How To Avoid Suture Damage in Simultaneous Anterior Cruciate Ligament Reconstruction and Lateral Meniscal Posterior Root Reinsertion With the Transtibial Pullout Technique: A Technical Note.

Lateral meniscus posterior root tears (LMPRTs) are estimated to occur in 7% to 12% of anterior cruciate ligament (ACL)-injured knees. This topic is of great interest because of their biomechanical consequences in terms of interruption of hoop stress distribution. If left unrepaired, the corresponding compartment is exposed to unfavorable contact dynamics, similar to those resulting from a total meniscectomy. This Technical Note describes a transtibial LMPRT repair using a Knee Scorpion and an 18-gauge spinal needle. It is a reproducible arthroscopic LMPR reinsertion technique combined with concomitant standard ACL + anterolateral ligament reconstruction with hamstring tendons and it describes how to safely avoid damage to root traction sutures during the ACL independent tibial tunnel drilling.

Penile incarceration with weight plate: An unusual case with review of literature.

Penile incarceration from constricting metallic or non-metallic objects is a urological emergency which warrants immediate interventions to prevent undesirable sequalae. Various methods such as aspiration technique, string methods, cutting devices and surgery has been described in the literature but each case needs individualized approach due to lack of consensus in the management. We report a case in a 24-year male who incarcerated his penis with a metallic weight plate weighing around 3 kg. To our knowledge this is the first case reported in the literature where a heaviest constricting object was successfully removed via circumcoronal incision.

Double outlet left atrium: successful management of a rare entity.

Double-outlet left atrium is an extremely rare congenital ventriculo-atrial mal-alignment anomaly, wherein, the left atrium drains into both ventricles, through either a common atrioventricular valve or two separate atrioventricular valves. The only egress from the right atrium is through an inter-atrial communication. We present a 16-month-old male, diagnosed to have double outlet left atrium and describe its surgical management.

Comparison of hemodynamic consequences of hand ventilation versus machine ventilation for transportation of post-operative pediatric cardiac patients.

Learning Objective: Hemodynamic monitoring during in-hospital transport of intubated patients is vital; however, no prospective randomized trials have evaluated the hemodynamic consequences of hand versus machine ventilation during transport among pediatric patients' post-cardiac surgery. The authors hypothesized that manual ventilation after pediatric cardiac surgery would alter hemodynamic and arterial blood gas (ABG) parameters during transport compared to mechanical ventilation. Design: A prospective randomized trial. Setting: Tertiary cardiac care hospital. Participants: Pediatric cardiac surgery patients. Materials and Methods: One hundred intubated pediatric patients were randomized to hand or machine ventilation immediately post-cardiac surgery during transport from the operating room to the pediatric post-operative intensive care unit (PICU). Hemodynamic variables, including end-tidal CO2 (ETCO2), oxygen saturation, heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), peak airway pressure (Ppeak), and mean airway pressure (Pmean), were measured at origin, during transport, and at the destination. ABG was measured before and upon arrival in the PICU, and adverse events were recorded. The Chi-square test and independent t-test were used for comparison of categorical and continuous parameters, respectively. Results and Discussion: The mean transport time was comparable between hand-ventilated (5.77 ± 1.46 min) and machine-ventilated (5.96 ± 1.19 min) groups (P = 0.47). ETCO2 consistently dropped during transport and after shifting in the hand-ventilated group, with significantly higher ETCO2 excursion than in machine-ventilated patients (P < 0.05). SBP and DBP significantly decreased during transport (at 5 and 6 min intervals) and after shifting in hand-ventilated patients than in the other group (P < 0.05). Additionally, after shifting, a significant increase in Ppeak (P < 0.001), Pmean (P < 0.001), and pH (P < 0.001), and a decrease in pCO2 (P = 0.0072) was observed in hand-ventilated patients than machine-ventilated patients. No adverse event was noted during either mode of ventilation. Conclusion: Hand ventilation leads to more significant variation in ABG and hemodynamic parameters than machine ventilation in pediatric patients during transport post-cardiac surgery. Therefore, using a mechanical ventilator is the preferred method for transporting post-operative pediatric cardiac patients.

Multifocal primary amyloidosis of the bladder presenting with gross hematuria: A case report and review of literature.

