Predictive factors for recurrence and outcomes in T1a renal cell carcinoma: Analysis of the INMARC (International Marker Consortium for Renal Cancer) database.

OBJECTIVE: Stage migration in renal cell carcinoma (RCC) has led to an increasing proportion of diagnosed small renal masses. Emerging knowledge regarding heterogeneity of RCC histologies and consequent impact on prognosis led us to further explore outcomes and predictive factors in surgically-treated T1a RCC. METHODS: The INMARC database was queried for T1aN0M0 RCC. Patients were stratified into groups based on recurrence. Primary outcome was overall survival (OS). Multivariable analyses (MVA) were performed for factors associated with recurrence, cancer-specific (CSM), and all-cause mortality (ACM). Kaplan-Meier analyses (KMA) assessed survival by histology and grade. Subset analysis for time to recurrence was conducted for grade and histologic groups and compared with recent AUA follow-up guidelines [low-risk (AUA-LR), intermediate-risk (AUA-IR), high-risk (AUA-HR), and very-high risk (AUA-VHR) groups]. RESULTS: We analyzed 1,878 patients (median follow-up 35.2 months); 101 (5.4%) developed recurrence. MVA for recurrence demonstrated increasing age (P = 0.026), male sex (P = 0.043), diabetes (P = 0.007), high/unclassified grade (P < 0.001-0.007), and variant histology (P = 0.017) as independent risk factors for increased risk, while papillary (P = 0.016) and chromophobe (P = 0.049) were associated with decreased risk. MVA identified high/unclassified grade (P = 0.003-0.004) and pT3a upstaging (P = 0.043) as predictive factors for worsened risk of CSM while papillary (P = 0.034) was associated with improved risk. MVA for ACM demonstrated increasing age (P < 0.001), non-white (P < 0.001), high-grade (P = 0.022), variant histology (P = 0.049), recurrence (P = 0.004), and eGFR<45 at last follow-up (P < 0.001) to be independent risk factors. KMA comparing clear cell, chromophobe, papillary, and variant RCC revealed significant differences for 5-year CSS (P = 0.018) and RFS (P < 0.001), but not OS (P = 0.34). Median time to recurrence was 23.8 months for low-grade (AUA-LR), 17.3 months for high-grade (AUA-IR), 18 months for pT3a upstaging (AUA-HR), and 12 months for variant histology (AUA-VHR; P < 0.001). CONCLUSION: We noted differential outcomes in T1a RCC based on histology and grade for recurrence and CSM, while renal functional decline in addition to pathological factors and recurrence were predictive for ACM. Our findings support recently promulgated AUA follow-up guidelines for low-grade and variant histology pT1a RCC, but call for consolidation of follow-up protocols for high-grade pT1a and pT3a upstaged patients, with intensification of frequency of imaging follow-up in pT1a high-grade RCC.

Linear Muscle Segmentation for Metastatic Renal Cell Carcinoma: Changes in Clinic-Friendly Estimation Predict Survival Following Cytoreductive Nephrectomy.

INTRODUCTION: Baseline sarcopenia and postoperative changes in muscle mass are independently associated with overall survival (OS) in patients with metastatic renal cell carcinoma (mRCC) undergoing cytoreductive nephrectomy (CN). Here we examine the relationships between preoperative (baseline), postoperative changes in muscle quantity, and survival outcomes following CN as determined by linear segmentation, a clinic-friendly tool that rapidly estimates muscle mass. MATERIALS AND METHODS: Our nephrectomy database was reviewed for patients with metastatic disease who underwent CN for RCC. Linear segmentation of the bilateral psoas/paraspinal muscles was completed for baseline imaging within 60 days of surgery and imaging 30 to 365 days postoperatively. Kruskal-Wallis for numerical and Fisher's exact test for categorical variables were used to test for differences between groups according to percent change in linear muscle index (LMI, cm2/m2). Multivariable Cox proportional hazards models evaluated associations between LMI percent change and cancer-specific (CSM) and all-cause mortality (ACM). Kaplan Meier curves estimated cancer-specific (CSS) and overall survival (OS). RESULTS: From 2004-2020, 205 patients were included of whom 52 demonstrated stable LMI (25.4%; LMI change < 5% [0Δ]), 60 increase (29.3%; LMI +5% [+Δ]), and 92 decrease (44.9%; LMI -5% [-Δ]). Median time from baseline imaging to surgery was 18 days, and time from surgery to postoperative imaging was 133 days. Median CSS and OS were highest among patients with 0Δ LMI (CSS: 133.6 [0Δ] vs. 61.9 [+Δ] vs. 37.4 [-Δ] months; P = .0018 || OS: 67.2 [0Δ] vs. 54.8 [+Δ] vs. 29.5 [-Δ] months; P = .0007). Stable LMI was a protective factor for CSM (HR 0.48; P = .024) and ACM (HR 0.59; P = .040) on multivariable analysis. DISCUSSION: Change in muscle mass after CN, as measured by the linear muscle segmentation technique, is independently associated with OS and CSS in patients following CN. Of note, lack of change was associated with longer survival.

