Adult brachial plexus injuries: Surgical strategies and approaches.

Traumatic brachial plexus injuries are devastating injuries commonly affecting the young population and leading to significant socioeconomic losses to the society. The results of brachial plexus surgery have been severely disappointing in the past. However, several technological advancements and newer surgical techniques, especially the advent of distal nerve transfers over recent years, have led to a paradigm shift in the outcome of patients with these injuries. The best time window for surgery is the first 3 months after injury, and the next best time is the next 3 months. The timing is a crucial factor as the neuromuscular junctions degenerate in 20-24 months. The presence of spontaneous fibrillations in a muscle on electromyography is an indication of denervated yet vital muscle. The restoration of elbow flexion is a priority followed closely by restoration of shoulder abduction and stabilization. The various surgical strategies in brachial plexus injuries should be directed toward accomplishing this goal. The global avulsion injuries have a poor outcome because of very limited source of donors in such types of injury whereas the partial injuries have a remarkable outcome in a majority of cases. This article presents the reader with the guidelines and management algorithms of repair strategy and various surgical approaches utilized in the surgical treatment of brachial plexus injuries.

The current techniques in dorsal augmentation rhinoplasty: a comprehensive review.

BACKGROUND: An essential aspect of rhinoplasty is the enhancement of the nasal dorsal contour by performing dorsal augmentation (DA) rhinoplasty. A wide range of techniques are available for DA as the demand for aesthetic nasal refinement grows. This review aims to provide a comprehensive overview of the current techniques used in DA rhinoplasty. MAIN BODY: Research articles on DA rhinoplasty techniques were identified through a comprehensive literature search. Scopus, PubMed, and Web of Science were used as electronic databases. Each database was searched for articles published since its inception. DA rhinoplasty techniques were examined in this literature review. Methodological quality was assessed for the selected studies, and data was extracted to examine materials used, surgical approaches, and reported outcomes for each technique. Various DA methods, including autologous grafts and synthetic implants, are examined in-depth in this review. Comparing approaches can help better understand their respective advantages and limitations. CONCLUSION: A wealth of techniques is available for DA rhinoplasty, each with advantages. Patients' nasal anatomy, desired outcomes, and potential risks must be considered by surgeons when determining their surgical approach. DA methods continue to evolve rapidly, creating a need for a thorough understanding of the current landscape to make informed decisions.

Echocardiographic Parameters Associated with Bendopnea in Patients with Systolic Heart Failure.

Background: Bendopnea, defined as dyspnea while bending, can be observed in patients with heart failure (HF). In this study, we investigated the frequency of this symptom in patients with systolic HF and its association with echocardiographic parameters. Methods: In this study, patients with left ventricular ejection fraction (LVEF) ≤45% and decompensated HF referred to our clinics were prospectively recruited. All the patients were examined by cardiologists for collecting data on the presence of bendopnea and baseline characteristics. They also underwent electrocardiographic and echocardiographic examinations. All findings were compared between the patients with or without bendopnea. Results: A total of 120 patients at a mean age of 65.19±12.62 years were evaluated, and 74.8% were men. Bendopnea was observed in 44.2% of the patients. The etiology of HF was ischemic in most patients (81.9%), and the functional class of most patients (85.9%) was III or IV. The mortality rate at the 6-month follow-up was comparable between the patients with or without bendopnea (6.1% vs 9.5%; P=0.507). The waist circumference (odds ratio [OR], 1.037, 95% confidence interval [CI], 1.005 to 1.070; P=0.023), paroxysmal nocturnal dyspnea (OR, 0.338, 95% CI, 0.132 to 0.866; P=0.024), and right atrial size (OR, 1.084, 95% CI, 1.002 to 1.172; P=0.044) were associated with bendopnea. Conclusion: Bendopnea can be frequently found among patients with systolic HF. This phenomenon is associated with obesity and baseline symptoms of patients and right atrial size upon echocardiographic examinations. It can help clinicians with the risk stratification of HF patients.

