Pedicle First Anterior Approach to Harvest Anterolateral Thigh Flap-Review of 304 Cases.

Background Although considered as a workhorse flap, the anterolateral thigh (ALT) flap has a steep learning curve that makes it difficult for microsurgeons to perform it early in their practice. In over 85% of patients, the perforator takes an intramuscular course making it difficult for beginners to safely secure the perforator dissection. In this technique, the pedicle is dissected first, utilizing the proximal incision by palpating the groove in between vastus lateralis and rectus femoris on the anterior aspect and extending the incision from 2 to 3 cm distal to the inguinal ligament to the flap markings caudally. Exposing the pedicle first makes it easier to proceed toward the skin perforator due to its easy identification and larger size at its origin. Patients and Methods This retrospective study was conducted from 2005 to 2020 in which 304 ALT flaps were performed by the pedicle first technique. Flap harvest time, incidence of injury to the skin perforator during harvest, flap re-exploration rates, and postoperative complications including incidence of flap necrosis, infection, and bleeding were the parameters that were measured. Results This study included a total of 304 patients of which 220 were male (72.3%). The average flap harvest time was 26 ± 3.2 minutes. Adverse events included perforator injury ( n = 1), flap re-exploration ( n = 15), and complete flap loss ( n = 8). The last eight patients were reconstructed secondarily with ALT flap from the opposite side and free latissimus dorsi flap ( n = 2). Conclusion The pedicle first technique makes ALT flap harvest easy, safe, and faster for plastic surgeons. The chances of injury to the skin perforator are markedly less thereby reducing postoperative complications.

Cameron lesions in patients with hiatal hernias: prevalence, presentation, and treatment outcome.

Cameron lesions, as defined by erosions and ulcerations at the diaphragmatic hiatus, are found in the setting of gastrointestinal (GI) bleeding in patients with a hiatus hernia (HH). The study aim was to determine the epidemiology and clinical manifestations of Cameron lesions. We performed a retrospective cohort study evaluating consecutive patients undergoing upper endoscopy over a 2-year period. Endoscopy reports were systematically reviewed to determine the presence or absence of Cameron lesions and HH. Inpatient and outpatient records were reviewed to determine prevalence, risk factors, and outcome of medical treatment of Cameron lesions. Of 8260 upper endoscopic examinations, 1306 (20.2%) reported an HH. When categorized by size, 65.6% of HH were small (<3 cm), 23.0% moderate (3-4.9 cm), and 11.4% were large (≥5 cm). Of these, 43 patients (mean age 65.2 years, 49% female) had Cameron lesions, with a prevalence of 3.3% in the presence of HH. Prevalence was highest with large HH (12.8%). On univariate analysis, large HH, frequent non-steroidal anti-inflammatory drug (NSAID) use, GI bleeding (both occult and overt), and nadir hemoglobin level were significantly greater with Cameron lesions compared with HH without Cameron lesions (P ≤ 0.03). Large HH size and NSAID use were identified as independent risk factors for Cameron lesions on multivariate logistic regression analysis. Cameron lesions are more prevalent in the setting of large HH and NSAID use, can be associated with GI bleeding, and can respond to medical management.

Innovative technique: Distal venous cannulation for salvaging free flap venous thrombosis by heparinised saline irrigation.

INTRODUCTION: Successful free tissue transfer depends on a multitude of factors, and adequate drainage of venous blood is one of the most critical part of successful free tissue transfers. MATERIAL AND METHODS: We report 6 cases of microvascular free flaps used for covering various defects, which developed venous congestion, that were salvaged with heparinised saline irrigation through the distal end of the congested vein by the help of an intravenous cannula. The irrigation was continued for 5 days. RESULTS: All the flaps were successfully salvaged. CONCLUSION: This method has potential applications in situations for successful salvage of free tissue transfer particularly due to venous thrombosis.

The conundrum of prolonged delirium.

Withdrawal delirium in alcohol dependence usually lasts 48 to 72 hours. However, certain factors can prolong delirium. We report a 39-year-old man with long-standing alcohol use who presented with delirium, which failed to resolve with treatment. On evaluation, he was found to have AIDS and limbic encephalitis due to herpes simplex virus.

Posttraumatic intradiploic epidermoid cyst of frontal bone.

