A Recurrent Case of Ameloblastic Fibroma in 37-year Old Male.

Ameloblastic fibroma (AF) is a benign mixed epithelial and mesenchymal odontogenic tumor. This was previously grouped in odontogenic tumor showing odontogenic epithelium with odontogenic ectomesenchyme, with or without hard tissue formation. This report describes a case of ameloblastic fibroma in a 37-yearold male who came with the complain of swelling in the left side of lower jaw since one year. Enucleation of the mass followed by reconstruction was done six years back. However, after two years of initial treatment; radiographic findings suggested recurrence. Histopathological examination confirmed the diagnosis of ameloblastic fibroma. Patient had no clinical and radiographic evidence of recurrence in three and six months' follow-up. Because of the higher proliferative capacity and malignant degree of the mesenchymal component in the recurrent neoplasm, sarcomatous transformation may occur. Hence, a long term clinical and radiographical follow-up is essential due to its transformation into ameloblastic fibrosarcoma.

Conjoint muscle transfer and subscapularis slide in brachial plexus birth palsy: Clinical outcomes in shoulder functions.

BACKGROUND: Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP. METHODS: 18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant. RESULTS: Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child. CONCLUSION: This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.

The safety and efficacy of radiofrequency ablation following endoscopic submucosal dissection for Barrett's neoplasia.

The current standard of treating early Barrett's neoplasia is resection of visible lesions using endoscopic mucosal resection (EMR) followed by ablative therapy to the Barrett's segment. There is increasing evidence to support the use of endoscopic submucosal dissection (ESD) where en-bloc resection and lower recurrence rates may be achieved. However, ESD is associated with deep submucosal dissection when compared to EMR. This may increase the risk of complications including stricture formation with subsequent radiofrequency ablation (RFA) therapy. The aim of this study is to compare the safety and efficacy of RFA following EMR and ESD as well as when RFA was used without prior endoscopic resection. The primary outcome measure was complication rates. Clearance of dysplasia (CRD) and clearance of intestinal metaplasia (CRIM) were secondary outcomes. A retrospective analysis of a cohort of 91 patients referred for RFA from a single academic tertiary center was performed. The choice of endoscopic resection method was tailored according to the lesion type and morphology. Focal and circumferential ablation was performed after initial follow up endoscopy postresection. Patients proceeded straight to RFA in the absence of any visible lesions. In this study, the ESD group had a higher proportion of cancers compared to the EMR cohort (74.1% vs. 30.2%, P < 0.01) prior to RFA. All complications post RFA occurred in the groups with previous endoscopic resection. There was no significant difference in the total complication rate (7.4% vs. 9.3%, P = 0.78) and stricture formation rate (3.7% vs. 9.3%, P = 0.38) between the ESD and EMR groups. CRD was achieved in 96.3% in the ESD group, 88.4% in the EMR group, and all patients in the RFA alone group. CRIM rates were similar in the EMR and ESD groups (81.4% vs. 85.2%) but higher in the RFA alone group (90.5%). In conclusion, RFA following ESD is very effective and not associated with an increased risk of complications compared to EMR. This supports the application of RFA in the treatment algorithm of patients undergoing ESD for Barrett's neoplasia.

Extended Spectrum ß-lactamase (ESBL) Producing Multi Drug Resistant (MDR) Urinary Pathogens in a Children Hospital from Nepal.

Background Multidrug resistant in clinical bacterial isolates has increasingly been reported through out the world and is associated with high morbidity, mortality and increased health care costs. It is important to determine the status of multidrug resistance pattern to understand the current resistance trend so that appropriate antibiotics can be used in practice. Objective To determine the antibiotic resistant profile and prevalence of extended spectrum ß-lactamase producing multidrug resistant strains in pediatric patients of Kanti Children's Hospital, Kathmandu, Nepal. Method Urine sample was cultured by standard microbiological techniques and bacterial isolates were identified using different biochemical tests. Antibiotic susceptibility testing was performed by Kirby Bauer disc diffusion method and extended spectrum ß-lactamase detection was carried out using combined disc method as recommended by Clinical Laboratory Standard Institute guidelines. Result All together 65 different bacteria were isolated and subsequently identified. E. coli was the most common isolate with 46 (71%) isolates 63% of these isolates were multidrug resistant. Gram negative isolates were most resistant to nalidixic acid (81.97%) followed by ampicillin (69.35%) and co-trimoxazole (69.35%). The extended spectrum ß-lactamase producing isolates were 43% among total isolates. Conclusion Higher rate of Extended Spectrum ß-lactamase production among multidrug resistant isolates suggested routine extended spectrum ß-lactamase testing in clinical isolates.

