Efficacy of Revision Using Distal Inflow in Patients with Symptomatic Dialysis Access-Associated Steal Syndrome.

Objectives: In this study, we aim to assess the efficacy of revision using distal inflow (RUDI) in patients with symptomatic dialysis access-associated steal syndrome (DASS). Materials and Methods: All consecutive patients who were diagnosed with grade 3 or 4 DASS and have undergone RUDI in 4 years were included in this study. Results: In total, 35 patients were included in this study; participants had a mean age of 47.5±7.52 years and 54% (n=19) were males. As per our findings, significant improvement was noted in terms of paresthesia (81.2%, p-value: 0.012), coolness (79.4%, p-value: 0.006), pain (78.1%, p-value: 0.006), discoloration (76.4%, p-value: 0.044), paresis (71.4%, p-value: 0.016), and ulcer healing (50%, p-value: 0.044). Gangrene did not further progress in all patients (n=35). Reduction in fistula flow rate after RUDI was 57.5% (682±121 ml/min, p-value: 0.001). Digital systolic pressure was noted to improve by 71.4% (60±9.2 mmHg, p-value: 0.002) after RUDI. Peak systolic velocity increased in both ulnar (66.1±8.2 cm/s, p-value: 0.04) and radial (64.2±7.6 cm/s, p-value: 0.024) arteries of the wrist. Cumulative patency of RUDI graft was 100%, 91.4%, and 85.7% at 3, 6, and 12 months, respectively. Conclusion: RUDI has resulted in significant improvements in terms of DASS symptoms. Using a native vein as conduit, RUDI should be considered a procedure of choice for patients with high-flow DASS.

Comparison Between Early Appendectomy vs. Conservative Management in Cases of Appendicular Mass.

INTRODUCTION: At present, the treatment of choice for appendicular masses is unclear. Recent studies claimed that conservative management of appendicular masses was safe in terms of frequency of perforation. However, there is controversy in the existing literature. OBJECTIVE: This research is designed to compare the results of early appendectomy versus conservative management of appendicular masses. MATERIAL AND METHODS: It was a randomized controlled trial performed in the Combined Military Hospital, Lahore. The study lasted six months, from 01/03/2019 to 30/09/2019. It involved 60 patients of both genders aged between 16 and 70 years diagnosed with appendicular masses with an Alvarado score of 4-7. These patients were randomly divided into two treatment groups. In Group A patients, an early appendectomy was performed, while patients in Group B were managed conservatively. Outcome variables were the mean length of hospital stay and frequency of appendicular perforation. RESULTS: The mean age of the patients was 26.8±11.9 years. There were 33 (55.0%) male and 27 (45.0%) female patients, with a male-to-female ratio of 1.2:1. The mean length of hospital stay was significantly longer in patients managed conservatively as compared to those undergoing early appendectomy (2.80±1.54 vs. 1.83±0.83; p=0.004). However, the frequency of perforation was not significantly higher in the conservative group as compared to the early appendectomy group (16.7% vs. 10.0%; p=0.448). CONCLUSION: Conservative management of patients with appendicular mass was associated with prolonged hospital stays, yet it was found equally safe in terms of frequency of appendicular perforation, which advocates conservative management of patients with appendicular mass, particularly in high-risk patients.

Clinical Efficacy Of Infra Popliteal Angioplasty For Below The Knee Peripheral Vascular Occlusive Disease.

BACKGROUND: Peripheral arterial disease (PAD) affects a substantial proportion of the global population, particularly older individuals, affecting around 200 million people worldwide highlighting its significant impact on human health. Critical limb ischemia (CLI) is the most severe clinical presentation of PAD characterized by ischemic rest pain tissue ulceration or gangrene. The objective of the study is to assess the efficacy of infra popliteal angioplasty (in terms of wound healing and limb salvage) in patients with below-the-knee total chronic occlusion (TCO). METHODS: In this cross-sectional study, all consecutive patients in one year with TCO and fulfilling the inclusion criteria were included. RESULTS: A total of 64 limbs underwent angioplasty. The mean age was 55.38 ± 13.12 (Range 22-88) years and there were 73% (n=47) males. Diabetes mellitus was the most prevalent risk factor in 59.4% (n=38) of patients. 48.4 % (n=31) of patients had below-knee TCO in all three arteries. Technical Success was achieved in 95.3% (n=61/64). All 3 patients who had technical failure ended up with below-the-knee amputation. Furthermore, 2 more patients who had technical success also ended up with below-the-knee amputation. The difference between these two rates was significant (100% vs 3.3%; p-value =0.004). In terms of wound healing, statistically significant improvement was noted within the first 6 months (p-value = 0.05). The limb salvage rate was 90.6% (n=59/64). The primary patency rate was 81.3% (n=52) and 76.6% (n=49) at 6 and 12 months respectively. CONCLUSIONS: Angioplasty results in statistically significant wound healing leading to a higher limb salvage rate, in patients with TCO of infrapopliteal arteries.

