Side-specific factors for intraoperative hemodynamic instability in laparoscopic adrenalectomy for pheochromocytoma: a comparative study.

BACKGROUND: Adrenalectomy for pheochromocytoma (PHEO) is challenging because of the high risk of intraoperative hemodynamic instability (HDI). This study aimed to compare the incidence and risk factors of intraoperative HDI between laparoscopic left adrenalectomy (LLA) and laparoscopic right adrenalectomy (LRA). METHODS: We retrospectively analyzed two hundred and seventy-one patients aged > 18 years with unilateral benign PHEO of any size who underwent transperitoneal laparoscopic adrenalectomy at our hospitals between September 2016 and September 2023. Patients were divided into LRA (N = 122) and LLA (N = 149) groups. Univariate and multivariate logistic regression analyses were used to predict intraoperative HDI. In multivariate analysis for the prediction of HDI, right-sided PHEO, PHEO size, preoperative comorbidities, and preoperative systolic blood pressure were included. RESULTS: Intraoperative HDI was significantly higher in the LRA group than in the LLA (27% vs. 9.4%, p < 0.001). In the multivariate regression analysis, right-sided tumours showed a higher risk of intraoperative HDI (odds ratio [OR] 5.625, 95% confidence interval [CI], 1.147-27.577, p = 0.033). The tumor size (OR 11.019, 95% CI 3.996-30.38, p < 0.001), presence of preoperative comorbidities [diabetes mellitus, hypertension, and coronary heart disease] (OR 7.918, 95% CI 1.323-47.412, p = 0.023), and preoperative systolic blood pressure (OR 1.265, 95% CI 1.07-1.495, p = 0.006) were associated with a higher risk of HDI in both LRA and LLA, with no superiority of one side over the other. CONCLUSION: LRA was associated with a significantly higher intraoperative HDI than LLA. Right-sided PHEO was a risk factor for intraoperative HDI.

Molecular docking, synthesis, characteristics and preliminary cytotoxic study of new coumarin-sulfonamide derivatives as histone deacetylase inhibitors.

OBJECTIVE: Aim: To evaluate the cytotoxic activity of newly synthesized a series of novel HDAC inhibitors comprising sulfonamide as zinc binding group and Coumarin as cap groups. PATIENTS AND METHODS: Materials and Methods: The utilization of sulfonamide as zinc binding group and Coumarin as cap groups known to possess antitumor activity in the designed of new histone deacetylase inhibitors and using the docking and MTT assay to evaluate the compounds. RESULTS: Results: Four compounds have been synthesized and characterized successfully by ART-FTIR, NMR and ESI-Ms. The synthesized compound assessed for their cytotoxic activity against hepatoblastoma HepG2 (IC50, I=0.094, II=0.040, III=0.032, IV=0.046, SAHA=0.141) and human colon adenocarcinoma MCF-7 (IC50, I=0.135, II=0.050, III= 0.065, IV=0.059, SAHA=0.107). The binding mode to the active site of [HDAC6] were determined by docking study which give results that they might be good inhibitors for [HDAC6]. CONCLUSION: Conclusions: The synthesized compounds (I, II, III and IV) showed a comparable cytotoxic result with FDA approved drug (SAHA) toward HepG2 and MCF-7 cancer cell lines and their docking analysis provided a preliminary indication that they are viable [HDAC6] candidates.

Intralesional Quadrivalent Human Papilloma Virus Vaccine Versus Candida Antigen in the Treatment of Multiple Recalcitrant Non-Genital Warts.

INTRODUCTION: Warts are the most prevalent clinical manifestation of Human Papilloma Virus (HPV) infections, which vary in morphological pattern depending on the site of the body affected. OBJECTIVES: To evaluate the safety and efficacy of intralesional quadrivalent HPV vaccine versus candida antigen in treatment of multiple recalcitrant non-genital warts. METHODS: A randomized-control clinical trial included 60 cases with multiple recalcitrant warts who were randomly distributed into three groups; Group I included 20 patients who received intralesional candida antigen at a dose of 0.3 mL of 1/1000 solution, Group II included 20 patients who received intralesional quadrivalent HPV vaccine at a dose of 0.3ml and Group III included 20 patients who received intralesional injection 0.3 ml of normal saline 0.9% as a control group). Each agent was injected at the base of the largest wart every three weeks until it was completely cleared, or for a total of four sessions. RESULTS: the highest response rate was detected in the quadrivalent HPV vaccine group (75% complete response) followed by the candida vaccine group (40% complete response and 15% partial response). Also, regarding the distant response rate, the highest response rate was detected in the quadrivalent HPV vaccine group (72.7% complete response and 27.3% partial response) followed by the candida vaccine group (33.3% complete response and 50% partial response). CONCLUSIONS: Intralesional immunotherapy appears to be effective and safe in treating multiple recalcitrant non-genital warts, with intralesional quadrivalent HPV vaccine outperforming intralesional candida antigen.

