Chemistry, biosynthesis, and theranostics of antioxidant flavonoids and polyphenolics of genus Rhododendron: an overview.

The genus Rhododendron is an ancient and most widely distributed genus of the family Ericaceae consisting of evergreen plant species that have been utilized as traditional medicine since a very long time for the treatment of various ailments including pain, asthma, inflammation, cold, and acute bronchitis. The chemistry of polyphenolics isolated from a number of species of the genus Rhododendron has been investigated. During the currently designed study, an in-depth study on the phytochemistry, natural distribution, biosynthesis, and pharmacological properties including their potential capability as free radical scavengers has been conducted. This work provides structural characteristics of phenolic compounds isolated from the species of Rhododendron with remarkable antioxidant potential. In addition, biosynthesis and theranostic study have also been encompassed with the aims to furnish a wide platform of valuable information for designing of new drug entities. The detailed information including names, structural features, origins, classification, biosynthetic pathways, theranostics, and pharmacological effects of about 171 phenolics and flavonoids isolated from the 36 plant species of the genus Rhododendron with the antioxidant potential has been covered in this manuscript. This study demonstrated that species of Rhododendron genus have excellent antioxidant activities and great potential as a source for natural health products. This comprehensive review might serve as a foundation for more investigation into the Rhododendron genus.

Predictors of Frailty in Patients With Liver Cirrhosis.

Introduction Frailty is noticed in a large number of cirrhotic patients with advanced liver disease. Frailty not only disposes cirrhotic patients to increased rates of decompensation and hospitalization but also leads to prolonged hospital stay and increased psychological and social impact, resulting in the delisting of these patients from the transplant list. Therefore, our aim was to identify the factors that are independent predictors of frailty in patients with liver cirrhosis. Methods This cross-sectional study was carried out at the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from March 1, 2022, to August 31, 2022. All the patients diagnosed with liver cirrhosis and aged 18-70 years were included in the study. The excluded patients comprised those with disorders that over-estimate frailty such as cardiopulmonary disease and hepatocellular carcinoma. The measurement of the Liver Frailty Index (LFI) was done using the hand grip strength method, timed chair stands, and balance testing. Patients with LFI >4.5 were considered frail. All data was entered and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp., Armonk, New York, United States). Continuous variables were analyzed using the student-t test while categorical variables were analyzed using the chi-square test. Variables with significance on univariate analysis then underwent multivariate analysis to identify the independent predictors of frailty in cirrhotic patients. A p-value < 0.05 was considered statistically significant. Results A total of 132 patients were included in the study. Out of them, 89 (67.4%) were males. On assessment, 51 (38.6%) patients were frail on presentation. On univariate analysis, female gender, advanced age, raised total leucocyte count, increased percentage of neutrophils on peripheral smear, raised serum creatinine, raised total bilirubin, raised prothrombin time, high Child Turcotte Pugh (CTP) score, and high model for end-stage liver disease along with low hemoglobin and low serum albumin levels were statistically significantly associated with frailty in cirrhosis. On multivariate analysis, female gender, age >40 years, CTP>B7, Hemoglobin <10g/dl, and neutrophils >60% on peripheral smear were independent predictors of liver frailty in cirrhotic patients. Conclusion Female gender, advanced age, increased neutrophils on peripheral smear, decreased hemoglobin along with increased degree of liver dysfunction were independent predictors of increased frailty in patients with chronic liver disease.

Diagnostic Accuracy of Narrow-Band Imaging in Predicting Helicobacter pylori Gastritis in Patients With Dyspepsia.

