Comparison of casting versus elastic nail for the treatment of pediatric tibial diaphyseal fractures

Objective: To assess outcomes of Titanium elastic nail (regarding radiologic union, a discrepancy of limb length, malalignment, pain and complications) in treating pediatric tibial fractures in comparison with the traditional Casting method.Methodology: This randomized controlled trial study was conducted in Department of Orthopaedics, Shaikh Zayed Hospital, Lahore through emergency /Outdoor patient department from May 2018 to Feb 2019. The total number of patients were categorized into two groups, 14 each group. In Group A, patients underwent treatment by elastic nails and patients in group B, underwent treatment with cast method. Post op X-Rays (serial) were done and Leg length inequality, Malalignment, pain and radiological union were assessed radiologically. Follow up of the patients was done in the outpatient department of Orthopaedic department after 1,3 and 6 months. The comparison for this among both groups was done by using Chi-square test. P value ≤ 0.05 was considered significant.Results: The mechanism of injury was statistically same in both groups, p-value > 0.05. In group-A, 7(50.0%) cases had Transverse, 4(28.6%) had Oblique and 3(21.4%) cases had comminuted fracture while in group-B there were 5(35.7%) cases who had Transverse, 2(14.3%) had Spiral, 4(28.6%) cases had Oblique and 3(21.4%) cases had Comminuted fracture, p-value > 0.05. In both groups, the leg length inequality, frequency of malalignment, pain severity and complications were statistically same, p-value was > 0.05.Conclusion: Similar outcomes of Titanium elastic intramedullary nailing as compared to cast application in terms of bone union, alignment and infection rates

Design and characteristics of the prophylactic intra-operative ventricular arrhythmia ablation in high-risk LVAD candidates (PIVATAL) trial

BACKGROUND: The use of a Left Ventricular Assist Device (LVAD) in patients with advanced heart failure refractory to optimal medical management has progressed steadily over the past two decades. Data have demonstrated reduced LVAD efficacy, worse clinical outcome, and higher mortality for patients who experience significant ventricular tachyarrhythmia (VTA). We hypothesize that a novel prophylactic intra-operative VTA ablation protocol at the time of LVAD implantation may reduce the recurrent VTA and adverse events postimplant. METHODS: We designed a prospective, multicenter, open-label, randomized-controlled clinical trial enrolling 100 patients who are LVAD candidates with a history of VTA in the previous 5 years. Enrolled patients will be randomized in a 1:1 fashion to intra-operative VTA ablation (n = 50) versus conventional medical management (n = 50) with LVAD implant. Arrhythmia outcomes data will be captured by an implantable cardioverter defibrillator (ICD) to monitor VTA events, with a uniform ICD programming protocol. Patients will be followed prospectively over a mean of 18 months (with a minimum of 9 months) after LVAD implantation to evaluate recurrent VTA, adverse events, and procedural outcomes. Secondary endpoints include right heart function/hemodynamics, healthcare utilization, and quality of life. CONCLUSION: The primary aim of this first-ever randomized trial is to assess the efficacy of intra-operative ablation during LVAD surgery in reducing VTA recurrence and improving clinical outcomes for patients with a history of VTA

Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit.

BACKGROUND: The appropriate use of pulmonary artery catheters (PACs) in critically ill cardiac patients remains debated. OBJECTIVES: The authors aimed to characterize the current use of PACs in cardiac intensive care units (CICUs) with attention to patient-level and institutional factors influencing their application and explore the association with in-hospital mortality. METHODS: The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Between 2017 and 2021, participating centers contributed annual 2-month snapshots of consecutive CICU admissions. Admission diagnoses, clinical and demographic data, use of PACs, and in-hospital mortality were captured. RESULTS: Among 13,618 admissions at 34 sites, 3,827 were diagnosed with shock, with 2,583 of cardiogenic etiology. The use of mechanical circulatory support and heart failure were the patient-level factors most strongly associated with a greater likelihood of the use of a PAC (OR: 5.99 [95% CI: 5.15-6.98]; P < 0.001 and OR: 3.33 [95% CI: 2.91-3.81]; P < 0.001, respectively). The proportion of shock admissions with a PAC varied significantly by study center ranging from 8% to 73%. In analyses adjusted for factors associated with their placement, PAC use was associated with lower mortality in all shock patients admitted to a CICU (OR: 0.79 [95% CI: 0.66-0.96]; P = 0.017). CONCLUSIONS: There is wide variation in the use of PACs that is not fully explained by patient level-factors and appears driven in part by institutional tendency. PAC use was associated with higher survival in cardiac patients with shock presenting to CICUs. Randomized trials are needed to guide the appropriate use of PACs in cardiac critical care