Hold your breath - Differential behavioral and sensory acuity of mosquitoes to acetone and carbon dioxide.

Host seeking in the yellow fever mosquito, Aedes aegypti, and the African malaria mosquito, Anopheles coluzzii, relies on specific and generic host-derived odorants. Previous analyses indicate that the behavioral response of these species depends differentially on the presence of carbon dioxide (CO2) and other constituents in human breath for activation and attraction. In this study, we use a flight tube assay and electrophysiological analysis to assess the role of acetone, a major component of exhaled human breath, in modulating the behavioral and sensory neuronal response of these mosquito species, in the presence and absence of CO2. When presented alone at ecologically relevant concentrations, acetone increases attraction in Ae. aegypti, but not in An. coluzzii. Moreover, in combination with CO2, human breath-equivalents of acetone ranging between 0.1 and 10 ppm reproduces a behavioral response similar to that observed to human breath in host-seeking Ae. aegypti, but not in An. coluzzii. Acetone does, however, reduce attraction to CO2 in An. coluzzii, when presented at a higher concentration of 10 ppm. We identify the capitate peg A neuron of the maxillary palp of both species as a dual detector of CO2 and acetone. The sensory response to acetone, or binary blends of acetone and CO2, reflects the observed behavioral output in both Ae. aegypti and An. coluzzii. We conclude that host recognition is contextual and dependent on a combination of ecologically relevant odorants at naturally occurring concentrations that are encoded, in this case, by differences in the temporal structure of the neuronal response. This information should be considered when designing synthetic blends for that optimally attract mosquitoes for monitoring and control.

Detection and perception of generic host volatiles by mosquitoes: responses to CO2 constrains host-seeking behaviour.

Natural selection has favoured specialization in anthropophilic mosquito host choice, yet in the absence of human hosts, females feed on a selected range of vertebrates. For host recognition, we hypothesize that mosquitoes primarily rely on generic host volatiles. Detection and perception of such compounds would provide the mosquito with a flexible, yet constrained, odour coding system that could delineate host preference. In this study, we show that the quintessential generic volatile for host-seeking, carbon dioxide, activates and attracts the malaria mosquito, Anopheles coluzzii, and the arbovirus vectors, Aedes aegypti and Culex quinquefasciatus, within boundaries set by the dynamic range and coding capacity of the CO2-sensitive olfactory receptor neurons. These boundaries are sufficiently broad to elicit behavioural responses to various hosts within their preferred host range. This study highlights the significance of the sensitivity of the carbon dioxide detection system and its regulation of host seeking and recognition.

Larval Habitat Substrates Could Affect the Biology and Vectorial Capacity of Culex quinquefasciatus (Diptera: Culicidae).

Culex quinquefasciatus Say is an important disease vector throughout much of the world. Experiments were conducted to determine the effects of different larval habitat substrates on the fitness and biting efficiency of Cx. quinquefasciatus adults. Our findings indicate that the development time (egg to adult) of larvae reared in irrigation water was 8.63 d while that of larvae reared in distilled water was 17.10 d (Effect size = 0.95). However, the rate of adult emergence was similar for all the tested treatments. Furthermore, the mean weight of an egg raft varied between larval habitats: distilled water (1.83 mg), rainfall water (1.25 mg), irrigation water (1.52 mg), and sewerage water (2.52 mg) (Effect size = 0.91). But, the fecundity (eggs per female) and hatchability (%) were statistically similar in all the rearing mediums (Effect size = 0.79). Longevity of females in all the tested populations did not differ significantly (Effect size = 0.91). The mean relative growth rates of larvae reared in tap water (0.80) and distilled water (0.86) habitats were lower than growth rates in all other rearing habitats (Effect size = 0.96). The intrinsic rate of natural increase in tap water (0.27) and irrigation water (0.35) was significantly higher than that in distilled water (0.09) and sewerage water (0.16) (Effect size = 0.84). Adults reared in rain water had the highest biting efficiency among all the tested populations. These results provide useful information for the management of Cx. quinquefasciatus.