Background Helicobacter pylori (H. pylori) is one of the most prevalent causes of chronic gastritis that can lead to gastric cancer if left untreated. Currently, endoscopy and histology are the gold standard tests for the diagnosis of H. pylori gastritis. Recently, studies have shown the utility of narrow-band imaging (NBI) in predicting H. pylori gastritis. Therefore, we aimed to determine the diagnostic accuracy of NBI in predicting H. pylori gastritis in patients with dyspepsia. Methodology After obtaining approval from the Ethical Review Committee, Sindh Institute of Urology and Transplantation, this cross-sectional study was conducted in the outpatient Clinic of Hepatogastroenterology of the institute. Inclusion criteria involved all patients of either gender aged 18 to 65 years with dyspeptic symptoms. We excluded patients with a history of proton pump inhibitor use within two weeks before endoscopy, heart failure, previous gastrectomy, portal gastropathy, cirrhosis, use of antiplatelet medications, non-steroidal anti-inflammatory drugs or anticoagulant medication, and hemorrhagic or thrombophilia disorders. Each patient underwent endoscopy-guided NBI studies followed by biopsies from the antrum and body of the stomach. Multivariate logistic regression analysis was performed for the type of NBI pattern predicting H. pylori infection. The diagnostic accuracy was obtained individually for each NBI type and then for the presence of either two or all three NBI types in predicting H. pylori gastritis. Results Out of the total 775 patients enrolled in the study, abnormal NBI patterns were observed in 401 (51.7%) patients. The presence of abnormal NBI antral mucosal pattern on endoscopy was significantly associated with H. pylori infection (p < 0.001) with excellent diagnostic accuracy. Among the three NBI types, individually, NBI type III had excellent specificity and better diagnostic accuracy in predicting H. pylori gastritis than the other two types. Furthermore, the presence of all three abnormal NBI patterns (I+II+III) together was significantly associated with the presence of H. pylori gastritis with a sensitivity of 94.54%, specificity of 86.55%, and diagnostic accuracy of 90.32%. Conclusions NBI on endoscopy shows excellent diagnostic accuracy in identifying H. pylori gastritis in patients with dyspepsia. However, multicenter studies are required not only to validate our results but also to predict the pre-cancerous lesions on NBI in patients with H. pylori gastritis.

A critical review on metal-organic frameworks (MOFs) based nanomaterials for biomedical applications: Designing, recent trends, challenges, and prospects.

Nanomaterials (NMs) have garnered significant attention in recent decades due to their versatile applications in a wide range of fields. Thanks to their tiny size, enhanced surface modifications, impressive volume-to-surface area ratio, magnetic properties, and customized optical dispersion. NMs experienced an incredible upsurge in biomedical applications including diagnostics, therapeutics, and drug delivery. This minireview will focus on notable examples of NMs that tackle important issues, demonstrating various aspects such as their design, synthesis, morphology, classification, and use in cutting-edge applications. Furthermore, we have classified and outlined the distinctive characteristics of the advanced NMs as nanoscale particles and hybrid NMs. Meanwhile, we emphasize the incredible potential of metal-organic frameworks (MOFs), a highly versatile group of NMs. These MOFs have gained recognition as promising candidates for a wide range of bio-applications, including bioimaging, biosensing, antiviral therapy, anticancer therapy, nanomedicines, theranostics, immunotherapy, photodynamic therapy, photothermal therapy, gene therapy, and drug delivery. Although advanced NMs have shown great potential in the biomedical field, their use in clinical applications is still limited by issues such as stability, cytotoxicity, biocompatibility, and health concerns. This review article provides a thorough analysis offering valuable insights for researchers investigating to explore new design, development, and expansion opportunities. Remarkably, we ponder the prospects of NMs and nanocomposites in conjunction with current technology.

Management of Tacrolimus-Induced Toxicity With Normal Serum Levels After Liver Transplant.

Drug-induced liver injury after liver transplant occurs in 1.7% of patients. Tacrolimus is an effective immunosuppressant that is used to treat acute rejection. Although rare, it can cause toxicity, which is demonstrated by cholestatic liver injury. Here, we present a case of a young male patient who was diagnosed with Wilson disease, had penicillaminechelating therapy, and underwent living related liver transplant. Within 1 month posttransplant, he developed deranged, predominantly cholestatic pattern liver function tests. Laboratory parameters showed total bilirubin of 1.12 mg/ dL, alanine aminotransferase of 553 IU/L, gammaglutamyltransferase of 624 IU/L, and tacrolimus level of 10.2 ng/mL. After thorough evaluation, a liver biopsy was performed. Liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. However, with normal level of tacrolimus, the biopsy was suggestive of drug-induced liver injury. Thus, tacrolimus dose was reduced, resulting in improved liver function tests and patient discharge from the hospital. Tacrolimus is an effective immunosuppressant after liver transplant and has the ability to treat early acute rejection. The patient's liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. Cholestatic liver injury after tacrolimus usually resolves after dose reduction or by switching to another agent. With demonstrated tacrolimus-induced toxicity in liver transplant recipients, despite normal serum levels, transplant physicians should keep high index of suspicion regarding toxicity in the posttransplant setting.