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Atpical Guillain–Barré Syndrome - Bilateral sixth nerve palsy and bilateral facial palsy with ascending upper extremity and descending lower extremity paralysis, a rare entity

Background: Guillain–Barré syndrome (GBS) is an acute immune-mediated polyneuropathies, which has many typical and atypical clinical presentations. The original description of “ascending paralysis” is the most commonly observed variant. Atpical GBS is a heterogenous disorder with various atypical features. Case report: We report a case of 30 year old male with acute onset of double vision and is more when looking far away. This was followed with deviation of angle of mouth towards right side followed by other side involvement This was followed by slurred speech and increasing upper extremity weakness that had progressed to proximal lower extremities, with no significant past medical history.Neurological examination showed bilateral sixth nerve palsy with bilateral seventh nerve palsy, symmetrical upper greater than lower limb weakness with absent deep tendon reflexes. There was no respiratory or bulbar muscle involvement. NCS examination revealed demyelinating polyradiculopathy. Cerebrospinal fluid examination was suggestive of albumin-cytological dissociation supporting GBS. MRI brain and orbit with contrast imaging showed no abnormalities. MRI cervical spine with screening of rest of spine showed no abnormalities. Diagnosis of a rare atypical GBS was clinically made. Patient was started on immunoglobins. Patient responded to treatment. Conclusion: Atypical presentation of GBS may delay diagnosis and treatment. Diagnosis can be confirmed by comprehensive clinical examination, followed by nerve conduction tests and CSF analysis. Objective of this case is to highlight rare and atypical clinical presentation of GBS, which can cause delay in diagnosis and further management

Osteoblastoma of the jaws: report of a case and review of literature

Benign osteoblastoma (OB) is a rare tumor of bone representing less than 1% of all tumors of the maxillofacial region. Vertebral column, sacrum, long bones, and calvarium are more frequent sites of this tumor. Clinically, patients present with pain and swelling. Histologically, contain a well vascularized, osteoblastic connective tissue stroma and occasionally, osteoclasts along with osteoid and varying degrees of calcification, as well as immature bone may also be noted. The main aim of this report is present a case of OB occurring in the mandible and a brief review of English Medical Literature of this tumor. Many bone-producing lesions possess some overlapping clinical, radiographic or histopathological findings similar to osteoblastoma. Understanding and correlating all features helps in correct diagnosis and adequate management of this rare entity. Hence, osteoblastoma has to be differentiated from other bone lesions for correct diagnosis

An asymptomatic presentation of gastric outlet obstruction secondary to congenital antral web in an extremely preterm infant

A case of gastric outlet obstruction secondary to antral web in a preterm infant born at 25 weeks gestation is reported. The diagnosis was suspected on plain abdominal radiograph performed postnatally to confirm position of the umbilical catheters. On the initial radiograph (at age 1 h), a dilated stomach with a gasless abdomen was noted. A repeat chest and abdominal radiograph performed 24 h later due to increased ventilatory requirements showed persistence of this finding and upper gastrointestinal obstruction was suspected. An upper gastrointestinal contrast study confirmed the diagnosis of gastric outlet obstruction. The infant underwent a curative pyloroplasty on day 11 of life. The postoperative course was uneventful

Renal function in a mouse model of acute kidney injury is improved by myristoylated protein kinase c epsilon inhibitor