Performance of Future Glomerular Filtration Rate Equation by Race in a Large, Racially Diverse Patient Cohort Undergoing Nephrectomy for Renal Cell Carcinoma.

OBJECTIVE: To examine the performance of the Palacios et al [Aguilar Palacios D, Wilson B, Ascha M, et al. New baseline renal function after radical or partial nephrectomy: a simple and accurate predictive model. J Urol. 2021;205:1310-1320] post-nephrectomy future glomerular function rate (fGFR) equation in a diverse cohort using both the Chronic Kidney Disease Epidemiology (CKD-EPI) 2009 equation with race, used in the creation of the formula, as well as the CKD-EPI 2021 equation without race. METHODS: Patients who underwent partial or radical nephrectomy for renal cell carcinoma from 2005-2021 were identified in our institutional database. Patients with creatinine values preoperatively and 3-12 months postoperatively were included. Correlation/bias/accuracy/precision of the fGFR equation (fGFR = 35+ [preoperative eGFR × 0.65] - 18 [if radical] - [age × 0.25] + 3 [if tumor >7 cm] - 2 [if diabetes]) with observed postoperative eGFR was determined by both the CKD-EPI-2021 and CKD-EPI 2009 equations. RESULTS: A total of 1443 patients were analyzed. Seventy-one percent (1024) were White and 22.9% (331) were Black. Most underwent radical nephrectomy (60.3%). 40% T3-T4 renal cell carcinoma (RCC), with 14.8% of patients having M1 disease. Median observed vs predicted fGFR was 58.0 vs 58.7 mL/min/1.73 m2 for CKD-EPI 2021 and 56.0 vs 57.5 for CKD-EPI 2009. For the total cohort, the correlation/bias/accuracy/precision of the fGFR equation was 0.805/-0.5/81.7/7.9-9.0 for CKD-EPI 2021 and 0.809/-0.8/81.3/-8.1 to 8 for CKD-EPI 2009. In Black patients, fGFR equation demonstrated >75% accuracy with both CKD-EPI equations; however, accuracy was lower in black patients with the CKD-EPI2021 equation (76.1% vs 83.4%, P = .003). CONCLUSION: The fGFR equation performed well in our large, diverse cohort, though accuracy was relatively lower when using CKD-EPI 2021 compared to CKD-EPI 2009.

Creatinine to Cystatin-C Ratio in Renal Cell Carcinoma: A Clinically Pragmatic Prognostic Factor and Sarcopenia Biomarker.