Investigation of novel bis-thiadiazole bearing schiff base derivatives as effective inhibitors of thymidine phosphorylase: Synthesis, in vitro bioactivity and molecular docking study.

Thymidine phosphorylase (TP) is an angiogenic enzyme. It is crucial for the development, invasion and metastasis of tumors as well as angiogenesis. In our current research, we examine how structurally changing bis-thiadiazole bearing bis-schiff bases affects their ability to inhibit TP. Through the oxidative cyclization of pyridine-based bis-thiosemicarbazone with iodine, a series of fourteen analogs of bis-thiadiazole-based bis-imines with pyridine moiety were developed. Newly synthesized scaffolds were assessed in vitro for their thymidine phosphorylase inhibitory potential and showed moderate to good inhibition profile. Eleven scaffolds such as 4a-4d,4f-4 h and 4j-4 m were discovered to be more effective than standard drug at inhibiting the thymidine phosphorylase enzyme with IC50 values of 1.16 ± 1.20, 1.77 ± 1.10, 2.48 ± 1.30, 12.54 ± 1.60, 14.63 ± 1.70, 15.53 ± 1.80, 17.47 ± 1.70, 18.98 ± 1.70, 19.53 ± 1.50, 22.73 ± 2.40 and 24.87 ± 2.80 respectively, while remaining three analogs such as 4n, 4i and 4ewere found to be more potent, but they were less potent than the standard drug. All analogs underwent SAR studies based on the pattern of substitutions around the aryl part of the bis-thiadiazole skeleton. The most active analogs in the synthesized series were then molecular docking study performed to investigate their interactions of active part of enzyme. The results showed that remarkable interactions were exhibited by these analogs with the targeted enzymes active sites. Furthermore, to confirm the structure of synthesized analogs by employing spectroscopic tools such as HREI-MS and NMR.

Carpal Tunnel Decompression Under Wide Awake Local Anaesthesia No Tourniquet Technique (WALANT): A Cost Effective and Outcome Analysis.

Introduction Wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, resource-friendly, and safe. This can be used as an alternative to hand surgery procedures in outpatient units. It can be performed in clinics or operating rooms. Methods We retrospectively evaluated the outcomes of WALANT for carpal tunnel decompression (CTD) over two years. Measured results include wound infections, relief of symptoms, paraesthesia, haematoma, Visual Analogue Scale (VAS), hospital anxiety and depression scale score (HADS) and cost-effectiveness. Results Eighteen patients underwent CTD under the WALANT technique over two years. VAS score was recorded at 3.1 ± 1.2 during the procedure and 1.67 ± 0.933 at two weeks follow-up. Persistent paraesthesia was found in only one patient at follow-up. Minimal bleeding was recorded during the procedure. No wound infections, revision surgery or post-operative haematoma formation were found. Hospital Anxiety and Depression Scale (HADS) was reported as 4.77 ± 2.1 after surgery. WALANT was also cost-effective, with an overall amount of £20. Conclusion Performing carpal tunnel decompression under WALANT in one stop upper limb clinic is a safe and cost-effective technique with no significant patient-related complications.

Molecular Modeling and Synthesis of Indoline-2,3-dione-Based Benzene Sulfonamide Derivatives and Their Inhibitory Activity against α-Glucosidase and α-Amylase Enzymes.

Diabetes is also known as a critical and noisy disease. Hyperglycemia, that is, increased blood glucose level is a common effect of uncontrolled diabetes, and over a period of time can cause serious effects on health such as blood vessel damage and nervous system damage. However, many attempts have been made to find suitable and beneficial solutions to overcome diabetes. Considering this fact, we synthesized a novel series of indoline-2,3-dione-based benzene sulfonamide derivatives and evaluated them against α-glucosidase and α-amylase enzymes. Out of the synthesized sixteen compounds (1-16), only three compounds showed better results; the IC50 value was in the range of 12.70 ± 0.20 to 0.90 ± 0.10 µM for α-glucosidase against acarbose 11.50 ± 0.30 µM and 14.90 ± 0.20 to 1.10 ± 0.10 µM for α-amylase against acarbose 12.20 ± 0.30 µM. Among the series, only three compounds showed better inhibitory potential such as analogues 11 (0.90 ± 0.10 µM for α-glucosidase and 1.10 ± 0.10 µM for α-amylase), 1 (1.10 ± 0.10 µM for α-glucosidase and 1.30 ± 0.10 µM for α-amylase), and 6 (1.20 ± 0.10 µM for α-glucosidase and 1.60 ± 0.10 µM for α-amylase). Molecular modeling was performed to determine the binding affinity of active interacting residues against these enzymes, and it was found that benzenesulfonohydrazide derivatives can be indexed as suitable inhibitors for diabetes mellitus.

