to May 2011, and comprised 19 patients in whom free fibula flap was performed for upper and lower limb reconstruction, using SPSS 16. Results showed that flap survival was 100%. One (5.2%) flap was re-explored for venous congestion and was salvaged. One (5.2%) patient of congenital pseudoarthrosis of tibia had a fracture of the fibula and was treated with external fixation. Average follow up was 8 months. Mean union time and full weight-bearing was 6.5 +/- 1.34 months (range 3-8 months) and 9 months, respectively. No recurrence of pseudoathrosis was observed until the last follow up, with only a 1.5 cm length discrepancy in one patient. The results proved that a microvascular free fibular flap heals rapidly, causes early functional recovery and it can be raised as an osteocutaneous flap.

Salivary progesterone as a biochemical marker to predict early preterm birth in asymptomatic high-risk women

OBJECTIVE

To evaluate salivary progesterone as a predictor of early preterm birth (PTB) and compare it with transvaginal sonographic (TVS) cervical length in asymptomatic high-risk women.

DESIGN

Prospective study.

SETTING

Departments of Obstetrics and Gynaecology and Biochemistry at UCMS & GTBH, Delhi, India.

SAMPLE

Ninety pregnant women.

METHODS

The progesterone concentration in saliva of asymptomatic pregnant women at high risk for preterm delivery was estimated by immunoassay, and cervical length was measured by TVS, at the first antenatal visit at 24-28 weeks of gestation, and then repeated 3-4 weeks later.

MAIN OUTCOME MEASURES

Early PTB, mean and critical cut-off values of salivary progesterone, and a diagnostic value comparison of salivary progesterone with TVS cervical length.

RESULTS

The mean value of salivary progesterone was significantly lower in all women who delivered at <37 weeks of gestation (n = 38), compared with the term group (n = 52; P < 0.001). Salivary progesterone decreased significantly from the first to the second visit, with the maximum decrease observed in women who delivered at <34 weeks of gestation (29.6%, 95% CI 17.8-41.4%, P < 0.002). The single predictive critical cut-off value for salivary progesterone was 2575 pg/ml, below which more than 80% of women delivered prematurely before 34 weeks of gestation, with sensitivity, specificity, and positive and negative predictive values of 83% (95% CI 58.6-96.4%), 86% (95% CI 75.9-93.1%), 60% (95% CI 38.6-78.8%) and 95% (95% CI 87.1-99.0%), respectively. The TVS cervical length decreased significantly (P < 0.001) in the women who delivered prematurely.

CONCLUSIONS

Low salivary progesterone concentration can be used for predicting early PTB in asymptomatic high-risk women.

Pulmonary dysfunctions, oxidative stress and DNA damage in brick kiln workers

Brick kilns in the suburban areas in developing countries pose a big threat to the environment and hence the health of their workers and people residing around them. The present study was planned to assess the lung functions, oxidative stress parameters and DNA damage in brick kiln workers. A total of 31 male subjects working in brick kiln, and 32 age, sex and socioeconomic status matched controls were included in the study. The lung volumes, capacities and flow rates, namely, forced expiratory volume in first second (FEV1), forced vital capacity (FVC), FEV1/FVC, expiratory reserve volume, inspiratory capacity (IC), maximal expiratory flow when 50% of FVC is remaining to be expired, maximum voluntary ventilation, peak expiratory flow rate and vital capacity were significantly decreased in the brick kiln workers. Increased oxidative stress as evidenced by increased malonedialdehyde levels and reduced glutathione content, glutathione S-transferase activity and ferric reducing ability of plasma were observed in the study group when compared with controls. Our results indicate a significant correlation between oxidative stress parameters and pulmonary dysfunction, which may be due to silica-induced oxidative stress and resulting lung damage.

Propoxur-induced acetylcholine esterase inhibition and impairment of cognitive function: attenuation by Withania somnifera

Propoxur (2-isopropoxyphenyl N-methylcarbamate) is widely used as an acaricide in agriculture and public health programs. Studies have shown that sub-chronic exposure to propoxur can cause oxidative stress and immuno-suppression in rats. Carbamates are also known to exhibit inhibitory effect on cholinesterase activity, which is directly related to their cholinergic effects. In the present study, the effect of Withania somnifera (Ashwagandha), a widely used herbal drug possessing anti-stress and immunomodulatory properties was studied on propoxur-induced acetylcholine esterase inhibition and impairment of cognitive function in rats. Male Wistar rats were divided into four groups. Group I was treated with olive oil and served as control. Group II was administered orally with propoxur (10 mg/kg b.wt.) in olive oil, group III received a combination of propoxur (10 mg/kg b.wt.) and W. somnifera (100 mg/kg b.wt.) suspension and group IV W. somnifera (100 mg/kg b.wt.) only. All animals were treated for 30 days. Cognitive behaviour was assessed by transfer latency using elevated plus maze. Blood and brain acetylcholine esterase (AChE) activity was also assessed. Oral administration of propoxur (10 mg/kg b.wt.) resulted in a significant reduction of brain and blood AChE activity. A significant prolongation of the acquisition as well as retention transfer latency was observed in propoxur-treated rats. Oral treatment of W. somnifera exerts protective effect and attenuates AChE inhibition and cognitive impairment caused by sub-chronic exposure to propoxur.