INTRODUCTION: Low creatinine to cystatin-C ratio (Cr/Cys-C) may be a biomarker for low-muscle mass. Furthermore, low Cr/Cys-C is associated with decreased overall survival (OS), but to date, has not been examined in patients with renal cell carcinoma (RCC). Our objective is to evaluate associations between low Cr/Cys-C ratio and OS and recurrence-free survival (RFS) in patients with RCC treated with nephrectomy. METHODS: We performed a retrospective review of patients with RCC treated with nephrectomy. Patients with end-stage renal disease and less than 1-year follow up were excluded. Cr/Cys-C was dichotomized at the median for the cohort (low vs. high). OS and RFS for patients with high versus low Cr/Cys-C were estimated with the Kaplan-Meier method, and associations with the outcomes of interest were modeled using Cox proportional Hazards models. Associations between Cr/Cys-C and skeletal muscle mass were assessed with correlations and logistic regression. RESULTS: A total of 255 patients were analyzed, with a median age of 64. Median (IQR) Cr/Cys-C was 1 (0.8-1.2). Low Cr/Cys-C was associated with age, female sex, Eastern Cooperative Oncology Group Performance Status ≥1, TNM stage, and tumor size. Kaplan-Meier and Cox regression analysis demonstrated an association between low Cr/Cys-C and decreased OS (HR = 2.97, 95%CI, 1.12-7.90, P =0.029) and RFS (HR = 3.31, 95%CI, 1.26-8.66, P = .015). Furthermore, a low Cr/Cys-C indicated a 2-3 increase in risk of radiographic sarcopenia. CONCLUSIONS: Lower Cr/Cys-C is associated with inferior oncologic outcomes in RCC and, pending validation, may have utility as a serum biomarker for the presence of sarcopenia in patients with RCC treated with nephrectomy.

Barriers and facilitators to physical activity prehabilitation in patients with kidney cancer.

PURPOSE: Timely and effective physical activity (PA) prehabilitation is an evidence-based approach for improving a patient's health status preoperatively. Identifying barriers and facilitators to PA prehabilitation can help inform best practices for exercise prehabilitation program implementation. We explore the barriers and facilitators to PA prehabilitation in patients undergoing nephrectomy. METHODS: A qualitative exploratory study was conducted by interviewing 20 patients scheduled for nephrectomy. Interviewees were selected via convenience sampling strategy. The interviews were semi-structured and discussed experienced and perceived barriers/facilitators to PA prehabilitation. Interview transcripts were imported to Nvivo 12 for coding and semantic content analysis. A codebook was independently created and collectively validated. Themes of barriers and facilitators were identified and summarized in descriptive findings based on frequency of themes. RESULTS: Five relevant themes of barriers to PA prehabilitation emerged: 1) mental factors, 2) personal responsibilities, 3) physical capacity, 4) health conditions, and 5) lack of exercise facilities. Contrarily, facilitators potentially contributing to PA prehabilitation adherence in kidney cancer included 1) holistic health, 2) social and professional support, 3) acknowledgment of health benefits, 4) exercise type and guidance, and 5) Communication channels. CONCLUSION AND KEY FINDINGS: Kidney cancer patient's adherence to physical activity prehabilitation is influenced by multiple biopsychosocial barriers and facilitators. Hence, adherence to physical activity prehabilitation requires timely adaptation of health beliefs and behavior embedded in the reported barriers and facilitators. For this reason, prehabilitation strategies should strive to be patient-centered and include health behavioral change theories as underlying frameworks for sustaining patient engagement and self-efficacy.

Seroma After Breast Reconstruction With Tissue Expanders: Outcomes and Management.

BACKGROUND: Seroma is a relatively common complication after breast reconstruction with tissue expanders. The main risk in the presence of seroma is development of periprosthetic infection, which can lead to implant loss. Our goals were to identify risk factors for seroma, and to describe our protocol for managing fluid accumulation. PATIENTS AND METHODS: An IRB approved breast reconstruction database was reviewed to identify patients who underwent tissue expander reconstruction. Patient characteristics, details of surgery, outcomes and treatment were recorded. RESULTS: Two hundred nineteen tissue expander reconstructions were performed in 138 patients. Twenty-eight reconstructions developed seroma (12.8%), and 75 were identified to have prolonged drains (34.2%). Seroma was more common in patients with lymph node surgery ( P = 0.043), delayed reconstruction ( P = 0.049), and prepectoral reconstruction ( P = 0.002). Seroma and/or prolonged drains were more commonly noted in patients with higher body mass index ( P = 0.044) and larger breast size ( P = 0.001). Aspiration was the most common intervention (85.7%), which was performed in the clinic utilizing the expander port site. There was no difference in infection or explantation rate between seroma and no-seroma patients ( P = 0.546 and 0.167), whereas patients with any fluid concern (seroma and/or prolonged drains) were more prone to developing infection and undergoing explantation ( P = 0.041 and P < 0.005). CONCLUSION: We recommend that prolonged drain placement longer than 3 weeks should be avoided, and patients should be screened for fluid accumulation after drain removal. Serial aspiration via expander port site and continuation of expansion provide a safe and effective method to manage seromas to avoid infection and expander loss.