Synthesis, DFT Studies, Molecular Docking and Biological Activity Evaluation of Thiazole-Sulfonamide Derivatives as Potent Alzheimer's Inhibitors.

Alzheimer's disease is a major public brain condition that has resulted in many deaths, as revealed by the World Health Organization (WHO). Conventional Alzheimer's treatments such as chemotherapy, surgery, and radiotherapy are not very effective and are usually associated with several adverse effects. Therefore, it is necessary to find a new therapeutic approach that completely treats Alzheimer's disease without many side effects. In this research project, we report the synthesis and biological activities of some new thiazole-bearing sulfonamide analogs (1-21) as potent anti-Alzheimer's agents. Suitable characterization techniques were employed, and the density functional theory (DFT) computational approach, as well as in-silico molecular modeling, has been employed to assess the electronic properties and anti-Alzheimer's potency of the analogs. All analogs exhibited a varied degree of inhibitory potential, but analog 1 was found to have excellent potency (IC50 = 0.10 ± 0.05 µM for AChE) and (IC50 = 0.20 ± 0.050 µM for BuChE) as compared to the reference drug donepezil (IC50 = 2.16 ± 0.12 µM and 4.5 ± 0.11 µM). The structure-activity relationship was established, and it mainly depends upon the nature, position, number, and electron-donating/-withdrawing effects of the substituent/s on the phenyl rings.

Synthesis, In Vitro Anti-Microbial Analysis and Molecular Docking Study of Aliphatic Hydrazide-Based Benzene Sulphonamide Derivatives as Potent Inhibitors of α-Glucosidase and Urease.

A unique series of sulphonamide derivatives was attempted to be synthesized in this study using a new and effective method. All of the synthesized compounds were verified using several spectroscopic methods, including FTIR, 1H-NMR, 13C-NMR, and HREI-MS, and their binding interactions were studied using molecular docking. The enzymes urease and α-glucosidase were evaluated against each derivative (1-15). When compared to their respective standard drug such as acarbose and thiourea, almost all compounds were shown to have excellent activity. Among the screened series, analogs 5 (IC50 = 3.20 ± 0.40 and 2.10 ± 0.10 µM) and 6 (IC50 = 2.50 ± 0.40 and 5.30 ± 0.20 µM), emerged as potent molecules when compared to the standard drugs acarbose (IC50 = 8.24 ± 0.08 µM) and urease (IC50 = 7.80 ± 0.30). Moreover, an anti-microbial study also demonstrated that analogs 5 and 6 were found with minimum inhibitory concentrations (MICs) in the presence of standard drugs streptomycin and terinafine.

A Tertiary Care Center's Experience with Clinicopathological Characteristics of Gallbladder Carcinoma in Our Population.