The effects of the ratio of pellets of wheat and barley grains to ground corn grain in the diet on sorting and chewing activities of heat stressed dairy cows.

BACKGROUND: Normal feeding behaviours is one of the criteria of the health condition of dairy cows particularly in the condition of heat stress. OBJECTIVE: The study evaluated the effects of the ratio of pellets of wheat and barley grains to ground corn grain on sorting activity and chewing behaviour of lactating dairy cows managed under ambient conditions including natural heat stress events. MATERIALS AND METHODS: Nine multiparous cows (650 ± 56 kg Body Weight; mean ± SD) averaging 102 ± 13 days in milk and producing 54 ± 6 kg/d were randomly assigned to a triplicate 3 × 3 Latin square. During each 21-d period, cows received one of three total mixed rations as dietary treatments. The dietary treatments were three ratio of pellets (containing 50% ground wheat and 50% ground barley): ground corn on a dry matter (DM) basis: 1) 33.3:66.6 (low); 2) 66.6:33.3 (medium); and 3) 100:0 (high). During the experiment, the ambient temperature-humidity index was equal or more than 72, indicating that the cows were predisposed to heat stress condition. RESULTS: Increasing the proportion of wheat-barley pellets in the diet had a minimal effect on sorting index of different particles during the first 6 h of the day. However, later in the day (6-18h), sorting against long particles (particles >19 mm) and in favour of fine particles (particles <1.18 mm) linearly increased with increasing the proportion of pellet; as a result overall daily sorting against long particles was increased with increasing the proportion of pellets. Although the average of daily eating and rumination was not affected by the treatments in the day times with high ambient THI, time spent for eating and rumination was low and eating time had more fluctuation for diet contained a high level of pellets. CONCLUSION: Increasing the proportion of pellets of barley and wheat grains in the diet under conditions of heat stress caused more fluctuation in daily eating behaviour and cows were predisposed to sort against long particles.

Surgical Treatment of Symptomatic Small Medial Petrous Meningiomas Causing Trigeminal Neuralgia.

BACKGROUND: Symptomatic trigeminal neuralgia caused by small (<3 cm) skull base meningiomas is treated by radiosurgery or surgical resection. Although radiosurgery is less invasive, surgical resection provides more rapid resolution of symptoms. We reviewed a short series of patients who underwent an anterior transpetrosal approach for surgical resection of meningiomas causing trigeminal neuralgia. METHODS: A retrospective review of 5 consecutive patients with meningiomas causing trigeminal neuralgia of the senior author was included. Preoperative parameters (size, proximity to critical neurovascular structures, presence of brainstem compression), intraoperative parameters (Simpson grade of resection, loss of brainstem evoked potentials, surgical approach), and outcomes (symptom resolution, extent of resection, follow-up) were recorded. RESULTS: Patient median age was 67 years (range, 60-73 years). All patients had symptoms concerning trigeminal neuralgia with 2 having associated areas of facial numbness. The anterior transpetrosal approach was used to achieve complete resection (Simpson grade I). Postresection, the trigeminal nerve and brainstem were clearly visible to evaluate neurovascular structures and ensure decompression. No postoperative complications were reported, and all patients experienced sustained symptomatic relief 1 month postsurgery. CONCLUSIONS: With the advent of radiosurgery for skull base meningiomas, surgical resection is not always considered; however, such meningiomas causing trigeminal neuralgia can be resected safely using the anterior transpetrosal approach allowing rapid resolution of symptoms. This review of operative nuances provides a guide for neurosurgeons to provide safe surgical resection.

Diagnostic accuracy of resistive index of capsular and intratesticular branches of testicular arteries in infertile men with oligoasthenospermia: A case-control study.