Report of the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology Colorectal Polyp Working Group: the development of a complex colorectal polyp minimum dataset.

AIM: The management of large non-pedunculated colorectal polyps (LNPCPs) is complex, with widespread variation in management and outcome, even amongst experienced clinicians. Variations in the assessment and decision-making processes are likely to be a major factor in this variability. The creation of a standardized minimum dataset to aid decision-making may therefore result in improved clinical management. METHOD: An official working group of 13 multidisciplinary specialists was appointed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) to develop a minimum dataset on LNPCPs. The literature review used to structure the ACPGBI/BSG guidelines for the management of LNPCPs was used by a steering subcommittee to identify various parameters pertaining to the decision-making processes in the assessment and management of LNPCPs. A modified Delphi consensus process was then used for voting on proposed parameters over multiple voting rounds with at least 80% agreement defined as consensus. The minimum dataset was used in a pilot process to ensure rigidity and usability. RESULTS: A 23-parameter minimum dataset with parameters relating to patient and lesion factors, including six parameters relating to image retrieval, was formulated over four rounds of voting with two pilot processes to test rigidity and usability. CONCLUSION: This paper describes the development of the first reported evidence-based and expert consensus minimum dataset for the management of LNPCPs. It is anticipated that this dataset will allow comprehensive and standardized lesion assessment to improve decision-making in the assessment and management of LNPCPs.

Negative pressure wound therapy in the management of mine blast injuries of lower limbs: Lessons learnt at a tertiary care center.

BACKGROUND: Mine blast injuries of foot are devastating injuries that result in composite tissue loss or amputations. Negative pressure wound therapy has helped in the management of such combat-related wounds. The aim of this study was to report experiences gained in managing such injuries at a tertiary care center. METHODS: 17 combatants who sustained mine blast injuries were included in this study. Severity of foot injury was assessed as per Foot and Ankle Severity Score. After wound debridement, negative pressure wound therapy was started and foot defect was appropriately reconstructed. Following wound healing, the foot was assessed for Foot and Ankle Severity Score in terms of impairment. The patients were then suitably rehabilitated by shoe modifications, orthosis, or custom-made prosthesis. RESULTS: Mean age of soldiers who sustained mine blast injuries was 30.2 years. The mean Foot and Ankle Severity Score was 3.76. Temporary wound closure was achieved using negative pressure wound therapy and it prevented local and systemic infection. The defect could be reconstructed appropriately using split skin graft, regional fasciocutaneous flap, or microvascular free flap. Mean time to definitive reconstructive procedure was 16.5 days. Mean Foot and Ankle Severity Score in terms of impairment was 4.11. All soldiers could be rehabilitated and were returned to their respective units and were able to perform sedentary duties assigned to them. CONCLUSION: The negative pressure wound therapy was helpful in preventing proximal amputations due to mine blast injury and was helpful in satisfactory reconstruction of foot defects.

Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis.

OBJECTIVE: To assess the efficacy and safety of endoscopic resection of large colorectal polyps. DESIGN: Relevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966-2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed. RESULTS: 50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%). CONCLUSIONS: Endoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.

Improvement over time in outcomes for patients undergoing endoscopic therapy for Barrett's oesophagus-related neoplasia: 6-year experience from the first 500 patients treated in the UK patient registry.