Quality of Life After Proximal Femoral Fractures Treated With Gamma Nail in Sudan.

Background Hip fracture is a public health problem globally, and it poses one of the biggest challenges in healthcare due to its associated complications. Objectives The aim of this study is to investigate the quality of life in adult patients in Khartoum State, Sudan, after they have undergone treatment using a gamma nail for proximal femoral fractures. Methodology This cross-sectional descriptive hospital-based study was conducted at Ibrahim Malik, Omdurman, and Bahri Teaching Hospitals over six months, from April to October 2022. The data were collected using an interview questionnaire that covered relevant aspects of the study. The data were analyzed using IBM SPSS Statistics for Windows, V. 26.0 (IBM Corp., Armonk, NY). The study was approved by the Sudan Medical Specialization Board, and ethical clearance was obtained. Results The study included 37 patients. More than half of the patients (59.5%, n=22) were women. The mean age of cases was 66.7 years (standard deviation, ±15.6). The mean time from the time of the fracture to the time of surgery was eight days (±15). Twenty-three (62.2%, n=23) (JRB1) of the patients started weight bearing on the second postoperative day. Regarding the health-related quality of life, 21.6% of the patients had a good health-related quality of life, 67.6% had a fair health-related quality of life, and 10.8% had a poor health-related quality of life. None of the patients reported an excellent quality of life. Based on the Oxford Hip Score, 54.1% of the patients had satisfactory joint function, 29.7% had mild to moderate hip joint function, 13.5% had moderate to severe hip joint function disturbance, and one patient (2.7%) had severe hip joint function problems. Conclusion In this study, the vast majority of the patients who underwent gamma nail surgery for hip fracture had quality of life scores in the fair to good range afterward. The results indicate that nailing is associated with good outcomes regarding quality of life and is an acceptable option for femoral fracture surgeries in Sudan.

Improving Care Continuity in Oncology Settings: A Lean Management Approach to Minimize Discharges Without Follow-Up Appointments.

OBJECTIVE: This study aimed to reduce the number of patients discharged without scheduled follow-up appointments by implementing lean management principles. METHODS: Conducted at the Sultan Qaboos Comprehensive Cancer Center in Muscat, Oman, the research utilized a one-group pretest-posttest quasi-experimental design to evaluate the impact of lean management interventions on the rate of patient discharges without follow-up appointments. Strategies such as the Kaizen principle, Gemba Walks, cross-functional collaboration, standard work procedures, and waste reduction were employed to enhance operational efficiency. RESULTS: Spanning from Quarter 3 of 2022 to Quarter 2 of 2023, the study demonstrated a significant decrease in the percentage of patients discharged without planned follow-up appointments. The rate dropped from 9% in September 2022 to 0% in March 2023, with statistically significant differences observed (X2= 65.05, p value=<.0001). CONCLUSION: By effectively implementing lean management principles, this research successfully enhanced care continuity for oncology patients after being discharged.

Comparative study of laparoscopic ventral mesh rectopexy versus perineal stapler resection for external full-thickness rectal prolapse in elderly patients: enhanced outcomes and reduced recurrence rates-a retrospective cohort study.