INTRODUCTION: Male infertility accounts for nearly 50% of couples' infertility. Only a few studies evaluate the diagnostic accuracy of resistive index (RI) of testicular arteries using color Doppler imaging to identify male infertility. The aim of this study was to investigate the diagnostic accuracy of RI of the capsular and intratesticular branches of testicular arteries in infertile men with oligoasthenospermia and its comparison with normal men. MATERIAL AND METHODS: In a case-control study, 30 patients with oligoasthenospermia (case group) and 30 healthy controls who meet the inclusion criteria, were selected. For all patients, RI was measured using color Doppler ultrasonography in upper and lower testicular poles. Also, testicular volumes were measured for all participants. RESULTS: Mean RI of the intratesticular artery (0.624 ± 0.051 versus 0.509 ± 0.054; P < 0.001) and capsular artery (0.663 ± 0.057 versus 0.557 ± 0.055; P < 0.001) were significantly higher in the case group compared to control group. The frequency of abnormal RI of intratesticular artery in the control (13.3%) and case (66.7%) groups were significantly different (OR: 13.0; 95% CI: 3.44-47.59; P < 0.001). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy (OA) of intratesticular artery RI were 66.67%, 86.67%, 83.33%, 72.22%, and 76.67%, respectively. The frequency of abnormal RI of capsular artery was 23.3% in the control group and 90.0% in the case group (OR: 29.57; 95% CI: 6.85-127.63; P < 0.001). The sensitivity, specificity, PPV, NPV and OA of capsular artery RI were 90.0%, 76.67%, 79.41%, 88.46% and 83.33%, respectively. CONCLUSION: The results of this study indicated that assessing testicular Doppler RI of capsular and intratesticular branches of the testicular arteries, as a bio-imaging biomarker, may be a valuable non-invasive and simple complementary diagnostic modality with a high diagnostic value in identifying infertile men with oligoasthenospermia.

Neurosurgical management of perineural metastases: A case series and review of the literature.

BACKGROUND: Perineural invasion (PNI) and spread are one of the grimmest prognostic factors associated with primary skin and head-and-neck cancers, yet remain an often confused, and underreported, phenomenon. Adding complexity to reaching a diagnosis and treating perineural spread (PNS) is the finding that patients may have no known primary tumor, history of skin cancer, and/or incidental PNI in the primary tumor. These delays in diagnosis and treatment are further compounded by an already slow disease process and often require multidisciplinary care with combinations of stereotactic radiosurgery, surgical resection, and novel treatments such as checkpoint inhibitors. METHODS: Six patients with metastatic cancer to the cranial nerves who underwent Gamma Knife radiosurgery (GKRS) treatment were chosen for retrospective analysis. This information included age, gender, any past surgeries (both stereotactic and regular surgery), dose of radiation and volume of the tumor treated in the GKRS, date of PNS, comorbidities, the patient follow-up, and pre- and post-GKRS imaging. The goal of the follow-up with radiographing imaging was to assess the efficacy of GKSS. RESULTS: The clinical course of six patients with PNS is presented. Patients followed variable courses with mixed outcomes: two patients remain living, one was lost to follow-up, and three expired with a median survival of 12 months from date of diagnosis. Patients at our institution are ideally followed for life. CONCLUSION: Given the morbidity and mortality of PNS of cancer, time is limited, and further understanding is required to improve outcomes. Here, we provide a case series of patients with PNS treated with stereotactic radiosurgery, discuss their clinical courses, and review the known literature.

Wernicke encephalopathy following gastrojejunostomy: A case report and review of the literature.