Introduction: Delayed graft function (DGF) is a post-transplant acute kidney injury that is caused by prolonged ischemia resulting in oxidative stress-mediated damage during reperfusion. Previously, myr-PKCε- reduced infarct size and serum H2O2 when administered upon reperfusion in an ex vivo rat heart ischemia-reperfusion (I/R) model and in vivo hindlimb I/R model, respectively. Myristoylated protein kinase C epsilon peptide inhibitor (N-myr-EAVSLKPT; myr-PKCε-) is known to confer protection by inhibiting superoxide production from uncoupled endothelial nitric oxide synthase and mitochondrial ATP-sensitive K+ channels. We hypothesized myr-PKCε- would attenuate renal injury, characterized by elevated serum creatinine (Cr) and decreased glomerular filtration rate (GFR), compared to a scrambled control peptide (N-myr-LSETKPAV; myr-PKCε-scram). Methods: Renal pedicles of male C57BL/6J mice (25–30g) were clamped bilaterally for 19 min. Myr-PKCε- or myr-PKCε-scram (1.6 mg/kg; 20 µM blood) were administered into the tail vein 1 min before unclamping. Cr was measured at baseline, 24h, 72h, and 96h post-injury. GFR was determined with fluorescein-isothiocyanate (FITC)-Sinistrin renal clearance. Data were evaluated by unpaired Student’s t-test. Results: This bilateral 19 min renal ischemia resulted in significant GFR reduction (Fig. 1) and Cr elevation (Fig. 2) throughout the post-ischemic time-course. Myr-PKCε- (n=6) significantly improved both GFR and Cr at 72h and 96h compared to myr-PKCε-scram control (n=4, p\u3c0.05). Conclusions: Results support the hypothesis that Myr-PKCε- improves kidney function after 19-min warm ischemic injury. Immunolabeling of PKCε, Kim-1, and NGAL biomarkers will be used to further evaluate PKCε localization and the extent of Myr-PKCε- protection against renal tubular damage

Myristoylated Protein Kinase C Beta II Inhibitor Attenuates Severe Acute Kidney Injury Induced by Ischemia-Reperfusion

INTRODUCTION: Acute kidney injury (AKI) due to ischemia-reperfusion (I/R) insult involves oxidative stress and inflammation leading to rapid renal decline. In this study, we test a novel myristoylated protein kinase C beta II peptide inhibitor (N-myr-SLNPEWNET; myr-PKCβII-), known to attenuate ex vivo rat myocardial I/R injury in a murine model of renal ischemia. We aim to demonstrate the attenuation of renal I/R injury by myr-PKCβII- in comparison to scrambled control peptide (N-myr-WNPESLNTE; myr-PKCβII-scram) by quantifying serum creatinine (Cr) and glomerular filtration rate (GFR). METHODS: Renal pedicles of anesthetized male C57BL/6J mice were clamped bilaterally for 20-min or 19-min. Five minutes before unclamping, 2.0 mg/kg (20 µM serum) myr-PKCβII- or myr-PKCβII-scram were given IV into the tail vein. Cr was measured at baseline, 24h, 72h, and 96h post-injury. GFR was determined with fluorescein-isothiocyanate (FITC)-Sinistrin renal clearance. Data were evaluated by unpaired Student’s t-test. RESULTS: Following 20-min renal ischemia, Myr-PKCβII- (n=9) significantly reduced Cr at 24h and 72h post-injury compared to myr-PKCβII-scram (n=8; p\u3c0.05). Three unexpected fatalities followed 20-min ischemia, but not 19-min ischemia. Serum Cr levels modestly increased following 19-min renal I/R and were similar for Myr-PKCβII-scram control and Myr-PKCβII- treated groups. Compared to myr-PKCβII-scram control, Myr-PKCβII- demonstrated a trend towards improved GFR at 72hr (130 ± 28 vs 96 ± 44 µl/ml; p=0.065) and 96 hr (133 ± 33 vs 113 ± 50 µl/ml; p=0.095) post-I/R injury. DISCUSSION: Results suggest 20-min renal ischemia was more severe, indicated by a 5-fold increase in Cr at 72h post-injury compared to 19-min ischemia and unanticipated fatalities of three mice. Myr-PKCβII- attenuated renal injury following 20-min renal ischemia, but not after 19-min in which Cr levels were too low to detect therapeutic benefit. The difference in injury severity between 20-min and 19-min renal ischemia emphasizes the temporal relationship between renal function and ischemic duration