BACKGROUND: In elderly patients with external full-thickness rectal prolapse (EFTRP), the exact differences in postoperative recurrence and functional outcomes between laparoscopic ventral mesh rectopexy (LVMR) and perineal stapler resection (PSR) have not yet been investigated. METHODS: We conducted a retrospective multicenter study on 330 elderly patients divided into LVMR group (n = 250) and PSR (n = 80) from April 2012 to April 2019. Patients were evaluated before and after surgery by Wexner incontinence scale, Altomare constipation scale, and patient satisfaction questionnaire. The primary outcomes were incidence and risk factors for EFTRP recurrence. Secondary outcomes were postoperative incontinence, constipation, and patient satisfaction. RESULTS: LVMR was associated with fewer postoperative complications (p < 0.001), lower prolapse recurrence (p < 0.001), lower Wexner incontinence score (p = 0.03), and lower Altomare's score (p = 0.047). Furthermore, LVMR demonstrated a significantly higher surgery-recurrence interval (p < 0.001), incontinence improvement (p = 0.019), and patient satisfaction (p < 0.001) than PSR. Three and 13 patients developed new symptoms in LVMR and PSR, respectively. The predictors for prolapse recurrence were LVMR (associated with 93% risk reduction of recurrence, OR 0.067, 95% CI 0.03-0.347, p = 0.001), symptom duration (prolonged duration was associated with an increased risk of recurrence, OR 1.131, 95% CI 1.036-1.236, p = 0.006), and length of prolapse (increased length was associated with a high recurrence risk (OR = 1.407, 95% CI = 1.197-1.655, p < 0.001). CONCLUSIONS: LVMR is safe for EFTRP treatment in elderly patients with low recurrence, and improved postoperative functional outcomes. TRIAL REGISTRATION: Clinical Trial.gov (NCT05915936), retrospectively registered on June 14, 2023.

Design, synthesis, insilco study and biological evaluation of new isatin-sulfonamide derivatives by using mono amide linker as possible as histone deacetylase inhibitors.

OBJECTIVE: Aim: To evaluate the cytotoxic activity of newly synthesized a series of novel HDAC inhibitors comprising sulfonamide as zinc binding group and Isatin derivatives as cap group joined by mono amide linker as required to act as HDAC inhibitors. PATIENTS AND METHODS: Materials and Methods: The utilization of sulfonamide as zinc binding group joined by N-alkylation reaction with ethyl-bromo hexanoate as linker group that joined by amide reaction with Isatin derivatives as cap groups which known to possess antitumor activity in the designed of new histone deacetylase inhibitors and using the docking and MTT assay to evaluate the compounds. RESULTS: Results: Four compounds have been synthesized and characterized successfully by ART-FTIR, NMR and ESI-Ms. the compounds were synthesized and characterized by successfully by ART-FTIR, NMR and ESI- Ms. Assessed for their cytotoxic activity against human colon adenocarcinoma MCF-7 (IC50, I=105.15, II=60.00, III=54.11, IV=56.57, vorinostat=28.41) and hepatoblastoma HepG2 (IC50, I=63.91, II=135.18, III=118.85, IV=51.46, vorinostat=37.50). Most of them exhibited potent HDAC inhibitory activity and significant cytotoxicity. CONCLUSION: Conclusions: The synthesized compounds (I, II, III and IV) showed cytotoxicity toward MCF-7 and HepG2 cancer cell lines and their docking analysis provided a preliminary indication that they are viable [HDAC6] candidates.

Intralesional injection of bleomycin in the management of low flow vascular malformations: Results and factors affecting the outcome.

OBJECTIVE: Ethanol has been a commonly used sclerosant for low-flow vascular malformations, but it carries a high risk of complications. Bleomycin has been recently introduced as a potentially effective treatment. The aim of this study was to evaluate the safety and efficacy of bleomycin intralesional injection for the treatment of low-flow vascular malformations and determine the different factors affecting the outcome. PATIENTS AND METHODS: A total of fifty patients with low-flow vascular malformations were enrolled in the study between April 2020 and March 2022. All patients underwent preoperative duplex ultrasound and magnetic resonance angiography. The procedure was performed under ultrasound and fluoroscopic guidance. All patients were assessed for the objective improvement, ultrasound assessment, and patient-reported outcome. RESULTS: The overall rate of objective improvement was 79.53% (78.05% in venous and 87.5% in lymphatic malformations), whereas 81.25% of the patients showed a degree of size reduction or complete obliteration on postoperative ultrasound. The patient-reported outcome analysis showed a statistically significant improvement in the mean score for the pain, overall symptoms, and self-confidence. On regression analysis, the only factor associated with poor objective outcome was diffuse lesions (ill-defined or extending in more than one body region or one compartment). No major complications were recorded. CONCLUSIONS: Bleomycin intralesional injection is a safe and effective treatment for low-flow vascular malformations.

Laryngeal Changes After Septoplasty and Turbinectomy.