Amyloidosis is defined as extracelluar deposition of amyloid, a fibrillary protein in one or more body sites. It can involve genito-urinary tract, primarily or secondarily, but isolated primary bladder amyloidosis is an extremely rare presentation. We herein report a rare case of 48-year-male patient presented with symptoms mimicking carcinoma urinary bladder especially painless haematuria. Transurethral resection of the mass was done in one sitting. The histopathological examination revealed to be a primary bladder amyloidosis. In the follow-up, patient had improvement in symptoms and no recurrence. We also briefly review the literature on primary bladder amyloidosis.

Endourological management of migrated intravesical intrauterine contraceptive device: Neglected case with stone formation.

Intrauterine contraceptive device (IUD) has been associated with numerous complications such as pelvic discomfort, spontaneous expulsion, and infections. In rare instances, perforation and migration can occur if neglected. We present a rare of 25-year-old female in whom a neglected perforated IUD (Cu-T) after two years completely migrated into the urinary bladder leading to large stone formation. The migrated IUD with stone was successfully managed via minimally invasive endourological management.

Reduction of a Depressed Femoral Lateral Notch at the Time of Lateral Extra-articular Tenodesis.

We present a surgical technique to address severe lateral femoral notch depressions using a small extension in the lateral approach for Lemaire extra-articular tenodesis in anterior cruciate ligament reconstruction. Through this approach, the surgeon is able to obtain good exposure of the lateral femoral condyle, with straightforward access for subchondral reduction, without adding any significant morbidity.

Standard Balloon Angioplasty Versus Serranator Serration Balloon Angioplasty for the Treatment of Below-the-Knee Artery Occlusive Disease: A Single-Center Subanalysis From the PRELUDE-BTK Prospective Study.

BACKGROUND: Endovascular interventions in infrapopliteal occlusive artery disease are becoming more complex, and this frequently tests the standard method of treatment, plain old balloon angioplasty (POBA). The potential that serration angioplasty could produce a more acceptable tibial artery lumen was assessed in this study. AIM: The aim of this single-center subgroup analysis was to compare acute angiographic results after endovascular treatment using the Serranator serration balloon catheter in patients participating in the PRELUDE-BTK trial with POBA of the infrapopliteal arteries. A secondary objective was to assess post-treatment hemodynamic improvements. METHODS: Our center enrolled 15 subjects and treated 17 lesions within the multicenter prospective core laboratory-adjudicated PRELUDE-BTK study. A 25 lesions analyzed separately were treated with POBA and then compared with the Serranator subset. In both cohorts, lesions were treated with either plain angioplasty or Serranator as a stand-alone therapy; subsequent methods, such as drug elution technologies, were not used. Acute angiographic results were analyzed by the SynvaCor angiographic core laboratory. To assess volumetric flow rates, data were analyzed with a fluid flow simulation software and compared against Poiseuille's Law. RESULTS: Final residual stenosis was 17.2%±8.2% in the Serranator group versus 33.7%±15.7% in the POBA group. The mean lumen diameter (MLD) gain for the Serranator group and the POBA group was 1.64±0.41 mm and 1.33±0.63 mm, respectively. The average atmospheric balloon inflation pressure was 5 ATM in the Serranator group versus 9 ATM in the POBA group. Neither group required a bailout stent; however, it was notable that there were significantly more chronic total occlusions (CTOs) treated in the Serranator group at 41.2% versus 12% in the POBA group. Regarding the effectiveness in improving hemodynamic blood flow for non-CTO lesions, the calculated average ratio of post-treatment to pre-treatment flow rates in the Serranator group was 238% than that for the POBA group. For CTO cases where pre-treatment flow rate was zero, final residual stenosis was used as the parameter for comparison. The Serranator group showed a 62% improvement in final residual stenosis over POBA. CONCLUSION: Endovascular treatment of the infrapopliteal arteries by use of the Serranator serration balloon provides a novel and promising method of action compared with standard balloon angioplasty and, thus, may have a leading role in complex below-the-knee arterial lesions. CLINICAL IMPACT: The Serranator device might help to adequately address issues with conventional routine techniques for the treatment of complex lesions in infrapopliteal arteries in patients with advanced stages of PAD and critical limb ischemia. Integrating modern technologies such as the Serranator balloon catheter into clinical routine is mandatory in order to gain a more favorable outcome in these severely diseased patients and, particularly, to reduce mortality and morbidity.

Comparison of neonatal and maternal outcomes of anti-diabetic drugs in the treatment of gestational diabetes mellitus: Findings from Bayesian network meta-analysis.