99m Tc-MIBI SPECT/CT Evaluation of a Renal Collision Tumor.

ABSTRACT: Preoperative differentiation of oncocytomas from renal cell carcinoma (RCC) is often challenging. 99m Tc-MIBI imaging could play a potential role in differentiating oncocytoma from RCC, which in turn could guide surgical decision-making. We present the use of 99m Tc-MIBI SPECT/CT to characterize a renal mass in a 66-year-old man with a complex medical history, including history of bilateral oncocytomas. 99m Tc-MIBI SPECT/CT showed features suspicious of a malignant tumor, which was confirmed postnephrectomy as a chromophobe and papillary RCC collision tumor. This case supports 99m Tc-MIBI imaging for preoperative differentiation of benign versus malignant renal tumors.

Low Skeletal Muscle as a Risk Factor for Worse Survival in Nonmetastatic Renal Cell Carcinoma with Venous Tumor Thrombus.

BACKGROUND: Renal cell carcinoma (RCC) with tumor thrombosis often requires nephrectomy and tumor thrombectomy. As an extensive and potentially morbid operation, patient preoperative functional reserve and body composition is an important consideration. Sarcopenia is a risk factor for increased postoperative complications, systemic therapy toxicity, and death solid organ tumors, including RCC. The influence of sarcopenia in RCC patients with tumor thrombus is not well defined. This study evaluates the prognostic ability of sarcopenia regarding surgical outcomes and complications in patients undergoing surgery for RCC with tumor thrombus. METHODS: We retrospectively analyzed patients with nonmetastatic RCC and tumor thrombus undergoing radical nephrectomy and tumor thrombectomy. Skeletal muscle index (SMI; cm2/m2) was measured on preoperative CT/MRI. Sarcopenia was defined using body mass index- and sex-stratified thresholds optimally fit via a receiver-operating characteristic analysis for survival. Associations between preoperative sarcopenia and overall (OS), cancer-specific survival (CSS), and 90-day major complications were determined using multivariable analysis. RESULTS: 115 patients were analyzed, with median (IQR) age and body mass index of 69 (56-72) and 28.6 kg/m2 (23.6-32.9), respectively. 96 (83.4%) of the cohort had ccRCC. Sarcopenia was associated with shorter median OS (P = .0017) and CSS (P = .0019) in Kaplan-Meier analysis. In multivariable analysis, preoperative sarcopenia was prognostic of shorter OS (HR = 3.38, 95% confidence interval [CI] 1.61-7.09) and CSS (HR = 5.15, 95% CI 1.46-18.18). Notably, 1 unit increases in SMI were associated with improved OS (HR = 0.97, 95% CI 0.94-0.999) but not CSS (HR = 0.95, 95% CI 0.90-1.01). No significant relationship between preoperative sarcopenia and 90-day major surgical complications was observed in this cohort (HR = 2.04, 95% CI 0.65-6.42). CONCLUSION: Preoperative sarcopenia was associated with decreased OS and CSS in patients surgically managed for nonmetastatic RCC and VTT, however, was not predictive of 90-day major postoperative complications. Body composition analysis has prognostic utility for patients with nonmetastatic RCC and venous tumor thrombus undergoing surgery.

Imaging Techniques to Determine Degree of Sarcopenia and Systemic Inflammation in Advanced Renal Cell Carcinoma.

PURPOSE OF REVIEW: The purpose of this review is to provide an up-to-date understanding regarding the literature on sarcopenia and inflammation as prognostic factors in the context of renal cell carcinoma (RCC). RECENT FINDINGS: Sarcopenia is increasingly recognized as a prognostic factor in RCC. Emerging literature suggests monitoring quantity of muscle on successive imaging and examining muscle density may be additionally informative. Inflammation has prognostic ability in RCC and is also considered a key contributor to development and progression of both RCC and sarcopenia. Recent studies suggest these two prognostic factors together may provide additional prognostic ability when used in combination. Ongoing developments include quality control regarding sarcopenia research and imaging, improving understanding of muscle loss mechanisms, and enhancing clinical incorporation of sarcopenia via improving imaging analysis practicality (i.e., artificial intelligence) and feasible biomarkers. Sarcopenia and systemic inflammation are complementary prognostic factors for adverse outcomes in patients with RCC. Further study on high-quality sarcopenia assessment standardization and expedited sarcopenia assessment is desired for eventual routine clinical incorporation of these prognostic factors.