Studies found only a little amount of evidence about the impact of septoplasty on the mechanism of voice production, as well as vocal cord and laryngeal mucosal changes. Nasal obstruction is a common medical issue that is linked to changes in the quality of resonance of voice. To assess patients with deviated nasal septum and inferior turbinate hypertrophy's voice alterations using laryngeal stroboscope before and after septoplasty and turbinectomy. In this prospective case-control study, patients in group A had inferior turbinate hypertrophy and a nasal septal deviation, while participants in group B were healthy controls who were matched for age and gender. All of the included patients had their laryngeal stroboscope and acoustic voice characteristics evaluated both preoperatively and three months after surgery. Only the baseline evaluation of healthy controls was done. We included 30 patients with mean age 24.43 ± 7.81 years, and males accounted for two thirds of the included cases, speech testing showed that Amplitude perturbation significantly improved post septoplasty with p values < 0.05, while Fundamental frequency and NHR parameters didn't show statistically significant improvement compared to preoperative measurements and control groups. Paired comparison of laryngeal erythema, mucosal edema and mucosal waves showed significant improvement compared to preoperative laryngeal stroboscopic findings with p values < 0.001 each. Significant improvements were made to septal deviation following surgery nasal obstruction caused by nasal septal deviation and inferior turbinate hypertrophy is associated with amplitude perturbation, laryngeal erythema, mucosal edema, and mucosal waves in the patients.

3D-Printed Implant Sliding Guide: A New Dental Implant Surgical Guide.

PURPOSE: To compare the linear and angular deviations of sites prepared for implants with the proposed 3D-printed sliding guide vs a 3D-printed conventional sleeveless static guide. MATERIALS AND METHODS: This study consisted of two groups: a control group of 14 3D-printed conventional sleeveless static guides, and a test group of 37 3D-printed sliding guides. The guides were designed to drill 37 implant sites in each group. Linear and angular deviations were determined after scanning the drilled casts. Linear deviations were measured at the coronal and apical aspects of the drilled implant sites at 5-, 10-, 15-, and 20-mm distances. RESULTS: There were no significant differences between the control and study groups regarding the coronal and 5-mm apical linear deviations. The angular and 10-, 15-, and 20-mm linear deviations of the 3D-printed sliding guide were significantly smaller than the control group. CONCLUSIONS: The proposed 3D-printed sliding guide could reduce the angular deviation of drilled implant sites from the planned positions, which is reflected in reducing the linear apical deviation of prepared implant sites longer than 5 mm.

Effectiveness of geriatric assessment and management in older cancer patients: a systematic review and meta-analysis.

BACKGROUND: Frailty and multimorbidity among older cancer patients affect treatment tolerance and efficacy. Comprehensive geriatric assessment and management is recommended to optimize cancer treatment, but its effect on various outcomes remains uncertain. OBJECTIVE: Our objective was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) and cost-effectiveness studies comparing comprehensive geriatric assessment (with or without implementation of recommendations) to usual care in older cancer patients. METHODS: We searched MEDLINE, EMBASE, CINAHL, and Cochrane trials from inception to January 27, 2023, for RCTs and cost-effectiveness studies. Pooled estimates for outcomes were calculated using random-effects models. RESULTS: A total of 19 full-text articles representing 17 RCTs were included. Average participant age was 72-80 years, and 31%-62% were female. Comprehensive geriatric assessment type, mode of delivery, and evaluated outcomes varied across studies. Meta-analysis revealed no difference in risk of mortality (risk ratio [RR] = 1.08. 95% confidence interval [CI] = 0.91 to 1.29), hospitalization (RR = 0.92, 95% CI = 0.77 to 1.10), early treatment discontinuation (RR = 0.89, 95% CI = 0.67 to 1.19), initial dose reduction (RR = 0.99, 95% CI = 0.99 to 1.26), and subsequent dose reduction (RR = 0.87, 95% CI = 0.70 to 1.09). However, the risk of treatment toxicity was statistically significantly lower in the comprehensive geriatric assessment group (RR = 0.78, 95% CI = 0.70 to 0.86). No cost-effectiveness studies were identified. CONCLUSION: Compared with usual care, comprehensive geriatric assessment was not associated with a difference in risk of mortality, hospitalization, treatment discontinuation, and dose reduction but was associated with a lower risk of treatment toxicity indicating its potential to optimize cancer treatment in this population. Further research is needed to evaluate cost-effectiveness.