INTRODUCTION: Non-alcoholic Wernicke encephalopathy (WE) is a life-threatening condition, which is caused due to thiamine deficiency. We reported a case of non-alcoholic WE following gastrojejunostomy. CASE PRESENTATION: A 31-year-old woman was admitted to our tertiary care center complaining about intractable nausea and vomiting following her gastrojejunostomy. She had undergone gastrojejunostomy because of gastric outlet obstruction after a suicide attempt with scale-remover. Two weeks after gastrojejunostomy, the altered mental status and confusion were reported and she also had a reduced range of motion, dysarthria, generalized muscle weakness, and vertical nystagmus. She gradually became uninterested in surroundings. WE was considered a differential diagnosis, which was confirmed by magnetic resonance imaging (MRI). High-dose intravenous thiamine administration was done for the patient and her symptoms were improved. We also reviewed the PubMed to evaluate studies on WE following gastrointestinal surgeries conducted through the last 10 years. CONCLUSION: WE is a rare presentation of gastrojejunostomy and it should be considered as differential diagnosis when patient had impaired mental status and other related WE symptoms following gastrojejunostomy. Early diagnosis and management of WE in the Emergency Department can reduce the mortality and morbidity of WE.

Association between sleep duration and electrocardiographic ischemic changes in middle-aged population: Isfahan Healthy Heart Program.

BACKGROUND: Recent studies examining the association between sleep duration and cardiovascular disease (CVD) showed inconsistent results. The aim of our study was to evaluate the association between self-reported night sleep duration and ischemic changes in electrocardiography (ECG). METHODS: We conducted this cross-sectional study on 3513 participants from Iranian middle-aged population as a part of Isfahan Healthy Heart Program (IHHP), Isfahan, Iran. Sleep duration was obtained by questioning participants. The frequency of electrocardiographic ischemic changes was calculated using ECG Minnesota coding system. RESULTS: Short sleep duration was associated with increased frequency of electrocardiographic ischemic changes. In a fully adjusted multiple logistic regression analysis, the odds ratio (OR) for short sleep duration less than 5 hours per night was 1.501 [95% confidence interval (CI) for OR: 1.085-2.076] compared to 8 hours of sleep. After stratifying the study population into sex groups, the association remained significant only in women. The OR for short sleep less than 5 hours per night was 1.565 (95% CI for OR: 1.052-2.329) and 1.455 (95% CI for OR: 0.833-2.539) in women and men, respectively. There was no association between long sleep duration and electrocardiographic ischemic changes in men and women. CONCLUSION: We concluded that there is a positive association between short sleep duration and frequency of electrocardiographic ischemic changes in middle-aged women. This association suggests that short sleep duration may increase the risk of ischemic heart disease (IHD) in women, and this need to be evaluated in further studies.

Assessment of Low-Level Laser Therapy Effects After Extraction of Impacted Lower Third Molar Surgery.

Introduction: The aim of this study was to assess the effect of low-level laser therapy (LLLT) on pain, swelling and maximum mouth opening in patients undergoing third molar surgery. Methods: A prospective, randomized double-blind study was undertaken on 44 patients at the Dental School, Ahvaz Jundishapur University of Medical Sciences, in 2015. A low-level laser was randomly applied on one of the two sides after surgery of 15 patients. The experimental side received 18 J/cm2 of energy density, wavelength of 980 nm, and output power of 1.8 W. On the control side, a hand-piece was applied intra-orally, but laser was not activated. In addition, in order to evaluate trismus, 13 patients were treated by unilateral laser therapy and 16 patients did not receive laser therapy at all. The laser was administered intraorally on two points of vestibular and lingual sides at 1 cm from the surgery site, and extraorally at the emergence of the masseter muscle, immediately after surgery, and repeated 24 hours later. The pain, swelling and maximum mouth opening (MMO) were compared between the two groups at 24 hours and a week after surgery. Results: The mean score of pain 24 hours after surgery in the laser therapy group (2.3 ± 3.5) was significantly lower than the mean score of pain in the drug therapy (4.19 ± 3.09) (P = 0.036). Moreover, the mean score of pain at one week after surgery in the laser therapy group (0.13 ± 2.33) was significantly lower than the drug therapy group (1.43 ± 2.45) (P = 0.046). The amount of swelling according to different measurements did not significantly differ between the two groups neither at 24 hours nor at 1 week after surgery. Conclusion: Our findings showed that LLLT was useful in reducing pain and could slightly reduce swelling compared to drug therapy in impacted third molar surgery.