Introduction: Gallbladder cancer (GBC) is the most common malignant biliary tract tumor with the shortest survival from the time of diagnosis. This poor prognosis is due to the destructive biologic behavior of GBC, lack of sensitive screening tests for early detection, and vague nature of first presentation. Here in this study, we will evaluate the baseline characteristics of the patients presenting with gallbladder carcinoma in our population. Materials and methods: This retrospective study was conducted in the Department of Gastroenterology at Sindh Institute of Urology and Transplantation (SIUT), Karachi. Patient data were compiled and composed from the in-patient health records, radiology, and operational records. Those patients with suspicion of GBC, but negative at histology, or patients having inconclusive radiologic findings, were excluded. Baseline characteristics were recorded. Results were presented as means ± SD for quantitative data or as numbers with percentages for qualitative data. Continuous variables were analyzed using the Student's t-test, while categorical variables were analyzed using the Chi-square test. A p-value of <0.05 was considered statistically significant. Results: A total of 162 patients were included in our study. Among them, 101 (62.3%) were females. Hypertension was the most common comorbid illness noted in 29 (17.9%) patients while 91 (56.2%) patients had no concurrent comorbidities. Most common risk factor for carcinoma of gallbladder was gallstones seen in 106 (65.1%) patients. The most common presenting complaint was combination of obstructive jaundice, weight loss with right hypochondrial pain seen in 66 (40.7%) patients. On CT abdomen, direct liver infiltration without lymphovascular invasion was noted in 77 (47.5%) patients followed by liver infiltration along with lymphovascular invasion in 26 (16%) patients and distant metastasis in 24 (14.8%) patients. On gallbladder (GB) mass biopsy, 58 (35.8%) patients had well-differentiated, 46 (28.4%) had moderately differentiated, while 33 (20.4%) had poorly differentiated adenocarcinoma. Of 162 patients, 103 (63.6%) patients underwent endoscopic retrograde cholangiopancreatography (ERCP). The most common finding on ERCP was proximal common bile duct (CBD) stricture with intrahepatic biliary system dilatation which was noted in 95 (58.6%) patients. Percutaneous transhepatic cholangiography (PTC) was performed only in 9 (5.6%) patients. Seventeen (10.5%) patients were managed by simple cholecystectomy, 39 (24.1%) patients underwent extended cholecystectomy, 14 (8.6%) patients underwent chemotherapy, while 102 (56.8%) patients were given palliative management. When followed for 1 year, 101 (62.3%) patients died within 6 months. Conclusion: The baseline characteristics, biopsy findings, modes of treatment, and rates of 1 year mortality were studied in patients with gallbladder carcinoma in our population. Advanced age, high white blood cell counts, and serum bilirubin at presentation with low lymphocyte count and presence of comorbid illnesses were the factors independently associated with increased mortality in patients with gallbladder carcinoma. However, further studies with large sample size and stratification with respect to age, gender, and different variables can be done in terms of mortality in patients with gallbladder carcinoma. How to cite this article: Akbar N, Yaseen T, Muhammad A, et al. A Tertiary Care Center's Experience with Clinicopathological Characteristics of Gallbladder Carcinoma in Our Population. Euroasian J Hepato-Gastroenterol 2022;12(1):35-39.

Foot school: Preoperative education before day case elective foot and ankle surgery reduces the length of stay after surgery.

BACKGROUND: This study evaluates the impact of preoperative education on the length of hospital stay after foot and ankle surgery. There are several studies on the benefits of preoperative education prior to hip and knee arthroplasty, especially their role in facilitating early discharges. But studies on the benefits of foot school (Preoperative education) prior to Foot and Ankle surgeries are limited. The aim of this study was to determine if Foot school played a role in expediting early and safe discharges in patients of elective foot and ankle surgeries METHODS: All patients listed for an elective foot and ankle procedure were invited to attend foot school, which consisted of a multi-disciplinary team whose aim was to educate patients about their surgical procedures, rehabilitation and discharge goals. Not all patients attended foot school, as attendance to foot school was recommended but not mandatory for surgery. Data on all foot and ankle surgeries performed in 2019 were collected, and patients were divided into two groups based on their foot school attendance. RESULTS: 92% of the patients who attended foot school were discharged on the same day. 65% of patients who did not attend foot school returned home the same day. There was a statistically significant difference in the observed mean hours after surgery between the two groups. Patients who attended foot school stayed at the hospital for a lesser duration than those who did not (mean difference = 8.55 h, p-value = 0.004). Early discharges can also increase the turnover of patients for day case procedures and improve cost savings. The cost analysis also showed that a portion of the savings from a reduced hospital stay could run foot school service. CONCLUSION: Our study demonstrates that preoperative education allows a significantly shorter hospital stay, thereby facilitating early patient discharges. This can improve the patient turnover rate and also would save the hospital cost per procedure. Patients should, therefore, be encouraged to attend Foot school before their surgical procedure.

Is the thrombolysis in myocardial infarction (TIMI) score a reliable source in a rural hospital for the management of unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI)?