PROSPECTIVE SINGLE CENTER ANALYSIS OF OUTCOME STEM CELLS TRANSPLANTS IN PATIENTS WITH CEREBRAL PALSY.

OBJECTIVE: Aim: To evaluate efficacy and safety of autologous bone marrow-derived mononuclear stem cell transplantation intrathecal in children with cerebral palsy. PATIENTS AND METHODS: Materials and Methods: 35 children have levels I-V cerebral palsy aged 8-months to 8-years-old were enrolled from September (2021-2022) at Iraqi private hospital. Gross Motor Function was assessed by a pediatrician and neurologist specialist, 5 mcg/kg/day of G-CSF subcutaneous single injection daily for three consecutive days. Bone marrow harvested from posterior iliac crest under light general anesthesia. Bone marrow mononuclear cells (BMMNCs) separation was performed using density gradient centrifugation with Ficoll, the cell viability checked by propidium iodide dye in a TALI machine (Invitrogen) in average 98%. The viable BMMNCs injected intrathecal in L4-L5 over a period of 5-10 min. RESULTS: Results: Males accounted for 57.14% (20/35) while female 42.86% (15/35), and main neurological symptoms included spastic disorder spastic disorder (quadriplegia 24 (68.6), tetraplegia 2 (5.7), diplegia 5 (14.28), hemiplegia4 (11.42)). Gross Motor Function Classification System and Gross Motor Function Measure-66 (GMFM-66) showed II 10 (28.58), III 11(31.42) and IV 14 (40). On mean follow-up of 3 months post-stem cell transplant improvement was observed in 80% cases. The improvement showed in gross motor function (6/8) p=0.01, and speech (2/4) p=0.04, neck holding (5/5) p=0.0003, sitting balance (4/4) p=0.04, postural tone (5/5) p=0.0003, as well as significant reduction in seizure frequency (2/3) p=0.04 and improvement in cognition (6/7) p=0.01 were observed. CONCLUSION: Conclusion: Stem cell therapy for cerebral palsy shows a significant positive effect on the gross motor function, without long adverse effects.

Transcatheter Mitral Valve Repair via MitraClip in Patients Aged <65 Years: Multicentre 2-year Outcomes.

Background: Transcatheter mitral valve repair (TMVR) using the MitraClip has become a well-established interventional therapy and is usually performed in elderly patients. The objective of this study was to assess 2-year clinical outcomes of TMVR in patients aged <65 years at three heart centres with severe mitral regurgitation (MR) and no surgical options. Methods: A retrospective study analysed data of 36 patients aged <65 years treated with TMVR . All patients were refused surgery by Heart Team decision. Baseline MR was assessed by biplane vena contracta width in two perpendicular views (mean 8.35 ± 1.87 mm). Degenerative MR was detected in 11 patients (30.6%); functional MR was detected in 25 patients (69.4%). Results: Acute procedural success was accomplished in 88.9% of patients. No procedure-related mortality during the first 30 days was detected. Over an average of 2 years of follow-up, all-cause mortality was 19.4% and cardiovascular death was 11.1% owing to advanced heart failure. The average follow-up period was 25.8 months (median was 20 months). Statistically significant difference (p-value <0.01) was detected for N-terminal prohormone of brain natriuretic peptide (pg/ml) at baseline (mean 9,870 ± 10,819; median 7,748) compared to follow-up visits (mean 7,645 ± 11,292; median 3,263). New York Heart Association functional class improvement was achieved in 69% of patients. A second intervention (reclipping) was required in two patients to correct recurrent significant MR. Conclusion: TMVR in patients aged <65 years refused surgical repair provides satisfactory clinical outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort.

Evaluating the Effect of Delayed Diagnosis on Disease Outcome in Fibromyalgia: A Multi-Center Cross-Sectional Study.