An Evidence-Based Stepwise Surgical Approach to Cervical Spondylotic Myelopathy: A Narrative Review of the Current Literature.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is the most common progressive degenerative disease of the spine in the geriatric population. The aim of the current review is to provide an evidence-based stepwise surgical approach to CSM according to the recent literature. METHODS: We searched for evidence regarding the surgical approach to CSM in medical databases with articles dated from 1985 to 2016. RESULTS: In patients with effective cervical lordosis (fewer than 3 levels of ventral disease), anterior cervical discectomy and fusion (ACDF) or arthroplasty is preferred. Patients with more than 3 levels of compression are generally treated by laminoplasty, especially with preserved lordotic curvature. In patients with straightened spine who have less than 3 involved levels, ACDF with a plate is recommended, whereas patients with more than 3 involved levels with instability should undergo posterior decompression and fusion. In young patients who have a stable cervical spine, laminoplasty is recommended and in old patients with ankylosed spine, only laminectomy should be performed. Patients with mild cervical kyphosis (kyphotic angle ≤10°) should be managed in the same way as patients with straightened spine. However, in severe kyphosis, cervical traction is recommended. If the kyphosis is reducible, further posterior decompression and fusion is adequate. In patients with irreducible kyphosis, if the number of involved levels is less than 2, ACDF is adequate, but if it is more than 2 levels, anterior cervical corpectomy and fusion should be performed using cervical magnetic resonance imaging for evaluation of the patency of the subarachnoid space (SAS). With patent SAS, only posterior fusion is adequate, whereas in closed SAS, posterior decompression with posterior fusion is required. These approaches are based on the most recent evidence. CONCLUSIONS: This article provides a stepwise evidence-based surgical approach for the management and treatment of patients with CSM.

Immunohistochemical analysis of B-cell lymphoma -2 in pleomorphic adenoma and mucoepidermoid carcinoma.

BACKGROUND: Salivary gland tumors form a major area in the field of oral pathology. B-cell lymphoma -2 (Bcl-2) is an anti-apoptotic gene with up-regulation in various neoplasms. The aim of the present case-control study was to comparatively investigate the expression of Bcl-2 protein in pleomorphic adenoma (PA) and mucoepidermoid carcinoma (MEC) and assess its potential diagnostic role in differentiating these tumors. MATERIALS AND METHODS: A total of 28 cases (18 specimens of PA [control] and 10 blocks of MEC [case]) were selected for analysis by streptavidin-biotin peroxidase method with antibody against Bcl-2. The percentage of positive cells was calculated from a minimum of 1000 neoplastic cells and H-score was identified (% positive cells × intensity of staining). Data were analyzed using two-way ANOVA, t-test, Spearman, Chi-square and Fisher tests (α = 0.05). RESULTS: bcl-2 expression was shown in 13 cases (71%) of PA and 3 cases (30%) of MEC. In addition, four cases of PA showed strong staining. There was a significant difference between the expression intensity of Bcl-2 in the two tumors (P = 0.048) according to ANOVA. No correlation was observed between Bcl-2 expression with the size and location of tumors (P > 0.05). CONCLUSION: Bcl-2 expression might be used for differentiating these tumors. Bcl-2 protein was overexpressed in PA compared with MEC. Hence, it seems that unlike what was observed in PA, Bcl-2 probably does not participate in the pathogenesis of MEC.

A polyglycerol-polycaprolactone-polycitric acid copolymer and its self-assembly to produce medium-responsive nanoparticles.