BACKGROUND: Barrett's oesophagus (BE) is a pre-malignant condition leading to oesophageal adenocarcinoma (OAC). Treatment of neoplasia at an early stage is desirable. Combined endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is an alternative to surgery for patients with BE-related neoplasia. METHODS: We examined prospective data from the UK registry of patients undergoing RFA/EMR for BE-related neoplasia from 2008 to 2013. Before RFA, visible lesions were removed by EMR. Thereafter, patients had RFA 3-monthly until all BE was ablated or cancer developed (endpoints). End of treatment biopsies were recommended at around 12 months from first RFA treatment or when endpoints were reached. Outcomes for clearance of dysplasia (CR-D) and BE (CR-IM) at end of treatment were assessed over two time periods (2008-2010 and 2011-2013). Durability of successful treatment and progression to OAC were also evaluated. RESULTS: 508 patients have completed treatment. CR-D and CR-IM improved significantly between the former and later time periods, from 77% and 56% to 92% and 83%, respectively (p<0.0001). EMR for visible lesions prior to RFA increased from 48% to 60% (p=0.013). Rescue EMR after RFA decreased from 13% to 2% (p<0.0001). Progression to OAC at 12 months is not significantly different (3.6% vs 2.1%, p=0.51). CONCLUSIONS: Clinical outcomes for BE neoplasia have improved significantly over the past 6 years with improved lesion recognition and aggressive resection of visible lesions before RFA. Despite advances in technique, the rate of cancer progression remains 2-4% at 1 year in these high-risk patients. TRIAL REGISTRATION NUMBER: ISRCTN93069556.

Duration of acetowhitening as a novel objective tool for diagnosing high risk neoplasia in Barrett's esophagus: a prospective cohort trial.

BACKGROUND AND STUDY AIMS: Acetic acid reacts with Barrett's mucosa to produce acetowhitening which disappears with time. The clinical significance of this is unknown. We aimed to quantify the acetowhitening time, developing an objective tool for diagnosis of neoplasia in Barrett's esophagus. PATIENTS AND METHODS: Prospective cohort study in a tertiary referral center, enrolling patients undergoing surveillance of Barrett's metaplasia or referred with suspected neoplasia. Acetic acid 2.5 % was applied to the mucosa via a spray catheter. Acetowhitening was observed and time to disappearance recorded. Targeted biopsies of any neoplasia and quadrantic 2-cm biopsies of residual Barrett's area were then taken. Histological findings were investigated in relation to duration of acetowhitening. RESULTS: 132 patients were examined. A receiver operating characteristic (ROC) curve was produced for identifying high risk neoplasia according to acetowhitening duration. The area under the curve (AUC) was 0.93 (0.89 - 0.97). Using a threshold of 142 seconds yielded a sensitivity for neoplasia of 98 % (95 % confidence interval [95 %CI] 89 % - 100 %) and specificity of 84 % (74 % - 91 %). The ROC curve for mucosal neoplasia (high grade dysplasia or intramucosal carcinoma) versus deep invasive cancer showed an AUC of 0.786 (0.61 - 0.96); a cutoff of 20 seconds yielded a sensitivity and specificity for invasive cancer of 67 % (35 % - 90 %) and 85 % (69 % - 95 %), respectively. CONCLUSION: The time to disappearance of acetowhitening can serve as a simple but very sensitive tool for the diagnosis of high risk neoplasia in Barrett's esophagus. It can be used to distinguish mucosal neoplasia from deep invasive cancer.

Posterior approach for both spinal accessory nerve to suprascapular nerve and triceps branch to axillary nerve for upper plexus injuries.

Restoration of stability and movements at the shoulder joint are the 2 most important goals in the management of brachial plexus injuries. The 2 nerves that are preferentially targeted for this purpose are the suprascapular (SSN) and the axillary (AXN) nerves. These nerve transfers have conventionally been performed by the anterior approach, but recently transfers performed by posterior incisions have been gaining popularity, by virtue of being selective and located close to the target muscles. Herein, we describe the technical details of spinal accessory nerve (SAN) to SSN and triceps branch to AXN for upper plexus injuries, both performed by the posterior approach.

Enzymatic debridement of large burn wounds with papain-urea: Is it safe?

