Limitations of U25 CKiD and CKD-EPI eGFR formulae in patients 2-20 years of age with measured GFR > 60 mL/min/1.73 m2-a cross-sectional study.

BACKGROUND: When applying Pierce U25 formula for estimating glomerular filtration rate (eGFR), we observed a higher proportion of eGFR < 90 mL/min/1.73 m2 (chronic kidney disease (CKD) stage 2). We compared agreement and accuracy of the Pierce U25 (ages 2-25), Pottel (ages 2-100), and CKD-EPI (ages 18-100) formulae to GFR measurements. METHODS: Post hoc analysis of the three eGFRs compared to 367 99m technetium-diethylene-triamine penta-acetic acid (99Tc DTPA) GFR measurements (240 patients) using 3 sampling points and Brockner/Mørtensen correction (body surface area calculation based on ideal weight) on simultaneous serum creatinine and cystatin C measurements. RESULTS: Overall, the U25 formula performed well with a Spearman r of 0.8102 (95% confidence interval 0.7706 to 0.8435, p < 0.0001) while diagnostic accuracy was low in patients with normal mGFR. The U25 formula reclassified 29.5% of patients with normal mGFR as CKD stage 2; whereas the average of the modified Schwartz formula based on serum creatinine and the Filler formula based on cystatin C, only over-diagnosed CKD stage 2 in 8.5%, 24.5% within 10% and 62.7% within 30%. We therefore combined both. The average Schwartz/Filler eGFR had 36.5% of results within 10%, 84.7% within 30%, and normal mGFR accuracy was 26.8%, 63.9% for 10% and 30%, respectively, outperforming the CKD-EPI and Pottel formulae. CONCLUSIONS: The Pierce U25 formula results correlated well with mGFR < 75 mL/min/1.73 m2. Over the entire GFR range, accuracy was better for patients with a higher mGFR, when averaging the combined Schwartz/Filler formulae. More work is needed to prospectively confirm our findings in other centers.

Watch One, Do One? A Systematic Review and Educational Analysis of YouTube Microsurgery Videos, and a Proposal for a Quality Assurance Checklist.

Background Educational resources on the internet are extensively used to obtain medical information. YouTube is the most accessed video platform containing information to enhance the learning experience of medical professionals. This study systematically analyzed the educational value of microsurgery-related videos on this platform. Methods A systematic review was conducted on YouTube from April 18 to May 18, 2020, using the following terms: "microsurgery," "microsurgical," "microsurgical anastomosis," "free flap," and "free tissue transfer." The search was limited to the first 100 videos, and two independent reviewers screened for eligible entries and analyzed their educational value using validated scales, including a modified version of the DISCERN score (M-DISCERN), Journal of the American Medical Association (JAMAS) benchmark criteria, and the Global Quality Score (GQS). Evaluation of video popularity was also assessed with the video power index (VPI). Results Of 356 retrieved videos, 75 (21%) were considered eligible. The educational quality of videos was highly variable, and the mean global scores for the M-DISCERN, JAMAS, and GQS for our sample were consistent with medium to low quality. Conclusions A limited number of videos on YouTube for microsurgical education have high-educational quality. The majority scored low on the utilized criteria. Peer-reviewed resources seem to be a more reliable resource. Although the potential of YouTube should not be disregarded, videos should be carefully appraised before being used as an educational resource.

Comparison of an Iranian Traditional Massage (Fateh Method) with Physiotherapy and Acupuncture for Patients with Chronic Low Back Pain: a Randomized Controlled Trial.

Background: Low back pain (LBP) is currently a major reason for disability worldwide. Therapeutic massage is one of the most popular non-pharmacological methods for managing chronic LBP (CLBP), and the Fateh method is a massage technique based on Iranian Traditional Medicine. Objectives: The current study aimed to compare the effects of Fateh massage with those of acupuncture and physiotherapy on relieving pain and disability in CLBP. Methods: Eighty-four patients with CLBP were categorized into groups that received Fateh massage, acupuncture, or physiotherapy. Each group included 28 randomly assigned patients who completed 10 sessions of therapy. Visual analogue scale (VAS) scores and Roland-Morris disability scores were evaluated at baseline, after intervention, and four weeks later. The findings were analyzed with SPSS software. Results: The baseline VAS and Roland-Morris scores of the three study groups did not indicate significant differences (p > 0.05). All three groups showed significant pre-post improvements in both scores (p < 0.05). At the end of the treatment sessions, the three groups showed no significant difference in the reductions in pain intensity and disability score (p > 0.05). Improvements in disability and pain between the first and third time points were significant in all three groups (p < 0.05 for each group). In addition, the results of massage, physiotherapy, and acupuncture groups were not significantly different (p > 0.05). No adverse events occurred in the patients. Conclusion: The effects of Fateh massage were comparable to those of acupuncture and physiotherapy in reducing pain and disability in patients with CLBP.