The safety and efficacy of different anti-diabetic drugs are not clear because of the lack of sufficiently powered clinical trials. This network meta-analysis was conducted to compare the efficacy and safety of three anti-diabetic drugs (insulin, glyburide, and metformin), and rank them as per their efficiency to control glucose levels, pregnancy, and neonatal outcomes. The study design is a systematic review, meta-analysis, and network meta-analysis. After a systematic search of existing databases, 34 randomized controlled trials were selected for inclusion in the analysis. We did pairwise network meta-analysis to calculate standardized mean difference and odds ratio (OR) as the summary measures for numerical and dichotomous variables, respectively, by using random-effects model. Our key outcomes were incidence of neonatal hypoglycemia, respiratory distress syndrome, macrosomia, C-section, admission to neonatal intensive care unit (NICU) and mean differences in the birth weight of neonates, gestational age at birth, HbA1C levels, fasting blood sugar, large at gestational age, and post-prandial glucose. It was found that metformin significantly lowered the post-prandial levels of glucose as compared with both glyburide and insulin in pairwise analysis (SMD = 14.11 [23-4.8]; SMD = 22.45 [30-14]), respectively. There was a significant reduction in birth weights of babies whose mothers were administered metformin as compared with either glyburide or insulin. The proportion of neonates admission to NICU was significantly lower for metformin when compared with insulin [Log OR = 0.334 (0.0184, 0.6814))]. Large at gestational age was significantly lower for metformin as compared with both glyburide and insulin [log OR = 0.6882 (0.171, 1.329), log OR = 0.393 (0.00179, 0.8218)], respectively. Oral anti-diabetic drugs especially metformin performed better than both glyburide and insulin for all neonatal and maternal outcomes except that it significantly lowered the neonatal birth weight.

Identification of 1,2,4-Oxadiazoles-Based Novel EGFR Inhibitors: Molecular Dynamics Simulation-Guided Identification and in vitro ADME Studies.

Background: In this work, we have identified heterocyclic derivatives with 1,2,4 oxadiazole scaffold mimicking the functions of tyrosine kinase inhibitors. Fourteen molecules that displayed the best fit were picked from the library of compounds and studied under in-silico and in-vitro conditions. Four compounds were selected for further cytotoxicity and ADME (Absorption, Distribution, Metabolism, Elimination) profiling showing IC50 (from 8-13 µM) values against EGFR positive cancer cell line (MCF7). Methods: A molecular dynamics simulation study was performed to understand the correlation of non-covalent binding energies with biological activity. The drug-like properties of the selected four compounds (7a, 7b, 7e, and 7m) were evaluated by in-vitro ADME studies. Compounds 7a, 7b, and 7m were the active compounds in the molecular dynamics simulations study. Further, EGFR binding activity was confirmed with EGFRWT and EGFRT790M kinase assay using a luminescence-based method. Results: These compounds (7a, 7b, and 7m) showed activity against EGFRWT and mutant EGFRT790M, exhibiting IC50 values of <10 and <50 micromolar, respectively. These compounds also possess moderate aqueous solubility in 40-70 µg/mL at pH 7.4 and 30-100 µg/mL at pH 4.0. Further, 7a, 7b, and 7m showed balanced lipophilicity with Log D values ranging from 1-3. They demonstrated a good correlation in Caco-2 permeability with Apparent permeability (Papp) 1 to 5 × 10-6 cm/s in comparison with 7e, which was found to be highly lipophilic (Log D >5) and showed high permeability (Papp 17 × 10-6 cm/s). Lastly, all these compounds were moderately stable in liver microsomes at alkaline pH with a half-life of 30-60 min, while at a highly acidic pH (2.0), the compounds were stable up to 15-20 min. Conclusion: Overall, in-vitro ADME results of these molecules showed good drug-like properties, which are well correlated with the in-silico ADME data, making them ideal for developing an oral drug delivery formulation.

Expert survey on management of prostate cancer in India: Real-world insights into practice patterns.

To gain insights on the diverse practice patterns and treatment pathways for prostate cancer (PC) in India, the Urological Cancer Foundation convened the first Indian survey to discuss all aspects of PC, with the objective of guiding clinicians on optimizing management in PC. A modified Delphi method was used, wherein a multidisciplinary panel of oncologists treating PC across India developed a questionnaire related to screening, diagnosis and management of early, locally advanced and metastatic PC and participated in a web-based survey (WBS) (n = 62). An expert committee meeting (CM) (n = 48, subset from WBS) reviewed the ambiguous questions for better comprehension and reanalyzed the evidence to establish a revote for specific questions. The threshold for strong agreement and agreement was ≥90% and ≥75% agreement, respectively. Sixty-two questions were answered in the WBS; in the CM 31 questions were revoted and 4 questions were added. The panelists selected answers based on their best opinion and closest to their practice strategy, not considering financial constraints and access challenges. Of the 66 questions, strong agreement was reached for 17 questions and agreement was achieved for 22 questions. There were heterogeneous responses for 27 questions indicative of variegated management approaches. This is one of the first Indian survey, documenting the diverse clinical practice patterns in the management of PC in India. It aims to provide guidance in the face of technological advances, resource constraints and sparse high-level evidence.