Detection and perception of generic host volatiles by mosquitoes modulate host preference: context dependence of (R)-1-octen-3-ol.

Natural selection favours a restricted host breadth in disease vector mosquitoes, indicating that there is an adaptive value associated with maintaining plasticity in host preference. One mechanism to maintain such plasticity is via the detection of generic cues by conserved peripheral olfactory pathways, which when perceived in different host odour contexts enable the identification of and discrimination among potential host species. Here, we show that the context of an odour cue shapes host perception in mosquitoes, by altering the release rate of the generic host-related volatile (R)-1-octen-3-ol, within its natural range, and in the background odour of known hosts and non-hosts. This result highlights that host recognition is contextual and dependent on quantitative and qualitative differences in odour blends and the olfactory codes evoked. From the perspective of vector management, understanding the perception of odour blends and their context is essential to the process of developing synthetic blends for the optimal attraction of mosquitoes in efforts to control and monitor populations.

In Vitro Evaluation of Biocompatibility of Uncoated Thermally Reduced Graphene and Carbon Nanotube-Loaded PVDF Membranes with Adult Neural Stem Cell-Derived Neurons and Glia.

Graphene, graphene-based nanomaterials (GBNs), and carbon nanotubes (CNTs) are being investigated as potential substrates for the growth of neural cells. However, in most in vitro studies, the cells were seeded on these materials coated with various proteins implying that the observed effects on the cells could not solely be attributed to the GBN and CNT properties. Here, we studied the biocompatibility of uncoated thermally reduced graphene (TRG) and poly(vinylidene fluoride) (PVDF) membranes loaded with multi-walled CNTs (MWCNTs) using neural stem cells isolated from the adult mouse olfactory bulb (termed aOBSCs). When aOBSCs were induced to differentiate on coverslips treated with TRG or control materials (polyethyleneimine-PEI and polyornithine plus fibronectin-PLO/F) in a serum-free medium, neurons, astrocytes, and oligodendrocytes were generated in all conditions, indicating that TRG permits the multi-lineage differentiation of aOBSCs. However, the total number of cells was reduced on both PEI and TRG. In a serum-containing medium, aOBSC-derived neurons and oligodendrocytes grown on TRG were more numerous than in controls; the neurons developed synaptic boutons and oligodendrocytes were more branched. In contrast, neurons growing on PVDF membranes had reduced neurite branching, and on MWCNTs-loaded membranes oligodendrocytes were lower in numbers than in controls. Overall, these findings indicate that uncoated TRG may be biocompatible with the generation, differentiation, and maturation of aOBSC-derived neurons and glial cells, implying a potential use for TRG to study functional neuronal networks.

Functional development of carbon dioxide detection in the maxillary palp of Anopheles gambiae.

Olfactory information drives several behaviours critical for the survival and persistence of insect pests and vectors. Insect behaviour is variable, linked to their biological needs, and regulated by physiological dynamics. For mosquitoes, CO2 is an important cue that signifies the presence of a host, and which elicits activation and attraction. To investigate the genetic basis of olfactory modulation in mosquitoes, we assayed changes in CO2 detection from receptor gene expression through physiological function to behaviour, associated with the onset of host seeking in the malaria vector, Anopheles gambiae. The gene encoding a subunit of the CO2 receptor, AgGr22, was found to be significantly up-regulated in host-seeking females, consistent with a significant increase in sensitivity of CO2-responsive neurons (cpA) housed in capitate peg sensilla of the maxillary palp. In addition, the odorant receptor AgOr28, which is expressed in cpC neurons, was significantly up-regulated. In contrast, AgOr8, which is expressed in cpB neurons, was not affected by this change in physiological state, in agreement with results for the obligate co-receptor Orco. Moreover, the sensitivity of the cpB neuron to (R)-1-octen-3-ol, a well-known mammalian kairomone, did not change in response to the onset of host seeking. The concentration of CO2 flux influenced both the propensity of A. gambiae to take off into the wind and the speed with which this activation occurred. Female A. gambiae mosquitoes responded to CO2 whether mature for host seeking or not, but onset of host seeking enhanced sensitivity and speed of activation at relevant doses of CO2.