Background: The impact of delayed diagnosis (DD) on fibromyalgia (FM) patients' symptomatology and disease outcome has not yet been systematically studied. Objective: To analyze the predictors of DD and the influence of DD on FM aggravation and disease evaluation measures. Methods: 370 FM patients were interviewed prospectively for this study. The following information was obtained: DD, widespread pain index (WPI), symptom severity scale (SSS), polysymptomatic distress scale (PDS) scale (SSS + WPI), and tender points. We identified three groups of patients: early diagnosis (ED: 2 years; 83 patients), late diagnosis (LD: > 2-7 years; 198 patients), and very late diagnosis (VLD: > 7 years; 89 patients). Results: The patients' average age was 33.9 (9.8) years, and 79% were female. The SSS, PDS, and tender point means were 7.8 (1.6), 16.46 (4.1), and 14.31 (2.3), respectively. The correlation between DD and SSS (r = 0.14), the PDS scale (r = 0.37), and FM tender points (r = 0.16) was significant, but not with WPI (r = 0.06). When the three groups were examined, the SSS mean was 7.54 (1.6), 7.73 (1.4), and 8.25 (1.7), respectively (P 0.008), while the PDS mean was 15 (3.8), 15.95 (3.8), and 18.96 (4.4), respectively (P 0.008). (P 0.001). Conclusion: Early FM diagnosis is associated with lower SSS, total severity scale, and FM tender points, indicating a less severe condition.

Implementation of clinical recommendations from the geriatric oncology clinic.

INTRODUCTION: While evidence on the value of routine geriatric assessment (GA) in cancer care for older patients is growing, there is limited data on the geriatric oncology (GO) clinic's specific recommendations and how they are implemented. In this study, we aimed to assess and evaluate the implementation of recommendations from the GO clinic at Princess Margaret Cancer Center, Toronto, Canada, within six months of the initial visit. MATERIALS AND METHODS: A retrospective chart review was conducted on 100 consecutive adults age 65+ visiting the GO clinic from 2018 to 2019. For each patient, we evaluated the number and type of recommendations from the GO clinic. Recommendations were grouped based on clinical judgement. Of the recorded recommendations, we measured the rate of implementation within six months of the initial visit including who implemented the recommendations and why recommendations were not implemented. Data were analyzed using descriptive statistics. RESULTS: One hundred patients visiting the GO clinic (mean age of 80.5 years, 62% male, 52% with planned curative intent, with the genitourinary site being most common) received a median of six recommendations (range of 2-12), regardless of sex, cancer stage, cancer site, and treatment intent. Medication optimization (27%), patient education (26%), and referral to allied health (14%) were the top recommendations from the GO clinic. At six-month follow-up, 83% of all recommendations were implemented, of which 94% were performed by the GO clinic team. Patient education was implemented at a 100% rate by the GO clinic at the time of initial assessment. GO follow-up visit and other diagnostic tests (hearing test, vision test) were the recommendations with the lowest implementation rates, at 51% and 31%, respectively. The most common reasons for recommendations not being implemented were patient transfer to palliative care/death and patient declining recommendations due to busy appointment schedules. DISCUSSION: A median of six recommendations were made per patient. The vast majority of recommendations were implemented, predominantly by the GO team. Overall, the study helps evaluate recommendations provided to patients visiting GO clinics, identify potential gaps, and assist with resource planning for optimal cancer care for older adults.

The Risk of Meningitis After Cochlear Implantation: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study aims to estimate the rate of postoperative meningitis (both immediate and long-term) in patients following cochlear implants (CIs). It aims to do so through a systematic review and meta-analysis of published studies tracking complications after CIs. DATA SOURCES: MEDLINE, Embase, and Cochrane Library. REVIEW METHODS: This review was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies tracking complications following CIs in patients were included. Exclusion criteria included non-English language studies and case series reporting <10 patients. Bias risk was evaluated using the Newcastle-Ottawa Scale. Meta-analysis was performed through DerSimonian and Laird random-effects models. RESULTS: A total of 116/1931 studies met the inclusion criteria and were included in the meta-analysis. Overall, there were 112 cases of meningitis in 58,940 patients after CIs. Meta-analysis estimated an overall rate of postoperative meningitis of 0.07% (95% confidence interval [CIs], 0.03%-0.1%; I2 = 55%). Subgroup meta-analysis showed this rate had 95% CIs crossing 0% in implanted patients who received the pneumococcal vaccine, antibiotic prophylaxis, those with postoperative acute otitis media (AOM), and those implanted less than 5 years. CONCLUSION: Meningitis is a rare complication following CIs. Our estimated rates of meningitis after CIs appear lower than prior estimates based on epidemiological studies in the early 2000s. However, the rate still appears higher than the baseline rate in the general population. The risk was very low in implanted patients who received the pneumococcal vaccine, antibiotic prophylaxis, received unilateral or bilateral implantations, developed AOM, those implanted with a round window or cochleostomy techniques, and those under 5 years.