Laparoscopic transmesocolic pyelolithotomy and pyeloplasty in an ectopic pelvic kidney: Case report and review of literature.

Renal ectopia is a developmental anomaly with pelvic kidney being the commonest location (55%). The incidence of uretero-pelvis junction (UPJ) obstruction, nephrolithiasis, and reflux are higher in ectopic kidneys than their counterparts. We herein report a case of left ectopic pelvic kidney with large stone associated with UPJ narrowing managed successfully simultaneously with laparoscopic transmesocolic pyelolithotomy and pyeloplasty in a 45-year female. This is the largest stone reported in the literature in an ectopic pelvic kidney managed successfully with favorable outcome.

Giant prostatic and bladder calculi: Endoscopic management and review of the literature.

Giant prostatic and bladder calculi is extremely rare entity with incidence increasing with age. These large stones can be concurrently managed via transurethrally, open retro-pubic surgery, radical prostatectomy and endoscopically depending on site and size. A 55-male presented with severe lower urinary tract symptoms mainly incontinence of urine for 8-10 years. On workup, he was diagnosed to have giant prostatic and bladder calculi. We report this rare case as such giant stones are managed with open surgery but we succeeded in removing them endoscopically with favorable outcome.

APDS Task Force on Resident Transfers: Guidelines for Program Directors.

OBJECTIVE: Resident attrition from the field of General Surgery has been extensively studied. Attrition from one General Surgery program to the benefit of another has not. General Surgery programs can be negatively affected when a resident decides to leave the program for another. When a resident in a general surgery residency program decides to attempt transfer to another program several decisions must be made. The resident applies for the open position, interviews and then may be offered a position in that program. If an offer is made and the resident accepts, at what point is the resident's current Program Director notified? At what point in the process does the resident leave his/her current program to begin the new program? At what point does the new Program Director obtain a summative evaluation of the resident? Does the resident experience retribution as a result of informing his/her fellow residents and faculty that s/he is leaving? These are all questions that Program Directors struggle with when they find themselves with an unexpected opening to fill. The APDS Task Force on Resident Transfers attempted to answer these and other questions. DESIGN: A 19-question survey was distributed via the APDS to all General Surgery Program Directors who utilize the list serve. The survey asked questions related to the following: acceptable reasons for transfer; timeline for the application, interview and transfer process; retaliation against residents who chose to transfer; and transparency in the transfer process. SETTING: The survey was distributed via e-mail nationwide. PARTICIPANTS: General Surgery Residency Program Directors are participated in the survey. RESULTS: The majority of the 99 respondents agreed to the following guidelines: (1) Program Directors must promote transparency in the transfer process; (2) Program Directors must make a statement against retaliation; (3) personal or family preference is the most acceptable reason for transfer; (4) an established transfer date must be agreeable to both programs; and, (5) a recruitment timeline should be established for both programs. All data are included below. CONCLUSIONS: The reasons that a resident chooses to leave a program and the effect this has on the program and the other residents requires further study. Program Directors should educate residents about the transfer process and that procedure should be available as a written policy. When a resident desires transfer to another program, following these guidelines may make the transition easier for all involved. The APDS supports putting them into practice.

Coumarin-carbazole based functionalized pyrazolines: synthesis, characterization, anticancer investigation and molecular docking.

A series of novel pyrazoline scaffolds from coumarin-carbazole chalcones were synthesized. We explored various acetyl, amide, and phenyl substituents at the N-1 position of the pyrazoline core. The synthesized compounds were characterized by FTIR, 1H-NMR, 13C-NMR, DEPT, and mass spectroscopic techniques. The in vitro cytotoxicity study of all the synthesized compounds was evaluated against HeLa, NCI-H520 and NRK-52E cell lines. Compounds 4a and 7b became the most active compounds and exhibited their potential to arrest the cell cycle progression and induce apoptosis in both the cell lines. In addition, molecular docking studies revealed a higher binding affinity of both the molecules with CDK2 protein. Based on the obtained results, a comprehensive analysis is warranted to establish the role of compounds 4a and 7b as promising cancer therapeutic agents.