Intracranial epidermoid cysts constitute about 1% of all intracranial tumors. They are usually congenital in origin and are thought to derive from ectodermal cell inclusions occurring during closure of the neural tube. Twenty-five percent of these are found in the skull as intradiploic epidermoid cysts. These intradiploic cysts are usually congenital, slow growing, and can grow to large size without causing symptoms. We present a case of intradiploic epidermoid cyst of frontal bone developed due to childhood trauma. The cyst expanded and eroded the walls of the frontal sinus causing proptosis, diplopia, and restricted eye movements with frontal headache. The bicoronal flap approach was used for complete removal of the cyst. Complete removal of the cyst wall is necessary to avoid recurrence.

Religion, Psychiatry, and Alternate Sexuality.

Religious institutions tend to display a conservative view towards individuals with alternate sexuality or identity. For managing patients with alternate sexuality, it is imperative that clinicians understand and take into account religious views and its effects on a person's mental health. We review the literature on religion, alternate sexuality, and psychiatry to ascertain their interaction and impact on the mental health of individuals with alternate sexuality or identity. Differing but overlapping perspectives on alternate sexuality persist across world religions. Individuals with conflict between religious and sexual identities are prone to have adverse mental health outcomes; adequate social supports result in more positive mental health outcomes. Education on lesbian, gay, bisexual, transgender, queer, and intersex-related topics in mental health professionals leads to better recognition of the issue and provision of respectful, effective mental health care within the context of socio-religious identity and background.

A comparative study of tissue expansion and free parascapular flaps in extensive facial burn scar reconstruction.

BACKGROUND: Large post burn scars are a very difficult problem to treat. Available methods include skin grafts and tissue expansion. The reconstructive method used should be tailored according to individual patient rather than following a textbook approach in each. PATIENTS AND METHODS: A retrospective analysis was done of cases with extensive facial burn scars in whom secondary reconstruction was done with either free parascapular flap cover or tissue expansion and flap advancement following facial burn scar excision by a single surgeon (GSK) in Department of Burns, Plastic and reconstructive surgery. RESULTS: A total of 15 patients with free parascapular flap and 15 patients with tissue expansion followed by flap advancement were analyzed in the group. There were no free flap failures, but 2 patients required skin graft at donor site. In patients undergoing tissue expansion, minor complication was noted in 1 patient. CONCLUSION: Tissue expansion is a useful technique in reconstruction of post burn scars, but has its limitations, especially in patients with extensive burns in head and neck region with limited local tissue availability. Parascapular free flap may provide a good alternative option for reconstruction in such cases.

Ovarian reserve may be compromised after adnexal surgery: Are we sufficiently fertility- focused in our surgical training?

There is a general trend towards delay in childbearing age amongst women. The ovarian reserve clearly falls with increasing age and the impact is greater with advancing age, particularly from late 30s. Presence of other risk factors can increase the risk of subfertility. A large number of women are exposed to pelvic surgery for various reasons, both elective and emergency. There is evidence that some of the pelvic surgery performed around ovaries and tubes has a negative impact on the ovarian reserve and in turn may cause a decline in woman's ability to conceive. A fertility-sparing focus on all pelvic surgery is likely to prevent further decline in ovarian reserve for women who are already at higher risk. Such focus seems to be currently lacking. It is proposed that integrating fertility-sparing focus to structured gynaecological surgical training will benefit women.

Percutaneous transatrial mitral commissurotomy: immediate and intermediate results.

OBJECTIVES: The purpose of this study was to evaluate the immediate and follow-up results of percutaneous transatrial mitral commissurotomy in 600 patients with rheumatic mitral stenosis. BACKGROUND: Percutaneous transatrial mitral commissurotomy has emerged as an effective nonsurgical technique for patients with symptomatic mitral stenosis. Several studies have shown that the immediate results are comparable to closed and open mitral valvotomy. METHODS: Percutaneous transatrial mitral commissurotomy was performed in 600 patients with rheumatic mitral stenosis by the double-balloon (290 patients [48.3%]) and flow-guided Inoue balloon (310 patients [51.7%]) techniques. There were 154 male (25.6%) and 446 female (77.4%) patients with a mean [+/- SD] age of 27 +/- 8 years (range 8 to 60). Atrial fibrillation was present in 26 patients (4.3%), mitral regurgitation < or = grade 2 in 62 (10.3%) and densely calcific valve in 12 (2%). All patients had clinical and echocardiographic (two-dimensional, continuous wave Doppler, color flow imaging) follow-up at 3-month intervals. RESULTS: Percutaneous transatrial mitral commissurotomy was successful in 589 patients (98.1%), and optimal commissurotomy was achieved in 562 (93.6%), with an increase in mitral valve area from (mean +/- SD) 0.75 +/- 0.18 to 2.2 +/- 0.38 cm2 (p < 0.001) and a decrease in transmitral end-diastolic gradient from 27.3 +/- 6.1 to 3.8 +/- 4.2 mm Hg (p < 0.001). Mitral regurgitation developed or increased in 208 patients (34.6%). Six patients (1%) with mitral regurgitation required mitral valve replacement. Cardiac tamponade occurred in 8 patients (1.3%). Six patients (1%) died. Restenosis developed in 10 patients (1.7%) during a mean follow-up period of 37 +/- 8 months (range 6 to 66). CONCLUSIONS: Percutaneous transatrial mitral commissurotomy is an effective, safe procedure with gratifying intermediate results. It should be considered the treatment of choice for rheumatic mitral stenosis.