Pesticide-induced oxidative stress: perspectives and trends

Pesticide-induced oxidative stress as a possible mechanism of toxicity has been a focus of toxicological research for the last decade. Yet for certain pesticides, mechanisms leading to oxidative stress are only partly understood. Pesticide-induced oxidative stress is the final manifestation of a multi-step pathway, resulting in an imbalance between pro-oxidant and antioxidant defense mechanisms. Concomitantly, pesticide intoxication induces a derangement of certain antioxidant mechanisms in different tissues, including alterations in antioxidant enzymes and the glutathione redox system. In this article, we discuss the impact of certain factors that are important in the potentiation of pesticide-induced oxidative stress, immunotoxicity, and apoptosis. Understanding risk factors largely depends upon the cellular and molecular events underlying pesticide-induced stress in experimental animals. These factors must be considered in the safety/toxicity evaluation of any pesticide. The identification and characterization of plant products/drugs might be helpful for understanding the mechanisms of compensation and repair that are due to oxidative stress-induced injury. This paper reviews the nature of such damage, the cellular conditions in which it occurs, and oxidative-stress data that may be applied to the development of risk-assessment methods and models that are designed to reduce some of these uncertainties.

Evaluation of oxidative stress in some cases of argimone oil poisoning during a recent outbreak of epidemic dropsy in India

The study was designed to evaluate the oxidative stress and modulation of anti-oxidant enzymes in 10 accidental argimone oil poisoning cases admitted in a hospital in Delhi, India during a recent outbreak of epidemic dropsy in 1998. Serum malondialdehyde (MDA) level, oxygen free-radical scavenging enzymes such as superoxide dismutase (SOD) and catalase (CAT), and glutathione (GSH) and related enzymes, e.g. glutathione reductase (GR), glutathione peroxidase (GPx), gamma glutamyl transpeptidase (GGT) and glutathione-S-transferase (GST) in erythrocytes were assayed. The sanguinarine level in serum was measured by high-performance liquid chromatography. The serum MDA level was higher and the GSH level in erythrocytes was lower in argimone oil poisoning cases than those in controls. There was a significant decrease in SOD and GPx activities in erythrocytes of epidemic dropsy cases but no changes were observed in CAT, GR and GST assay. The depletion of GSH in erythrocytes, serum MDA level and clinical severity were dependent on serum sanguinarine level. The results indicate that sanguinarine (argimone oil) poisoning creates an oxidative stress in humans. The oxidative stress and differential modulation of anti-oxidant enzymes by sanguinarine might play a pathogenic role in epidemic dropsy, which suggests the incorporation of anti-oxidant drugs in the treatment protocol of the disease.

Influence of dietary ginger (Zingiber officinales Rosc) on antioxidant defense system in rat: comparison with ascorbic acid

Ginger (Z. officinale; 1% w/w) significantly lowered lipid peroxidation by maintaining the activities of the antioxidant enzymes--superoxide dismutase, catalase and glutathione peroxidase in rats. The blood glutathione content was significantly increased in ginger fed rats. Similar effects were also observed after natural antioxidant ascorbic acid (100 mg/kg, body wt) treatment. The results indicate that ginger is comparatively as effective as ascorbic acid as an antioxidant.

Influence of dietary ginger (Zingiber officinales Rosc) on oxidative stress induced by malathion in rats

Pesticide chemicals may induce oxidative stress leading to generation of free radicals and alterations in antioxidants or oxygen free radical (OFR) scavenging enzymes. Hence, the effect of subchronic malathion (O,O-dimethyl-S-1,2, bis ethoxy carbonyl ethyl phosphorodithioate) exposure was evaluated on lipid peroxidation, glutathione and related enzymes and OFR scavenging enzymes in albino rats. Administration of malathion (20 ppm) for 4 weeks increased the malondialdehyde (MDA) levels in serum, activities of superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) in erythrocytes and glutathione reductase (GR) and glutathione S-transferase (GST) in serum. However, it decreased the glutathione (GSH) level in whole blood. Concomitant dietary feeding of Zingiber officinales Rosc (ginger 1%, w/w) significantly attenuated malathion induced lipid peroxidation and oxidative stress in these rats. These results indicate the possible involvement of free radicals in organophosphate-induced toxicity and highlight the protective action of ginger, an indigenous medicinal plant product.