Objective assessment of mouth opening after buccal mucosal graft urethroplasty: A prospective study.

INTRODUCTION AND OBJECTIVES: Buccal mucosal graft (BMG) is frequently used for the reconstruction of urethral strictures with acceptable donor-site morbidity after graft harvest. There are only a few prospectively designed studies with a small number of patients reporting oral complications, particularly the mouth opening in the long terms. We did an objective assessment of mouth opening before and after 6 months of BMG urethroplasty as well as pain scores. MATERIALS AND METHODS: Fifty-eight patients who underwent BMG urethroplasty were included in the study between May 2013 and December 2014. Preoperative mouth opening (reference point between two incisors with the highest of three readings taken as final) was measured using a Vernier caliper. Harvest site was left open to heal by secondary intentions. Postoperatively, mouth opening and pain scores using self-administered (Visual Analog Scale [VAS]) assessed on day 1 and day 3, and follow-up at 1 week, 1 month, and 6 months. Data were analyzed as mean (standard deviation [SD]), proportion, and median (inter-quartile range [IQR]) with two-tailedP < 0.05 as statistically significant. RESULTS: The mean age was 39.6 years. The graft was harvested from a single cheek in 50% of patients. In remaining, it was taken from both cheeks, both cheeks with lip, and both cheeks with the tongue in 29.31%, 17.24%, and 3.5%, of patients, respectively. Preoperative mouth opening (5.13 cm [0.08]) was statistically significantly more than mouth opening on day 1 (4.34 cm [0.09]), day 3 (4.48 [0.09]), and day 7 (4.69 cm [0.09]). Mean difference became insignificant at the interval of 1 month (4.91 cm [0.09]) with 6 months' values showing marginal improvement over preoperative values (5.14 cm [0.07]). Pain was tolerable and patients reported low median VAS 2 (2-4) on day 1 and day 3 each. Reported median VAS became 0 (0-0) on day 7. CONCLUSION: Mouth opening restriction after BMG urethroplasty is a definite entity in the initial postoperative period, which becomes nonsignificant by 6 months. The pain has no effect on mouth opening.

Macrocystic Adult Penile Lymphangioma: A Rare Presentation.

Adult penile lymphangioma (APL) is a rare multifactorial vascular malformation. Usually, it is asymptomatic and located on the coronal sulcus or shaft of the penis. It is benign in nature with rare chances of recurrence. APLs can be approached via various modalities from simple "watch and wait" to electrofulguration, laser ablation, and surgical excision. We report a rare variant of lymphangioma of the penis inculcating the shaft being excised surgically with favorable outcome along with brief review of literature.

FDA collaboration to improve safe use of fluoroquinolone antibiotics: an ex post facto matched control study of targeted short-form messaging and online education served to high prescribers.

OBJECTIVE: This ex post facto matched control study was conducted to evaluate the effect of targeted short-form messages or continuing medical education (CME) on fluoroquinolone prescribing among high prescribers. METHODS: A total of 11,774 Medscape healthcare provider (HCP) members prescribing high volumes of fluoroquinolones were randomized into three segments to receive one of three unique targeted short-form messages, each delivered via email, web alerts, and mobile alerts. Some HCPs receiving targeted short-form messages also participated in CME on fluoroquinolone prescribing. A fourth segment of HCPs participated in CME only. Test HCPs were matched to third-party-provider prescriber data to identify control HCPs. We used prescriber data to determine new prescription volume; percentage (%) of HCPs with reduced prescribing; new prescription volume for acute bacterial sinusitis (ABS), uncomplicated urinary tract infection (uUTI), and acute bacterial exacerbations of chronic bronchitis in those with chronic obstructive pulmonary disease (ABECB-COPD). Open rates for emailed targeted short-form messages were also measured. RESULTS: Targeted short-form messages and CME each resulted in significant new prescription volume reduction versus control. Combining targeted short-form messages with CME yielded the greatest percentage of test HCPs with reduced prescribing (80.1%) versus controls (76.2%; p<0.0001). New prescription volume decreased significantly for uUTI and ABS following exposure to targeted short-form messages, CME, or both. Targeted short-form messages containing comparative prescribing information with or without clinical context were opened at slightly higher rates (10.8% and 10.6%, respectively) than targeted short-form messages containing clinical context alone (9.1%). CONCLUSIONS: Targeted short-form messages and CME, alone and in combination, are associated with reduced oral fluoroquinolone prescribing among high prescribers.