Outcomes of major head and neck reconstruction during the COVID-19 pandemic: The St. Andrew's centre experience.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. METHODS: A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri­operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. RESULTS: Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36-92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. CONCLUSION: Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri­operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

Microvascular grafting to enhance perfusion in colonic long-segment oesophageal reconstruction.

PURPOSE: Oesophagectomy with long-segment colon reconstruction is the first-line treatment when the stomach is not available. Supercharging of the newly formed conduit can improve vascular function utilizing intraoperative perfusion imaging system, following thoracoscopic oesophagectomy for distal-oesophageal and gastroesophageal junction cancer. The purpose of this study is to examine the safety and efficacy of microvascular augmentation of left colonic interposition following oesophagectomy for oesophageal cancer. METHODS: A retrospective analysis of 156 consecutive oesophagectomies between January 2016 and July 2018 was performed. All oesophagectomies involving left colon interposition with microvascular augmentation were included in the study. In all cases, oesophageal mobilization was performed thoracoscopically in prone position and the left colon was used as neo-oesophagus in an isoperistaltic fashion. Conduit perfusion was assessed with the Spy system and neck supercharging was performed using microsurgical technique. RESULTS: A total of n = 5 (3.2%) patients were identified. Two cases had delayed and 3 had immediate reconstruction. The conduit was microsurgically augmented in 3 cases with both venous and arterial anastomoses (supercharging) and in 2 cases with venous anastomosis only (superdrainage). No anastomotic leak was identified. One case developed left recurrent laryngeal nerve palsy with associated aspiration pneumonia. CONCLUSIONS: Supercharged colonic interposition is a safe way of oesophageal reconstruction when long-segment interposition graft is needed. In oesophageal cancer and in the absence of a viable stomach with intact gastroepiploic arcade, it should be considered a feasible option with favourable outcomes, when the expertise and facilities are available. Use of intraoperative perfusion imaging reveals improved conduit blood supply post-supercharging.

Thoracoscopic total esophagogastrectomy with supercharged colon interposition for the treatment of esophageal adenocarcinoma in situs inversus.

Background: Esophagectomy in situs inversus is challenging. With long-segment supercharged reconstruction, it becomes more perplexing and multidisciplinary surgical skills are needed. Challenges met and the surgical technique used is presented in this case report. Methods: The case of a 49-year old patient with situs inversus abdominus and a locally advanced distal esophageal adenocarcinoma extending to the stomach is presented. Results: Following neoadjuvant chemotherapy and due to inability to use the stomach as a conduit, a thoracoscopic total esophagogastrectomy with long-segment reconstruction was performed. The conduit used was the left colon and was supercharged with venous and arterial anastomoses in the neck. Conduit perfusion, as assessed by the Spy system revealed marked improvement post supercharging. No anastomotic leak was noted and oral diet was started on day 4. On day 26 the patient developed pneumonia necessitating intubation that was declined. Organ support was withheld with patient death at day 29. Conclusion: In long-segment esophageal reconstruction with supercharged colon, although thoracoscopy is feasible, laparoscopy is found unsafe. Careful preoperative planning and colon assessment via computed tomography(CT) colonography/angiography and a multidisciplinary team approach is recommended. Adjuncts to assess conduit perfusion like the Spy system are helpful. Supercharging the long colonic conduit is a way of minimizing ischemia-related complications.

Management of a transcranial abscess secondary to interleukin-1 receptor associated kinase 4 deficiency.

Interleukin-1 receptor associated kinase 4 (IRAK-4) deficiency is a primary immunodeficiency that predisposes to opportunistic pyogenic infections in affected patients. The presentation can be variable, and the microbiological and immunologic management of this condition has been documented; however, the atypical nature of its presentation calls for a different approach in its surgical management. This is the first reported case of transcranial progression of a soft tissue abscess in a patient with IRAK-4 deficiency, with an emphasis on a multidisciplinary approach to treat infection at an extremely vulnerable anatomic site.

Amelioration of Chiari type 1 malformation and syringomyelia following posterior calvarial distraction in Crouzon's syndrome--a case report.