Biochemical studies on combined effects of garlic (Allium sativum Linn) and ginger (Zingiber officinale Rosc) in albino rats

Adult male rats of wistar strain were fed diets containing (w/w) 2% garlic (group II), 0.5% ginger (group III) and a combination of garlic plus ginger (group IV) for 4 weeks to study their effects on serum biochemical parameters. A significant increase in body weight was observed in all groups except that fed ginger (group III). A significant decrease in blood glucose, serum total cholesterol and serum alkaline phosphatase were found in all groups, whereas serum triglycerides were decreased significantly only in group IV. Serum HDL-cholesterol was significantly increased only in groups III and IV. However, HDL-cholesterol, VLDL-cholesterol and atherogenic index were significantly decreased in animals fed with combination of the two, compared to garlic/ginger alone. Hence, a combination of garlic and ginger is much more effective in reducing blood glucose and serum lipids.

Effect of inducers on hepatic microsomal mixed function oxidase system of male rats during food restriction

Phenobarbital (PB; 80 mg/kg, ip) or 3-methylcholantrene (3-MC; 20 mg/kg, ip) was administered to Wistar male rats at the end of the feeding period of 30 days and the effects of food restriction (FR) and FR followed by inducer treatment on hepatic drug metabolizing enzymes, microsomal electron transport components, NADPH dependent lipid peroxidation and glutathione-s-transferase activities were studied. In both, PB and 3-MC treatment, the magnitude of increase in microsomal protein content, cytochrome b5 and aminopyrine N-demethylase (APND) activity was less in FR animals than in ad libitum fed; while cytochrome P-450 levels and activities of cytochrome c reductase and acetanilide hydroxylase (ACOH) were higher in FR animals. NADPH dependent lipid peroxidation and cytosolic glutathione-s-transferase activity were also enhanced due to PB and 3-MC treatment but the magnitude of increase was less in FR animals. The ACOH activity increased to a greater extent than APND activity in FR animals following PB and 3-MC treatment. It is suggested that the response to inducers in the FR animals differ from that in the ad libitum fed rats.

Immunotoxicity of tri-n-butyltin oxide (TBTO) and tri-n-butyltin chloride (TBTC) in the rat

In a 1-month feeding trial, pure and commercial tri-n-butyltin oxide (TBTO) and tri-n-butyltin chloride (TBTC) were fed to rats at concentrations of 5 ppm and 25 ppm. At all times, the mean body weight gain and the food consumption was significantly less in rats treated with 25 ppm pure TBTO or pure TBTC as compared to control rats or rats receiving commercial TBTO. Histological examination of the thymus of rats treated for 7 days with TBTO showed atrophy with severe lymphocytic depletion in the cortex. After 28 days of exposure, most of the lesions reversed and the thymus became markedly smaller than in control rats, both in absolute terms and in relation to body weight. Seven days of exposure to TBTO increased liver weight but this change was reversed during a further 3-week exposure. Tin concentrations were the highest in livers and kidneys. Concentrations in the thymus were less than one-fifth of hepatic values. Changes in the rats treated with the commercial TBTO were very similar. Rats treated with TBTC showed lower tin levels and less immunotoxicity as compared to those treated with TBTO.

Hepatic nuclear and cytoplasmic effects following intermittent feeding of rats with di(2-ethylhexyl) phthalate

The effects on rats of intermittent feeding with the peroxisome proliferator and hepatocarcinogen di(2-ethylhexyl) phthalate (DEHP) have been examined. Male Wistar rats were fed for alternate 7-day periods diets containing 20,000 ppm DEHP or the control diet. The rats were examined 3 days after the start or recommencement of administration of the DEHP-containing diet or after 7 days on the control diet. After the commencement or recommencement of feeding with DEHP the expected increases in liver weight and in the number of peroxisomes were found. The increase in liver: body-weight ratio in response to administration of DEHP-containing diets was greater in rats that had been previously exposed to the compound, but re-administration of DEHP had a less marked effect on the increase in peroxisome number. Morphometric analysis showed that administration of DEHP-containing diets resulted in an increase in cell number in the liver and that a fall in the cell number occurred after the rats had been returned to the control diet for 7 days. Analysis of nuclear size gave results consistent with an increase in tetraploid hepatocytes after treatment with DEHP which was reversed when the rats were returned to control diet.