Management of Bilateral Quadriceps Tendon Ruptures Post Total Knee Arthroplasty by Kesler Technique Using Fiber Tape.

Total knee arthroplasty is an effective way to manage osteoarthritis patients surgically. However, patients may encounter post-surgical complications, such as quadriceps rupture in rare instances, in addition to surgical complications. In our clinical practice, we encountered a 67-year-old Saudi male patient with a rare bilateral quadriceps rupture two weeks post-total knee arthroplasty. The cause of the bilateral rupture was a history of falls in both knees. The patient was reported to our clinic with clinical features like pain in the knee joint, immobility, and bilateral swelling in the knees. The X-ray did not show any periprosthetic fracture, but an ultrasound of the anterior thigh revealed a complete cut of the quadriceps tendon on both sides. The repair of the bilateral quadriceps tendon was done by direct repair using the Kessler technique and was reinforced with fiber tape. Following knee immobilization for six weeks, the patient began intensive physical therapy management to decrease pain, enhance muscle strength, and increase range of motion. After rehabilitation, the patient regained a complete range of motion in the knee and improved functionality, and he could walk independently without crutches.

Ovine endometrial estrogen receptor expression is altered following PG-600 administration.

BACKGROUND: Dysregulation of the estrogen receptor 1 (ESR1) expression during the establishment of pregnancy could contribute to reduce fertility reported in ewes treated with PG-600. OBJECTIVES: The objective of this study was to evaluate the effect of treatment with PG-600 on ESR1 expression in the ovine endometrium during early diestrus. METHODS: Polypay ewes (n = 24) that had exhibited an oestrous cycle of normal duration (16-18 days) were treated with intravaginal progesterone-releasing device (CIDR) for 9 days. Cloprostenol was administrated two days before CIDR withdrawal. On the day of CIDR withdrawal (day 0), ewes received a 5 mL intramuscular injection of PG-600 (400 IU equine chorionic gonadotropin and 200 IU human chorionic gonadotropin) or saline. Blood samples were collected before treatment and on the day of tissue collection to determine serum estradiol-17ß and progesterone concentrations using radioimmunoassay. On days 4 and 7, six ewes from each treatment group were anaesthetised and a laparotomy was performed to obtain intercaruncular endometrial samples. Endometrial samples were collected ipsilateral to the ovary bearing the highest number of corpora lutea. An estradiol exchange assay was used to determine ESR1 concentration. RESULTS: Estradiol concentrations did not differ by time or treatment, but progesterone concentrations were significantly higher in the PG-600-treated group on day 7 despite a similar number of corpora lutea. Endometrial ESR1 concentration was significantly reduced on day 7 in the PG-600 group. CONCLUSIONS: In conclusion, although progesterone was higher than controls on day 7, ESR1 did not differ from controls suggesting that treatment with PG600 is unlikely to impair reproductive potential.

Systematic review of the diagnosis and management of necrotising otitis externa: Highlighting the need for high-quality research.

OBJECTIVES: To present a systematic review and critical analysis of clinical studies for necrotising otitis externa (NOE), with the aim of informing best practice for diagnosis and management. DESIGN: Medline, Embase, Cochrane Library and Web of Science were searched from database inception until 30 April 2021 for all clinical articles on NOE. The review was registered on PROSPERO (ID: CRD42020128957) and conducted in accordance with PRISMA guidelines. RESULTS: Seventy articles, including 2274 patients were included in the final synthesis. Seventy-three percent were retrospective case series; the remainder were of low methodological quality. Case definitions varied widely. Median patient age was 69.2 years; 68% were male, 84% had diabetes and 10% had no reported immunosuppressive risk factor. Otalgia was almost universal (96%), with granulation (69%) and oedema (76%) the commonest signs reported. Pseudomonas aeruginosa was isolated in 62%, but a range of bacterial and fungal pathogens were reported and 14% grew no organism. Optimal imaging modality for diagnosis or follow-up was unclear. Median antimicrobial therapy duration was 7.2 weeks, with no definitive evidence for optimal regimens. Twenty-one percent had surgery with widely variable timing, indication, or procedure. One-year disease-specific mortality was 2%; treatment failure and relapse rates were 22% and 7%, respectively. CONCLUSION: There is a lack of robust, high-quality data to support best practice for diagnosis and management for this neglected condition. A minimum set of reporting requirements is proposed for future studies. A consensus case definition is urgently needed to facilitate high-quality research.