Rate-dependent hemodynamic responses during incremental atrial pacing in chronic constrictive pericarditis before and after surgery.

Chronic constrictive pericarditis is a frequent cause of diastolic dysfunction, and results in impaired ventricular filling. Unlike in normal subjects, ventricular filling in constrictive pericarditis occurs almost entirely in the initial one third of diastole, and cardiac output is dependent predominantly on heart rate. Tachycardia impairs ventricular filling in normal subjects, but its effects in patients with constrictive pericarditis have not been studied. The effect of increasing heart rate alone with atrial pacing on the central and peripheral hemodynamics of patients with untreated chronic constrictive pericarditis before and after pericardiectomy was evaluated. Increased heart rate with atrial pacing increased cardiac output, whereas stroke volume remained unchanged up to heart rates of 140 beats/min. Further increases in heart rate resulted in reductions of cardiac output and stroke volume. There were no significant changes in ventricular filling pressures. Infusion of 300 ml of saline solution at peak pacing rates did not improve cardiac output. After successful surgical pericardiectomy, the hemodynamic effects of atrial pacing returned to normal. It is concluded that moderate tachycardia improves the hemodynamic profile of patients with constrictive pericarditis.

The value of intracardiac electrophysiologic techniques in recurrent syncope of "unknown cause".

We prospectively evaluated and followed-up 45 patients with syncope in whom conventional cardiovascular and neurological investigations did not reveal the cause. All patients underwent electrophysiologic studies to assess the function of the sinus node and the integrity of atrioventricular conduction. These included the ajmaline test and the inducibility of supraventricular or ventricular tachycardia. Seven patients (15.5%) had evidence of sinus node dysfunction, 8 patients (17.7%) had evidence of infra-His atrioventricular block after ajmaline administration and 5 patients (11.1%) had inducible ventricular tachycardia. The remaining 25 patients (55.5%) had non-diagnostic studies. All patients with sinus node dysfunction and inducible infra-His atrioventricular block were asymptomatic during a mean follow-up period of 14.3 +/- 9.5 months after implantation of a permanent pacemaker. Patients with inducible ventricular tachycardia (except 1 with poor left ventricular function who died) were likewise asymptomatic while receiving laboratory guided anti-arrhythmic drug therapy. Twenty-five patients with non-diagnostic studies who were treated empirically are alive but the symptoms persist in 14 (56%). Provocative electrophysiological studies are of diagnostic and therapeutic utility in a significant number of patients with recurrent syncope of "unknown cause".

Assessment of mitral valvar stenosis by echocardiography: utility of various methods before and after mitral valvotomy.

Cross-sectional and Doppler echocardiography are currently the most important non-invasive tests for the evaluation of mitral stenosis. Recent experience has, however, shown that parameters that are reliable before mitral valvotomy may not be valid after the procedure. We have studied the validity of estimation of the area of the mitral valve by echo-planimetry, by Doppler pressure half time and the transmitral end-diastolic pressure gradient calculated by continuous wave Doppler in 100 patients (aged 10-30 years) before and after balloon mitral valvoplasty (n = 70) or surgical closed mitral valvotomy (n = 30). These patients underwent cardiac catheterisation and echocardiographic studies before, immediately after and 8-12 (9.3 +/- 2.2) weeks following balloon valvoplasty or closed valvotomy. The area as estimated echocardiographically correlated well with that obtained by the Gorlin formula before (r = 0.80), but not immediately after (r = 0.67) or on follow up after mitral valvotomy. There was good correlation between Doppler pressure half time and the area as estimated by the Gorlin formula before (r = 0.89) and on follow up after valvotomy (r = 0.82), but the correlation was not as good in the immediate period after valvotomy (r = 0.60). The end-diastolic pressure gradients obtained by Doppler examination and at cardiac catheterisation correlated well with each other before (r = 0.94), immediately after valvotomy (r = 0.92) and on follow up (r = 0.94). Hence, the reliability of estimation of the area of the mitral valve by echo-planimetry and by Doppler pressure half time varies according to the time at which the examination is performed following commissurotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Enalapril as initial and sole treatment in severe chronic heart failure with sodium retention.