Mayo Adhesive Probability Score Does Not Have Prognostic Ability in Locally Advanced Renal Cell Carcinoma.

Nephrectomy remains standard treatment for renal cell carcinoma (RCC). The Mayo Adhesive Probability (MAP) score is predictive of adherent perinephric fat and associated surgical complexity, and is determined by assessing perinephric fat and stranding. MAP has additionally predicted progression-free survival (PFS), though primarily reported in stage T1-T2 RCC. Here, we examine MAP's ability to predict overall survival (OS) and PFS in T3-T4 RCC. From our prospectively maintained RCC database, patients that underwent radical nephrectomy (2009-2016) with available abdominal imaging (<90 days preop) and T3/T4 RCC underwent MAP scoring. Survival analyses were conducted with MAP scores as individual (0-5) and dichotomized (0-3 vs 4-5) using Kaplan-Meier method. Multivariable Cox proportional hazard regression models for PFS and OS were built with backward elimination. 141 patients were included. 134 (95%) and 7 (5%) had pT3 and pT4 disease, respectively. 46.1% of patients had an inferior vena cava thrombus. Mean MAP score was 3.22±1.52, with 75 (53%) patients having a score between 0-3 and 66 (47%) having a score of 4-5. Both male gender (p=0.006) and clear cell histology (p=0.012) were associated with increased MAP scores. On Kaplan-Meier and multivariable analysis, no significant associations were identified between MAP and PFS (HR=1.01, 95% CI 0.85-1.20, p=0.93) or OS (HR=1.01, 95% CI 0.84-1.21, p=0.917). In this cohort of patients with locally advanced RCC, high MAP scores were not predictive of worse PFS or OS.

Cervical spine flexion-extension radiography versus magnetic resonance imaging in pediatric patients following blunt traumatic injury.

Background: In pediatric trauma patients, 60-80% of spinal cord injuries involve the cervical vertebrae. While the American College of Radiology offers guidelines for best imaging practices in the setting of acute pediatric trauma, there is a lack of uniformity in imaging-decision protocols across institutions. MRI has been shown to demonstrate high sensitivity for both bony and ligamentous injuries while also avoiding unnecessary radiation exposure in the pediatric patient population. However, the efficacy of flexion-extension (FE) radiography following initial MRI has not been evaluated in children. Our hypothesis is that FE radiography conducted following an initial MRI does not contribute significant diagnostic information or reduce time to cervical collar removal and thus can be removed from institutional protocols in order to avoid unnecessary testing and reduce pediatric radiation exposure. Methods: Trauma data were collected for pediatric patients presenting with suspected acute cervical spine injury from 2014 to 2021. A total of 108 patients were subdivided into 41 patients who received "MRI Only" and 67 patients who received both "MRI and FE" diagnostic cervical spine imaging. Chi-square testing and t-tests were performed to determine differences between MRI and FE radiographic detection rates of bony and ligamentous injuries in the subgroups. Results: In patients for whom FE did not find any injury, MRI detected bony and ligamentous injuries in 9/63 and 12/65 cases, respectively. In 3/21 (14.3%) cases in which MRI detected a bony and/or ligamentous injury and FE did not, patients eventually required surgical intervention for c-spine stabilization. No patients required surgical fixation when FE radiography showed an abnormality and MRI was normal. Addition of follow-up FE radiography after initial MRI did not have a significant effect on overall hospital length of stay (MRI Only vs MRI+FE: 9.2±12.0 days vs 8.6±13.5 days, p=0.816) or on rates of collar removal at discharge or greater than 48 hours after imaging (MRI Only vs MRI+FE: 41.5% vs 56.7%, p=0.124). Conclusions: FE radiography following initial MRI did not have a significant effect on reducing time to cervical collar removal or overall hospital length of stay. In addition, in 3 of 6 cases (50.0%) in which surgical fixation was required, MRI detected ligamentous and/or bony injury while FE radiography was normal. Level of Evidence: This study contributes Level 2b scientific evidence consistent with a well-designed cohort or case-control analytic study.