INTRODUCTION: Enzymatic debridement is a method by which burn wounds can be prepared for coverage by skin grafts in patients presenting late. Many agents have been used in the past but none of them have been thoroughly evaluated. The present study was undertaken to assess the efficacy of Debridace, a commonly available debriding agent with papain and urea as its constituents. MATERIAL AND METHODS: A prospective descriptive study design was used to evaluate our experience. Almost symmetrical areas of the burnt surface were assessed and used for comparison. On one half of the wound, Debridace was applied while on the other silver sulphadiazine was used. The primary end point of this study was the extent of the achieved debridement at the end of the study period. Secondary outcomes were the presence of adverse effects such as pain and fever. All patients with sepsis were excluded from the study. RESULTS: The age of the subjects ranged from 9 to 80 years with an SD of 16. Large areas ranging from 5% to 20% body surface area with an SD of 4.27 were debrided by Debridace. Only two patients (3.33%) could complete the study. The rest of the recruited patients either had high fever (63.33%), excruciating pain (13.33%) or both (16.66%), which brought an end to enzymatic debridement. CONCLUSION: Debridace, a papain-urea product, cannot be considered safe as an enzymatic debriding agent in its present form for use in major burn patients who present late with deep burn wounds that are large in size.

Nasal Measurements in Indian Population of North-East Region: Angular Parameters with Literature Review.

Background: Just like linear nasal parameters, angular nasal parameters form the basis of any rhinoplasty, especially in various ethnic groups to maintain the specific racial characteristics while creating an aesthetic nose. The objective of this study was to measure and study the outcomes of angular nasal parameters in north-east Indians and to contrast them with available literature on Oriental, Caucasian and Indian population in general. Methods: This cross-sectional study was carried out in 150 young adults from north-east region of India. Surface landmarks were marked, and standard photographs were taken. Nine angular parameters were measured from the left lateral and basal view photographs of the face using computer software. Data were analysed by Student's 't'-test for parametric data and Mann-Whitney U-test for non-parametric data using SPSS v.25. Results: All the angular measurements were found to be greater in females except nasofacial angle, columella tip angle and interaxial angle. Differences in nasofrontal angle, columella labial angle, nasofacial angle and columella tip angle between males and females were statistically significant. Nasofrontal and columella labial angles were more acute in the study population compared to Caucasians, Orientals and other Indians while nasofacial, interaxial and interalar angles were larger. Conclusion: The north-east Indian nose is dissimilar to that of rest of the country as well as that of Caucasians and Orientals with respect to angular parameters.

Micro-CT imaging of multiple K-edge elements using GaAs and CdTe photon counting detectors.

Objective.To evaluate the performance of two photon-counting (PC) detectors based on different detector materials, gallium arsenide (GaAs) and cadmium telluride (CdTe), for PC micro-CT imaging of phantoms with multiple contrast materials. Another objective is to determine if combining these two detectors in the same micro-CT system can offer higher spectral performance and significant artifact reduction compared to a single detector system.Approach. We have constructed a dual-detector, micro-CT system equipped with two PCDs based on different detector materials: gallium arsenide (GaAs) and cadmium telluride (CdTe). We demonstrate the performance of these detectors for PC micro-CT imaging of phantoms with up to 5 contrast materials with K-edges spread across the x-ray spectrum ranging from iodine with a K-edge at 33.2 keV to bismuth with a K-edge at 90.5 keV. We also demonstrate the use of our system to image a mouse prepared with both iodine and bismuth contrast agents to target different biological systems.Main results.When using the same dose and scan parameters, GaAs shows increased low energy (<50 keV) spectral sensitivity and specificity compared to CdTe. However, GaAs performance at high energies suffers from spectral artifacts and has comparatively low photon counts indicating wasted radiation dose. We demonstrate that combining a GaAs-based and a CdTe-based PC detector in the same micro-CT system offers higher spectral performance and significant artifact reduction compared to a single detector system.Significance.More accurate PC micro-CT using a GaAs PCD alone or in combination with a CdTe PCD could serve for developing new contrast agents such as nanoparticles that show promise in the developing field of theranostics (therapy and diagnostics).

High-definition vs. standard-definition colonoscopy in the characterization of small colonic polyps: results from a randomized trial.