Background: The Thrombolysis in Myocardial Infarction (TIMI) score is considered a method for early risk stratification in patients with unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI). It is composed of seven factors and if present, each factor contributes a value of one point toward the TIMI risk score, making it a simple tool that does not require differential weights for each factor. A higher score implies a higher likelihood of adverse cardiac events and/or risk of mortality. A TIMI risk score ≥3 recommends early invasive management with cardiac angiography and revascularization. As per CDC study in 2014, Americans living in rural areas are more likely to die from leading causes such as cardiovascular diseases. An estimated number 25,000 deaths than their urban counterparts, which coincide with a TIMI risk score of ≥3, potentially limit the utility of the TIMI risk score in risk stratification in rural catherization laboratories. The objective of this study was to assess the reliability of TIMI score as early risk stratification in patients with unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI) in rural hospital. Methods: A retrospective chart review study in a rural hospital was conducted for subjects that received left heart catheterizations, exercise stress tests, or chemical stress tests for a diagnosis of UA/NSTEMI. A total of 399 subjects who underwent left heart catheterization and/or stress testing were recruited for this study. A total of 153 subjects who were transferred out to a larger facility, transitioned to comfort care, refused intervention, or passed away were excluded from the study. The 246 remaining subjects were classified into two groups, those with TIMI 0-2 compared with those having TIMI ≥ 3. A null hypothesis was postulated that there was no significant difference between the two groups with regard to prevalence of either positive stress test or evidence of obstructive coronary disease following coronary angiography. T-test and Wilcoxon rank-sum analysis were performed through SPSS statistical analysis. Results: Formal statistical analysis using T-test as well as Wilcoxon rank-sum test comparing the two groups showed p = 0.34 for T-test and p = 0.60 for Wilcoxon rank-sum test. This is consistent with the postulated null hypothesis: that there is no significant difference between the two surgery groups with respect to the mean/median TIMI score. Conclusion: There was no statistical difference between high and low TIMI score in the intervention of unstable angina/non-ST elevated myocardial infarctions (UA/NSTEMI) in a rural hospital.

A systematic review of mechanical stabilization by screw fixation without bone grafting in the management of stable scaphoid non-union.

INTRODUCTION: Sixty percent of all carpal fractures affect the scaphoid bone, with an annual incidence of 4.3/10,000. Displacement and instability are the main risk factors for non-union, but missed diagnosis, location of fracture and poor blood supply are also risk factors. Non-union is defined as non-healed fracture on radiographs 6 months after the injury and this can lead to degenerative wrist arthritis. Treatment options vary from internal fixation with bone grafting to salvage procedures including arthrodesis of carpals. We aimed to determine the effectiveness of screw fixation without bone grafting for the treatment of stable well-aligned scaphoid non-union. METHODS: In this systematic review, MEDLINE, Science Direct, Web of Science and CINHAL were searched from inception to May 2019. All clinical studies that examined the functional and radiological outcomes of screw fixation without bone grafting to treat stable scaphoid non-union were included. RESULTS: 838 articles were retained of which 6 case series, describing 95 patients who had undergone scaphoid non-union fixation without bone grafting, were included. Favourable functional outcomes were reported by the 6 included studies using validated functional outcome measures ROM improved to weighted mean of 67.5° (±13°) and 62.12° (±13°) for flexion and extension respectively. The fracture had united in 91 out of 95 participants with a union rate of 95.7% (95%, CI 89.5 to 98.8) and the weighted mean time to union was 3.8 (±1.5) months. CONCLUSION: Rigid screw fixation without bone grafting can be suggested for the treatment of selected well aligned scaphoid nonunions to achieve healing and good functional outcomes. However, adequately powered clinical studies with good methodology are essential to draw an accurate conclusion.

Delay in Initial Debridement for Open Tibial Fractures and Its Possible Impact on Patient Outcomes: A Single-Center Prospective Cohort Study.

The current consensus regarding the management of open fracture indicates that the initial debridement should be performed within the first 6 hours after injury. Unfortunately, in Pakistan, the emergency medical services are not well-established and patient arrival at the hospital is delayed the majority of the time. In this study, we present our experience with delayed surgical management of open tibial fractures. METHODS: A prospective study of patients who presented to the accident and emergency department of the authors' institution was performed. The duration of the study was 4 years. All patients ≥18 years of age with an isolated open fracture of the tibia were included in the study. Open fractures were graded using the Gustilo-Anderson (GA) classification. The study participants were divided into 3 groups based on the timing of the surgery. Infection and nonunion rates were compared using chi-square analysis. P < 0.05 was considered significant. RESULTS: A total of 1,896 patients were included in the study. There was no significant difference between the results of surgery performed before 48 hours and those of surgery performed after 48 hours with regard to the infection rates associated with GA type-I (p = 0.48), type-II (p = 0.70), or type-III (p = 0.87) fractures or the nonunion rates associated with type-I (p = 0.6338), type-II (p = 0.4030), or type-III (p = 0.4808) fractures. A higher GA classification was associated with higher rates of infection and nonunion independent of the timing of the surgery (95% confidence interval [CI] = 1.24 to 1.89, p < 0.01). CONCLUSIONS: Our study indicates that the risks of infection and nonunion remain acceptable despite delays in the management of open tibial fractures within a 24 to 96-hour window. A delay in the initial time to debridement is acceptable only when early care cannot be provided. Prompt initial debridement remains the best possible treatment for open tibial fractures. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Scarf-Akin osteotomy with Lapidus-Akin fusion in cases of Hallux Valgus with a disrupted Meary's line: A case series study.