Multisutural craniosynostosis as seen in Crouzon's syndrome can result in raised intracranial pressure, Chiari malformation (CM) and syringomyelia. Posterior calvarial distraction (PD) is a technique for addressing cranio-cephalic disproportion, and this case report describes the reversal of both CM and syrinx in a 6-year-old child who underwent PD initially for raise intracranial pressure.

Frontofacial monobloc distraction in the very young: a review of 12 consecutive cases.

BACKGROUND: Frontofacial monobloc advancement by distraction osteogenesis is now accepted as an effective treatment for children with syndromic and other complex forms of craniosynostosis because it combines cosmetic advantages with the ability to treat such complications as raised intracranial pressure, advancing exorbitism, and upper airway obstruction in one procedure. In the severely affected child, these complications may be present at an early age, but because of the scale of monobloc surgery, surgeons have been reluctant to perform it on very young children. METHODS: The authors report a series of 12 children younger than 30 months with various craniosynostosis-associated syndromes complicated by multiple functional problems--including raised intracranial pressure, exposure of the eyes, airway obstruction, and feeding problems--who underwent frontofacial monobloc surgery by distraction osteogenesis. RESULTS: The mean age at operation was 18 months. Mean advancement achieved was 16.6 mm for the upper face and 17 mm for the midface. Ocular protection and reduction of intracranial pressure (when raised) were achieved in all children. Airway improvement was achieved in all but one child. Although not the primary indication for surgery, there was also a marked improvement in every patient's appearance. Complications included two cerebrospinal fluid leaks, pin-site infections, frame slippage requiring replacement, and enophthalmos in one patient. CONCLUSION: The frontofacial monobloc advance incorporating distraction osteogenesis can be undertaken with acceptable morbidity even in the very young child and good functional outcomes achieved with one operation where previously more were required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Heat shock protein 70 expression following hepatic radiofrequency ablation is affected by adjacent vasculature.

BACKGROUND: Heat shock proteins are a highly conserved family of stress response proteins. Members of the heat shock protein 70 (Hsp70) family prevent protein misfolding and aggregation. Following radiofrequency ablation of unresectable liver tumors an interface appears between the irreversibly damaged and normal liver. The fate of this transition zone is critical and is believed to be responsible for local recurrences. Hsp70 is expressed in response to thermal stress and may influence the fate of cells in this transitional zone. It is also recognized that the presence of large vessels or a perivascular location of tumors also influences the recurrence rate. The aim of this study is to examine the transition zone and observe the effect of local blood flow on ablation morphology and Hsp70 expression. METHODS: Radiofrequency ablation was performed in 25 rats at various distances from the liver hilum. Tissue was retrieved and analysed at time points 0, 4, 24, 48 h, and 2 wk following treatment. Tissue was analyzed histologically with hematoxylin and eosin staining (H and E,) and immunohistochemically for Hsp70 expression. RESULTS: All rats survived the procedure. H and E staining revealed previously unreported foci of apoptosis at the ablation edge and deep in the normal hepatic parenchyma. Hsp70 was expressed in the transition zone at 4 h and peaked at 24 h. The degree of Hsp70 expression was significantly influenced by the distance from surrounding vasculature. CONCLUSIONS: This study reports several previously unreported findings. There is increased apoptosis distal to the ablated zone suggests leakage of radiofrequency (RF) current down blood vessels originating in the ablation zone. The degree of Hsp70 expression in the transition zone correlates with time after treatment and the size and location of any adjacent vasculature. These findings suggest that heat shock proteins may play a role in the ability of damaged cells to recover and survive at the periphery of an ablation zone.

Changes in interleukin-1ß and 6 after hepatic microwave tissue ablation compared with radiofrequency, cryotherapy and surgical resections.

BACKGROUND: Cytokine changes after microwave tissue ablation (MTA) were compared with hepatic resection, cryotherapy (CRYO), and radiofrequency ablation (RFA). Cytokine production was measured at various ablation volumes for each modality and correlated with the transitional inflammatory zone produced by the ablation techniques. METHODS: Live rats underwent MTA, surgical resection, CRYO or RFA of 15%, 33%, or 66% of the total hepatic volume. Serum samples were collected preoperatively and at 1, 3, 6, 24, and 48 hours after surgery and analyzed for pro-inflammatory cytokines interleukin (IL)-1ß and IL-6. RESULTS: Significantly higher levels of both cytokines were present after CRYO and RFA compared with MTA, hepatic resection, or controls (P < .001). All animals survived except those undergoing RFA or CRYO of 66% of the hepatic volume, which died within 6 hours. Transitional zones produced after RFA were larger than those after CRYO or MTA, but no correlation was present with the amount of cytokines. CONCLUSIONS: Large-volume MTA is associated with a significant decreased cytokine response and is well tolerated compared with RFA and CRYO.