The Gracilis Muscle Flap: A "Work Horse" Free Flap in Diabetic Foot Reconstruction.

BACKGROUND: Diabetes is a leading cause of foot ulcers and lower limb amputation throughout the world. Adequate wound debridement and cover is the standard of care, but lack of adequate vascularised local tissue poses a major challenge. The gracilis flap offers various advantages in this respect, which we would like to discuss in this study, and hence makes it an attractive option in diabetic foot patients. MATERIAL AND METHODS: This retrospective study was conducted over a period of 2 years, from 2018 to 2020 in the Department of Plastic Surgery, Kauvery Hospital, Trichy, India. The flap harvest time, total operation time, flap take and complications associated with the procedure were noted. RESULTS: Overall, 56 patients were enrolled. The average flap harvest time was 55 +/- 10 min and the average overall operation time was 240+/- 30 minutes. There was complete flap survival in 42 (75%) patients, a partial survival in 12 (21.42%) patients and complete flap loss in 2 (3.57%) patients. In the donor site complications hypertrophic scarring was reported in 5 (8.92%) and donor site seroma in 3(5.3%) patients. CONCLUSION: The free gracilis flap offers good wound healing and excellent foot contour besides being safe and effective in small to medium sized defects makes it an excellent free flap in diabetic foot reconstruction.

Aortic valve surgery: management and outcomes in the paediatric population.

Congenital anomalies of the aortic valve frequently necessitate intervention in childhood. The most common aortic valve pathologies present in childhood are aortic stenosis and insufficiency. Presentation of aortic valve disease depends on severity and presence of concomitant syndromes and valvular disorders. Treatment options are largely categorised as medical, percutaneous repair or surgical repair and replacement. Surgical techniques have been refined over the last few years making this the mainstay of treatment in paediatric cases. Whilst repair is considered in most instances before replacement, there are substantial limitations which are reflected in the frequency of reintervention and restenosis rate. Replacements are typically undertaken with tissue or mechanical prosthesis. The current gold-standard aortic valve replacement surgery is called the Ross procedure-where replacement is undertaken with a competent pulmonic valve and a simultaneous pulmonary homograft.Conclusion: In this review, we aim to outline the various surgical options and discuss efficacy and complications of various interventions. What is Known: • Congenital aortic valve defects repair options medically and surgically What is New: • Comparisons between surgical options for aortic valve repair including efficacy, risks and long-term outcomes.

Surgical Management of Gallstone Ileus in Low-Settings Hospital during COVID-19 Outbreak: A Case Report.

Introduction Gallstone ileus is a very infrequent complication of cholelithiasis in which single or multiple stones pass through an abnormal fistula to the lumen of the intestine leading to a true mechanical obstruction. We are reporting a case of a female who developed intestinal obstruction due to gallstones during the coronavirus disease 2019 (COVID-19) outbreak and was managed urgently surgically in a low-settings hospital. Case Presentation An 85-year-old white female with 40 years history of gallstone disease, hypertension, and type-2 diabetes presented to the accidents and emergency unit with upper central crampy abdominal pain for 5 days associated with green color vomiting and absolute constipation. On examination, she was barely stable, dehydrated, had a distended abdomen, and guarding in the epigastric region. Her electrolytes were disturbed and had elevated serum creatinine and blood urea. Imaging studies confirmed gallstone ileus. Management was surgical despite the lack of facilities and equipment including COVID-19 personal protective equipment. Conclusion Despite being an infrequent complication, gallstone ileus might present at the most unexpected time and in the least equipped hospital where the surgeon's suspicion, risk stratification, and improvisation by utilizing what is available are the keys for successful management and saving lives.

Comparison study between the usage of harmonic scalpel versus classical suture method for thyroidectomy in Iraqi patients.