Five patients, who had never received any drug treatment but who had severe chronic congestive heart failure with salt and water retention, were studied before and after a single dose of enalapril (10 mg orally). Three patients continued on enalapril as monotherapy (10 mg b.d. orally) for one month. Central haemodynamics, body fluid volumes, renal function and plasma hormones were measured at rest. The initial mean right atrial pressure was 13 +/- 4 mm Hg, pulmonary wedge pressure 29 +/- 4 mm Hg and cardiac index 1.8 +/- 0.21/min/m2. Enalapril, given acutely, caused only small changes. Two patients were withdrawn after the single dose of enalapril and treated with diuretics for clinical reasons. The remaining three patients each lost more than 4 kg in weight after one month of treatment with enalapril alone. Total body exchangeable sodium and total body water were reduced but central haemodynamics were unchanged. Although enalapril was of some benefit when given alone to patients with severe congestive heart failure, all five patients were finally treated with diuretics for clinical reasons. Enalapril is not recommended as the initial and only therapy for patients with severe congestive heart failure.

Mitral regurgitation following percutaneous transvenous mitral commissurotomy: a single-center experience.

BACKGROUND AND AIM OF THE STUDY: Percutaneous transvenous mitral commissurotomy (PTMC) has revolutionized the treatment of patients with symptomatic mitral stenosis and is now established as the procedure of choice. Despite high technical expertise in PTMC using the Inoue balloon, mitral regurgitation (MR) remains a major procedure-related complication. We retrospectively analyzed our data of PTMC using the Inoue balloon with regard to the incidence of MR, its likely causative mechanism, and follow up of these patients. METHODS: During the past ten years, PTMC was performed in 3,650 patients (median age 26 years; range: 8-76 years), of whom 910 (24.9%) were juveniles. Preprocedure mitral valve area (MVA) was 0.9 +/- 0.4 cm2 (range: 0.3-1.3 cm2); MR was mild in 1,396 cases (38.2%), moderate in 394 (10.8%) and severe in 22 (0.6%). None of the patients was rejected on the basis of echocardiographic score. RESULTS: The procedure was successful in 3,276 (89.8%), with post-procedure MVA of 1.7 +/- 0.6 cm2 (range: 1.4-2.6 cm2), and without development of any major complication. Severe MR was seen in 120 patients (3.3%), of whom 66 (1.8%) required urgent mitral valve replacement (MVR). Echocardiography in these latter patients showed leaflet rupture in 48 (72.7%), chordal rupture in 12 (18.2%) and excessive commissural tear in six (9.1%). Fifty-four patients (1.5%) with severe MR post PTMC were followed with medical treatment; echocardiography in these patients revealed chordal rupture in 40 (74.1%) and excessive commissural tear in 14 (25.9%). Follow up data were available in 49 patients (1.3%); 30 (0.8%) required MVR and 19 (0.5%) were in NYHA class II at a median follow up of 24 months. Moderate MR was seen in 188 cases (5.1%), with predominant causative mechanisms of excessive commissural tear in 120 (63.8%) and chordal rupture in 68 (36.2%). Severity of MR worsened in 30 cases (0.8%), of which 20 (0.6%) required elective MVR on follow up. MR decreased in 58 patients (1.6%), in whom excessive commissural tear was the causative mechanism. CONCLUSION: Significant MR (moderate or severe) after PTMC was seen in 308 patients (8.4%), of whom 116 (3.2%) required MVR urgently or on follow up. All patients with leaflet rupture during PTMC developed severe MR and required urgent MVR. There was a tendency for the severity of MR to decrease with time in cases where excessive commissural tear was the causative mechanism.

Propagation of linear waves in relativistic anisotropic magnetohydrodynamics.