Large volume hepatic microwave ablation elicits fewer pulmonary changes than radiofrequency or cryotherapy.

BACKGROUND: Lung changes after microwave tissue ablation (MTA) of different volumes of liver were compared with hepatic resection, cryotherapy (CRYO) and radiofrequency ablation (RFA). METHODS: Live rats underwent MTA, surgical resection, CRYO or RFA of 15%, 33% and 66% of total hepatic volume and lung samples were collected at the time of death. Lung impairment was assessed directly by examining the tissue specimens for the degree of interstitial pneumonia and by comparing the alveolar thickness in the different groups. RESULTS: All RFA and CRYO rats undergoing 66% of ablations died, but the MTA group had no fatalities. Following 66% RFA or CRYO ablations, the animals had a significantly increased thickness of the alveolar septa compared to 15% or 33% ablations and to 66% ablations in the MTA group. CONCLUSIONS: Large volume MTA is associated with a significant reduction in consequent lung damage and is well tolerated compared to RFA and CRYO.

Renal effects of microwave ablation compared with radiofrequency, cryotherapy and surgical resection at different volumes of the liver treated.

BACKGROUND: Renal changes after microwave tissue ablation (MTA) were compared with those following hepatic resection, cryotherapy (CRYO), and radiofrequency ablation (RFA). Structural damage producing renal impairment has been assessed directly by examining tissue specimens and by serum analysis for two sensitive biomarkers, retinol binding protein (RBP) and the heat shock protein 70 (HSP-70) for each modality at different ablation volumes. METHODS: Live rats underwent MTA, surgical resection, CRYO or RFA of 15, 33 or 66% of total hepatic volume. Urine and tissue samples were collected at the time of death. Percentage of tubules with casts and glomerular damage, tissue expression of HSP-70 and urine RBP were evaluated and compared. Behaviour of the animals was also assessed by means of five different parameters and combined to produce a response score. RESULTS: All RFA and CRYO rats undergoing 66% died and these animals had >60% of damaged tubuli and 8% of altered glomeruli. No animals treated by MTA or surgical resection died. Cut-off values (those predicting fatal treatments) could be identified for levels of HSP-70 and RBP. CONCLUSIONS: Large volume MTA is associated with a significant reduced renal damage and is well tolerated compared with RFA and CRYO.

Reconstruction of the extensor central slip using a distally based flexor digitorum superficialis slip.

Several methods have been reported for reconstruction of the extensor central slip. We describe the successful use of a distally based slip of the flexor digitorum superficialis tendon for the reconstruction of an incompetent central slip of the extensor mechanism. The flexor digitorum superficialis tendon was transferred from volar to dorsal through the base of the middle phalanx and then woven through the extensor tendon over the proximal phalanx. The technique is straightforward and appears to be robust.

Buckling and hydraulic mechanisms in orbital blowout fractures: fact or fiction?

Since the first description of orbital blowout fractures, there has been much confusion as to their etiology. Two principal mechanisms have been proposed to explain their production, the buckling and the hydraulic mechanisms caused, respectively, by trauma to the orbital rim and the globe of the eye. The aim of this study was to evaluate both mechanisms qualitatively and quantitatively. Our protocol used intact cadavers, quantifiable intraocular pressure, variable and quantifiable force, and quantifiable bone strain distribution with strain gauge analysis. One orbit of each cadaver was used to simulate each of the two mechanisms, allowing direct comparison. Fractures produced by the buckling mechanism were limited to the anterior part of the orbital floor, with strain readings reaching up to 3756 microepsilon. Posteriorly, strain did not exceed 221 microepsilon. In contrast, hydraulic-type fractures were much larger, involving anterior and posterior parts of the floor as well as the medial wall of the orbit. Here, strain exceeded 3756 microepsilon in both parts of the floor. Furthermore, we have demonstrated that the average energy required to fracture the orbital floor by the buckling mechanism is 1.54 J, whereas an average energy of 1.22 J is needed to produce this fracture by the hydraulic mechanism. Our results suggest that efforts to establish one or another mechanism as the primary etiology are misplaced. Both mechanisms produce orbital blowout fractures, with different and specific characteristics. We believe this provides the basis for our reclassification of such fractures.