BACKGROUND: Hallux Valgus associated with medial column instability (disrupted Meary's line) can be corrected either with Lapidus-Akin or Scarf-Akin procedure. This study compares these two procedures to ascertain if type of surgical procedure performed affects the correction achieved and recurrence rate at 6 months following operative intervention. MATERIALS AND METHODS: This is a retrospective case series that reviews the incidence of early recurrence of Hallux Valgus deformity in 60 patients with an associated disrupted Meary's line who underwent either a Scarf-Akin osteotomy (n = 30) or a Lapidus-Akin procedure (n = 30) between January 2014 and January 2020. Radiographs, operative and clinical notes were utilized to determine degree of correction and recurrence of deformity at 6 months between both groups. RESULTS: The study found a 47% higher recurrence rate in the Scarf-Akin osteotomy group compared to the Lapidus-Akin group at 6 month follow up. This result was statistically significant with a p-value of 0.002 (95% CI 7-49%). Lapidus-Akin procedure was also found to be superior to the Scarf-Akin procedure in achieving a better degree of correction in the Hallux Valgus angle by an average of 11 degrees. CONCLUSION: A disrupted Meary's line is a risk factor for recurrence of Hallux Valgus deformity. The authors recommend that Lapidus-Akin procedure has a significantly reduced recurrence rate compared to a Scarf-Akin osteotomy in Hallux Valgus with disrupted Meary's line.

Treatment of fragility ankle fractures using hindfoot nail, systemic review.

With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. An extensive literature review (inception of data until September 2019) was undertaken to locate previous studies that have addressed the same topic. Seven studies met the inclusion criteria. The post-operative Olerud and Molander scores were comparable/slightly lower than pre-injury scores. Bony union was achieved in 90.3%-100% of cases. Hindfoot nails, when used to treat fragility ankle fractures, can facilitate early rehabilitation and restoration of function among elderly osteoporotic patients.

A Rare Case of Hemophagocytic Lymphohistiocytosis Triggered by Sepsis Due to Methicillin-Resistant Staphylococcus aureus Bacteremia.

Hemophagocytic lymphohistiocytosis (HLH) is a rare disease that occurs due to unregulated immune system activation induced by various causes including infection and cancer. In this article, we report a case of a 67-year-old male with history of small cell lung cancer who developed HLH triggered by methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The patient was initially admitted for septic shock and gastrointestinal bleed. Further workup showed that the patient met criteria for HLH diagnosis as he was positive for 5 of the 8 parameters. Unfortunately, the patient's condition worsened and he eventually expired. With this case, we wish to draw attention to the fact that sepsis due to MRSA bacteremia can be a trigger for HLH.

Yield of prostate cancer screening at a community based clinic in Saudi Arabia.

OBJECTIVES: To estimate the incidence and prevalence of prostate cancer in Saudi Arabia. METHODS: This is a retrospective cohort study including male patients aged 40 years and over. The prostate-specific antigen screening tests were carried out in a community-based clinic affiliated with King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia between September 2002 and December 2016. RESULTS: A total of 2,160 male patients were included in the study. Of these, 1,521 (70%) were Saudi nationals and 639 (30%) were non-Saudi nationals. A total of 108 (5%) patients underwent a prostate biopsy. The biopsy results confirmed that 31 (2%) Saudi patients and 6 (0.93%) non-Saudi patients had prostate adenocarcinoma. The age-standardized incidence rate of prostate cancer in the Saudi male population is 70 per 100,000 males. Nearly two-thirds (71%) of the Saudi patients' prostate cancer was found to be in the early stages. Conclusion: The prevalence of prostate cancer in the Saudi male population is higher than that reported by the Saudi Cancer Registry; however, it is low compared with prevalences in developed countries. The mortality rate is also very low. Prostate-specific antigen screening in Saudi Arabia should not be carried out routinely; instead, it should only be carried out on an individual basis.