A hyperbranched-linear-hyperbranched amphiphile (HLHA) consisting of polyglycerol, polycaprolactone and polycitric acid blocks was synthesized and characterized. The self-assembly of HLHA in aqueous solutions produced nearly monodispersed nanoparticles. The average size of the nanoparticles in aqueous solutions was 120 nm. Spectroscopy and microscopy analysis showed that the nanoparticles change their structure in response to changes in the polarity of the medium in the solution state, so that the hydrophobicity or hydrophilicity of the solvent dominates the structure and properties of the nanoparticles. This property was used to load hydrophobic anticancer drugs inside the nanoparticles and also to deliver them to cancer cells successfully. In addition to the mentioned properties, the efficient uptake and low toxicity enable the prepared nanoparticles to be potential new systems for future cancer therapy.

The effect of positive family history of autoimmunity in juvenile idiopathic arthritis characteristics; a case control study.

OBJECTIVE: To compare Juvenile Idiopathic Arthritis (JIA) patients with and without family history of autoimmune disease with respect to clinical features and laboratory data. METHODS: Sixteen JIA patients with family history of autoimmune disease were identified during study, 32 patients were chosen for comparative group from referred patients to the rheumatology clinic according to the date of referral. Two groups were compared with respect to age of onset, sex, subtype, disease activity, duration of active disease and laboratory variables. FINDINGS: The age of onset was significantly lower in JIA patients with family history of autoimmunity (4.7 years vs. 7.0 years; P=0.02), polyarthicular subtype was more frequent in patients with positive family history (50% vs.25%; P=0.04) most of JIA patients with positive family history were in the active phase at the time of study (64% vs 25%; P=0.02) and had a longer duration of active disease (21.0 months vs 12.3 months; P=0.04). Patients with positive family history had more positive ANA (43.5%% vs 12.5%; P=0.01) and also more positive ADA (75% vs 20.8%; P=0.002). Two groups were similar according to sex, and other laboratory variables. CONCLUSION: JIA patients with family history of autoimmune disease seem to have a more severe disease than patients without such family history, they are younger at the onset, and have mostly poyarthicular subtype. They also have more ANA and ADA positivity. These findings are different from familial JIA case-control studies according to active disease duration, subtype, and ANA positivity.

Quality of life and sleep in hemodialysis patients.

The purpose of this study was to determine the quality of life and sleep of chronic hemodialysis (HD) patients. Quality of sleep was measured using the Pittsburgh Sleep Quality Index (PSQI) and quality of life (QoL) was measured using the Medical Outcomes Study 36-item Short Form (SF-36) in 115 HD patients. One hundred (87%) patients were "poor sleepers" (global PSQI ≥5). The SF-36 mental component summary and physical component summary (PCS) scores were higher than 50 only in 43% and 32% of the subjects, respectively. No significant differences were found in QoL and sleep according to the patient's gender, presence of diabetes and time on HD. Correlation between total SF-36 score and global PSQI was statistically significant (r = -0.227, P <0.05). Poor sleep is common in dialysis patients and is associated with lower QoL, especially with mental health component of life quality.

Effect of progesterone administration on prognosis of patients with diffuse axonal injury due to severe head trauma.

OBJECTIVE: Severe traumatic brain injury (TBI) has a major role in mortality rate among the other types of trauma. The aim of this clinical study was to assess the effect of progesterone on the improvement of neurologic outcome in patients with acute severe TBI. METHODS: A total of 76 patients who had arrived within 8h of injury with a Glasgow Coma Score≤8 were enrolled in the study. In a randomized style 38 received progesterone (1mg/kg per 12h for 5 days) and 38 did not. RESULTS: There was a better recovery rate and GOS score for the patients who were given progesterone than for those in the control group in a 3-months follow-up period (50% vs. 21%); subgroup analysis showed a significant difference in the percentage of favorable outcome between the two groups with GCS of 5-8 (p=0.03). CONCLUSION: The use of progesterone may significantly improve neurologic outcome of patients suffering severe TBI up to 3 months after injury, especially those with 5≤GCS≤8, providing a potential benefit to the treatment of acute severe TBI patients. Considering this drug had no significant side effects, so progesterone could be used in patients with severe TBI as a neuro-protective drug.