COMPARISON OF OPEN AND CLOSED TECHNIQUES OF HAEMORRHOIDECTOMY IN TERMS OF POST-OPERATIVE COMPLICATIONS.

BACKGROUND: Haemorrhoids have been diagnosed and treated since the dawn of civilization, yet their cause, nature, symptomatology and especially their treatment options, remain hotly debated. The general principle however is that treatment should be directed by symptoms and the degree of haemorrhoids. The objective of the study is to compare early and late complications and wound healing time in open versus closed methods of haemorrhoidectomy. METHODS: This was a Randomized control trial conducted at Department of Surgery CMH Kharian for a period of 3 years. During the period of study, patients presenting in Surgical OPD (Age Range 20-72 Years) with 3rd or 4th degree haemorrhoids requiring haemorrhoidectomy (n = 364) were divided in two groups:--Group-1 was subjected to haemorrhoidectomy by open (Milligan-Morgan) technique and Group-2 underwent closed (Ferguson) haemorrhoidectomy. All patients were followed up for 2 months post-operatively and assessed for duration of wound healing and post-operative complications. RESULTS: In group-1 (Open haemorrhoidectomy) patients' ages ranged from 21-70 years with a mean age of 43 years (SD ± 12.51). Duration of wound healing in this group was on the average 22 days (SD ± 5.76). Incidence of early post-operative complications including haemorrhage, infection and urinary retention was 4.94%, 8.24% and 7.14% respectively. The only late complication observed was anal stenosis in one patient (0.55%). No fissure or faecal incontinence was observed in this group. In group-2 (subjected to closed haemorrhoidectomy), patients' ages ranged from 20-72 years with a mean age of 42 years (SD ± 10.31). Duration of wound healing was on the average 14 days (SD ± 3.25). Incidence of early post- operative complications, i.e., haemorrhage, infection and urinary retention was 2.19%, 7.69% and 2.75% respectively. No late complications (stenosis, fissure or incontinence) were observed in this group. CONCLUSION: There is no statistical significant difference between open and closed haemorrhoidectomy for the treatment of 3rd and 4th degree haemorrhoids in terms of wound healing time and post-operative complications.

Missed vascular injuries: presentation and outcome.

OBJECTIVE: To describe the different presentation, diagnostic evaluation, management and outcome of complications of missed vascular injuries. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Combined Military Hospital, Rawalpindi and Combined Military Hospital, Kharian Cantt, from June 2009 to June 2012. METHODOLOGY: All the patients with vascular injuries missed at the time of causative trauma who reported during this study period were included. Patients presented with acute vascular injuries and iatrogenic aneurysm at the vascular anastomosis site were excluded. All cases were evaluated with either CT or conventional angiography and managed with various open vascular surgical techniques and their results were assessed. RESULTS: Twenty eight patients with missed vascular injury underwent various vascular repairs. Age of patients ranged from 16 to 78 years (mean = 33.7 ± 15.4 years). Male to female ratio was 6:1. Twelve (42.8%) patients presented with pseudoaneurysm alone, 10 (35.7%) with traumatic arteriovenous fistulae, 4 (14.3%) with post-traumatic thrombosis and occlusion and 2 (7.1%) with pseudoaneurysm and hemorrhage. Penetrating injuries were the commonest cause in 19 (67.8%). The time interval between injury and presentation in hospital ranged from 2 to 1300 weeks (mean 228 weeks). Lower limb vessels were affected in 20 (71.4%), the upper limb in 5 (17.8%) and neck vessels in 3 (10.7%). Superficial femoral artery was the most frequently involved artery in 9 (32.1%) cases. Interposition reverse autogenous saphenous vein graft was most common type of repair in all types of missed vascular injuries. One (3.5%) patient had amputation after secondary hemorrhage. CONCLUSION: Low velocity penetrating trauma was the common cause of missed vascular injury. Pseudoaneurysm was the most common presentation.

Polypropylene suture versus skin staples for securing mesh in lichtenstein inguinal hernioplasty.