Gedalin [Phys. Rev. E 47, 4354 (1993)] derived a dispersion relation for linear waves in relativistic anisotropic Magnetohydrodynamics (MHD). This dispersion relation is used to point out the regions where the relativistic anisotropic MHD leads to new results that cannot be obtained using usual collisional relativistic MHD. This is highlighted by plotting a Fresnal ray surface. Conditions for the onset of firehose and mirror instabilities are also indicated. Such a study can be applied to astrophysical features such as pulsar winds, propagation of cosmic rays, etc.

Fasciocutaneous flaps for burn contractures of the axilla.

Fasciocutaneous flaps do not compromise the function of joints, are less bulky and are easier to dissect. Their use prevents the uncomfortable prolonged splintage of the axilla with the shoulder in abduction which follows split skin grafting. Fasciocutaneous flaps are reliable and failure is minimal, if at all, unlike split skin grafting. Parascapular, lateral thoracic and cervicohumeral fasciocutaneous flaps have been used in 23 patients (aged 8-36 years) with a total of 30 flaps. The mean hospital stay was 12 days and no recurrence of the contracture was observed in the follow-up period of 3-18 months.

Tessier number 2 cleft, a variation. Case report.

The number 2 craniofacial cleft as described by Tessier is an extremely rare cleft of unknown aetiology with distinct soft tissue and bony characteristics. The location of the deformity on the nostril rim is a distinguishing feature of the cleft. It traverses the alveolar arch at the level of the lateral incisor, middle third of the alar rim, the junction between the nasal bone and the frontal process of the maxilla and continues cranially as a number 12 cleft. One such patient with bilateral interruption of the middle third of the alar rim and mild asymmetrical hypertelorism is described.

Persistent buccopharyngeal membrane: a report of two cases.

Persistent buccopharyngeal membrane is an extremely rare clinical entity that can be diagnosed easily by simple examination of the oral cavity and confirmed by a lateral contrast x-ray. The abnormality can be easily corrected surgically.

Atrial septal defect after balloon mitral valvuloplasty: a transesophageal echocardiographic study.

Fifty patients with rheumatic mitral stenosis aged twelve to thirty-six (twenty +/- six) years were studied by two-dimensional, pulsed and color Doppler echocardiography during, seventy-two hours after, and biweekly for three months after balloon mitral valvuloplasty (BMV). Transesophageal echocardiography (TEE) done immediately after BMV (in the catheterization laboratory) detected a new atrial septal defect (ASD) in 46 (92%) patients. These measured 1 to 2 (mean 1.2 +/- 0.3) mm in diameter. Doppler color flow mapping guided the location of the ASD in most of the cases. A narrow jet of left-to-right shunt could be evaluated by pulsed Doppler studies. Velocity time integral (VTI) of the jet across one cardiac cycle and the diameter of the ASD were used to calculate the left-to-right shunt (shunt = VTI x pi (D/2)2 x heart rate). The estimated shunt was 0.04-0.39 (mean 0.20 +/- 0.10) L/minute. A repeat study at seventy-two hours revealed the defect in 40 (80%) patients. At three months, the defect persisted in only 5 (10%) cases. The mean interval of closure of ASD was 4.6 +/- 2.2 weeks. The authors conclude: (1) ASD occurs commonly after BMV, (2) the septal defect and the resultant left-to-right shunt are insignificant, and (3) ASD disappears in the majority of cases by three months after BMV.

Balloon dilatation of native coarctation of aorta in infancy: immediate and follow up results.

We attempted balloon dilatation of native coarctation of aorta in 11 consecutive neonates and infants (age range 28 days-12 months, mean 4.6 +/- 4 months, all males) presenting with congestive heart failure. The peak to peak aorto-aortic systolic pressure gradient fell from 60 +/- 21 mmHg to 13 +/- 7 mmHg (range 0-30 mmHg) (p < 0.001). The diameter of coarcted segment increased from 2.5 +/- 0.65 mm (range 2-3.4 mm) to 5.4 +/- 0.9 mm (range 4-6.4 mm) (p < 0.001). No patient required surgical intervention. The peak instantaneous aorto-aortic systolic Doppler pressure gradient at 17.5 +/- 8.8 months (range 2-21 months) did not show any significant change (mean 17.5 +/- 8.89 mmHg range 0-30 mmHg). All patients except one showed improvement in congestive heart failure. None developed restenosis. On the basis of this experience we recommend that balloon dilatation of native coarctation of aorta in infants in congestive heart failure is a safe and effective procedure.