OBJECTIVE: To compare the outcome of harmonic scalpel use in thyroid surgery versus conventional suture method in a sample of Iraqi patients. METHODS: A prospective, comparative, interventional study with analytic elements was conducted on 76 patients complaining of different types of goitre attending Al-Yarmouk Teaching Hospital, Baghdad, from October 2017 to October 2019. Patients were divided into two groups, a test group including 25 patients operated upon by harmonic scalpel and the control group of 51 patients who underwent conventional suture ligation. Informed consent was obtained from all patients after explaining the procedure. The necessary investigations were done preoperatively with anaesthetic consultation. After surgery, type of thyroidectomy (Total, near total, subtotal, lobectomy), time of surgery, the results of the postoperative checkup including vital signs, voice state, any stridor or dyspnoea, drains (amount drained) and signs of hypocalcaemia were noted. RESULTS: The 76 patients were divided into 2 groups. Most of the patients were female (61 females, 23 in harmonic & 38 in conventional group" Vs. 15 males, 2 in harmonic & 13 in conventional group). The mean ages in both groups were comparable. The mean age was 40.0±9.7 years for conventional suture ligation group with females being 39.7±10.3 years and males being 40.8±7.9 years old. The mean age of patients in the harmonic scalpel group was 40.5±11.7 years with females being 40.4±12.5 years old and males 42.0±1.0 of age. Most of the HS devise patients had thyrotoxic goiter in comparison to simple goiter in the control group. The study shows a significant reduction in the time of surgery in the harmonic scalpel group, therefore most of them showed a significant reduction in the amount of blood in their drain and the drain was removed within 24 hours. Regarding the remaining post-operative complications like bleeding, stridor, and recurrent laryngeal nerve injury. The results had no statistical significant difference in both groups. CONCLUSIONS: Both HS and ligation sutures were effective in thyroid surgery except the reduction in operation time and postoperative drainage in the HS group. Both techniques were taken as reasonably safe procedures.

The Effect of Oral Propranolol versus Oral Corticosteroids in Management of Pediatric Hemangiomas.

BACKGROUND: Hemangiomas are the most common benign tumors of infancy. This study evaluated the efficacy of oral propranolol comparing to oral steroids in management of pediatric hemangiomas. METHODS: In North India from January 2012 to January 2015, sixty children <6 years old with superficial hemangiomas were divided into 2 groups; oral propranolol vs. oral prednisolone. All participants were assessed for electrocardiogram, heart rate, blood pressure and sugar and initial therapy was started using 1 mg/kg and in absence of adverse effects, 2 mg/kg was administered after 2 weeks. The hemangioma Activity Score (HAS) was used for scoring and patients were followed up for 6 months. RESULTS: The propranolol group mostly showed early response to the drug and needed the drug for less time compared to corticosteroid group. In propranolol group, 16.5%, 23% and 59% needed the drug to be continued for 8-12, 4-8 and 4 months. In corticosteroid group, the therapy was continued for 8-12, and 4-8 months in 76.8% and 16.5% and in 6.6% was stopped within 4 months. In propranolol group, the response was 70% compared to 40% in other group. The mean HAS decreased significantly in propranolol group when compared to steroid group. Three patients on prednisolone developed Cushingoid features, while 1 patient in propranolol group had mild flue like symptoms. CONCLUSION: Two mg/kg of oral propranolol significantly decreased HAS, when compared to oral prednisolone, with good parent satisfaction, minimal adverse effects and no recurrence/relapse of hemangiomas after a follow up period of 6 months.

Hand Injuries by the Killer Kite Manja and Their Management.

Although hand injuries due to kite strings seem to be trivial, these injuries could be serious enough to lose the function of hand. This case series in the division of Plastic and Reconstructive Surgery of our institution from August 2014 to January 2016 evaluated the clinic-etiological profile, severity and management of hand injuries due to kite strings assessed clinically and radiologically. Eleven patients reported kite related injuries during two years, and 5 presented during 17 months. Of 11 patients, 8 were male and 3 were female with a M:F ratio of 2.66:1. The majority of patients presented with the mean age of 19.9±4.27 years. Eight patients presented acutely to the emergency while 3 believed the injury to be trivial and had delayed presentation. Injuries in the right hand were 8 and 3 in the left hand. Seven patients had injuries in zone II of the hand while 4 presented with zone III injuries. Total number of injured digits was 14 (1.4±1.11), total number of injured tendons was 26 (2.36±2.18), only one patient had nerve injury (mean=0.09), and no patient had any major vessel injury. So strict attention to safety measures and parental/guardian supervision while flying kites can avoid many preventable injuries to life and limb and also let the sport be an enjoyable and safe.