OBJECTIVE: To compare polypropylene suture and skin staples for securing mesh in Lichtenstein inguinal hernioplasty in terms of mean operating time and postoperative pain. STUDY DESIGN: Randomized clinical trial. PLACE AND DURATION OF STUDY: Surgical Ward, Combined Military Hospital, Kharian, from August 2011 to February 2012. METHODOLOGY: All individuals fulfilling inclusion criteria underwent elective Lichtenstein inguinal hernioplasty as admitted patients, under spinal anaesthesia and with aseptic measures. In group 1, during the operation, mesh fixation was done with 2/0 polypropylene suture and skin was closed with subcuticular 2/0 polypropylene suture whereas in group 2, the anchorage of mesh was done with skin staples and skin was closed with staples from the same stapler. Mean operative time and postoperative pain, assessed on a visual analog score, were compared between the groups. RESULTS: The overall postoperative pain was lower (p = 0.026) when staples were used to anchor mesh. Moreover, operative time was also lower (37.42 ± 2.69 minutes) in staple group versus (42.44 ± 2.55 minutes in polypropylene group). CONCLUSION: Mean operating time and postoperative pain is less in securing mesh with skin staples as compared to polypropylene suture in Lichtenstein inguinal hernioplasty.

Impact of elevated CO2 background levels on the host-seeking behaviour of Aedes aegypti.

Mosquitoes rely on carbon dioxide (CO2) to detect and orient towards their blood hosts. However, the variable and rapid fluctuations of atmospheric CO2 concentrations may have an impact on the host-seeking behaviour of mosquitoes. In this study, we analysed the effect of transient elevated background levels of CO2 on the host-seeking behaviour and the physiological characteristics of the CO2-sensitive olfactory receptor neurones (ORNs) in female yellow fever mosquitoes, Aedes aegypti. We show that the take-off and source contact behaviour of A. aegypti is impeded at elevated background levels of CO2 as a result of masking of the stimulus signal. The mechanism underlying this masking during take-off behaviour is one of sensory constraint. We show that the net response of the CO2-ORNs regulates this CO2-related behaviour. Since these neurones themselves are not habituated or fatigued by the transient elevation of background CO2, we propose that habituation of second-order neurones in response to the elevated CO2-ORN activity could be one mechanism by which the net response is transduced by the olfactory system. The findings from this study may help to predict future shifts in mosquito-host interactions and consequently to predict vectorial capacity in the light of climate change.

Pyrene-POSS nanohybrid as a dispersant for carbon nanotubes in solvents of various polarities: its synthesis and application in the preparation of a composite membrane.

In this study we report the preparation of nanohybrid dispersant molecules based on pyrene and polyhedral oligomeric silsesquioxanes for non-covalent functionalization of multi-walled carbon nanotubes (MWCNTs). The prepared dispersant improves the dispersion of MWCNTs in organic solvents with very different polarities such as tetrahydrofuran, toluene, and n-hexane. The functionalized MWCNTs were used to introduce conductivity into polydimethylsiloxane membranes which can be used for electrostatic discharge applications.

Mesenteric neurofibromatosis.

Neurofibromatosis (NF) is a group of heterogeneous multisystemic neurocutaneous disorders that may affect any organ in the body and clinical presentation depends on the body system involved. We present a case of a middle-aged male who presented with a relatively fast growing abdominal mass in the hypogastric and right inguinal area, associated with diarrhea. At laparotomy, a large, solid mass was found in the lower mesentery with loops of small intestine adherent to it. Mass was removed in total along with the loops of intestine and was found to be neurofibroma of mesentery on histopathology.

Mucormycosis: a devastating fungal infection in diabetics.

Mucormycosis is a highly invasive, devastating and usually fatal fungal infection of the sinuses, brain, or lungs that occurs primarily in people with immune disorders. Despite advances in diagnosis and treatment, a high mortality still exists. We present a middle aged diabetic male with this serious fungal infection involving nose, paranasal area and adjacent periorbital regions with a high risk of progressing further towards the dura mater. He was promptly diagnosed and managed with serial surgical debridements with systemic antifungals and was later fitted with a nasal prosthesis.

Lingual thyroid as a cause of snoring and sleep apnea.

Lingual thyroid is a rare developmental abnormality. We describe a case of lingual thyroid in a 28 years old female who presented with symptoms of heroic snoring and obstructive sleep apnea. She was treated with surgery and was advised a life long thyroid hormone replacement therapy.

Neurofibromatosis and Caroli's disease: an extremely rare association.

Neurofibromatosis type-1 (NF-1) is a rare genetic disorder with an extremely variable phenotype. A broad spectrum of associations have also been reported with it. We present a florid case of NF, presenting with unusual symptoms, which was found to have an associated Caroli's disease, a rare congenital disorder of the intrahepatic bile ducts. The case is reported along with a brief review of both the disorders.