BACKGROUND AND STUDY AIMS: The resolution of endoscopes has increased in recent years. Modern Fujinon colonoscopes have a charge-coupled device (CCD) pixel density of 650,000 pixels compared with the 410,000 pixel CCD in standard-definition scopes. Acquiring high-definition scopes represents a significant capital investment and their clinical value remains uncertain. The aim of the current study was to investigate the impact of high-definition endoscopes on the in vivo histology prediction of colonic polyps. PATIENTS AND METHODS: Colonoscopy procedures were performed using Fujinon colonoscopes and EPX-4400 processor. Procedures were randomized to be performed using either a standard-definition EC-530 colonoscope or high-definition EC-530 and EC-590 colonoscopes. Polyps of <10 mm were assessed using both white light imaging (WLI) and flexible spectral imaging color enhancement (FICE), and the predicted diagnosis was recorded. Polyps were removed and sent for histological analysis by a pathologist who was blinded to the endoscopic diagnosis. The predicted diagnosis was compared with the histology to calculate the accuracy, sensitivity, and specificity of in vivo assessment using either standard or high-definition scopes. RESULTS: A total of 293 polyps of <10 mm were examined­150 polyps using the standard-definition colonoscope and 143 polyps using high-definition colonoscopes. There was no difference in sensitivity, specificity or accuracy between the two scopes when WLI was used (standard vs. high: accuracy 70% [95% CI 62­77] vs. 73% [95% CI 65­80]; P=0.61). When FICE was used, high-definition colonoscopes showed a sensitivity of 93% compared with 83% for standard-definition colonoscopes (P=0.048); specificity was 81% and 82%, respectively. CONCLUSIONS: There was no difference between high- and standard-definition colonoscopes when white light was used, but FICE significantly improved the in vivo diagnosis of small polyps when high-definition scopes were used compared with standard definition.

Acetic acid-enhanced chromoendoscopy is more cost-effective than protocol-guided biopsies in a high-risk Barrett's population.

To examine the efficacy and potential cost implications of acetic acid (AA) chromoendoscopy in the assessment of Barrett's neoplasia. Our prospective database of patients referred between 2005 and 2010 with suspected early neoplasia was reviewed. High-resolution Fujinon gastroscopes and EPX-4400 processor were used. Inspection of Barrett's neoplasia was carried out using white light followed by AA. Neoplastic areas were noted, and targeted biopsy was carried out. This was followed by quadrantic biopsies of the remaining Barrett's neoplasia. The cost of protocol-guided biopsies was compared with AA-guided biopsy protocols. Two hundred sixty-three procedures on 197 patients were examined. High-risk neoplasia was found during 143 procedures. In 96% of cases it was identified with AA. The cost of histological evaluation by Cleveland protocol would be £139,416.30. The cost by AA-targeted biopsy followed by random biopsies in one pot would be £25,032.50. For AA-targeted biopsies alone the cost would be £9,541.8 but results in a 4% miss rate. AA localizes neoplastic lesions in the majority of patients and could potentially represent a significant cost saving in patients with suspected neoplasia.

Circulating tumour markers can define patients with normal colons, benign polyps, and cancers.

BACKGROUND: Early diagnosis represents the best opportunity for cure of colorectal cancer. Current screening programmes use faecal occult blood testing for screening, which has limited sensitivity and poor specificity. METHODS: In this study we looked at a series of previously described diagnostic markers utilising circulating free DNA (cfDNA), with a preparation method allowing small DNA fragments to be isolated. The Circulating free DNA was isolated from samples obtained from 85 patients, including 35 patients without endoscopic abnormality, a group of 26 patients with benign colorectal adenomas, and 24 patients with colorectal carcinomas. In each case, polymerase chain reaction (PCR) was performed for Line1 79 bp, Line1 300 bp, Alu 115 bp, Alu 247 bp, and mitochondrial primers. In addition, carcinoembryonic antigen (CEA) was measured by ELISA. Each marker was analysed between normal, polyp, and cancer populations, and the best performing analysed in combination by logistic regression. RESULTS: The best model was able to discriminate normal from populations with adenoma or carcinoma using three DNA markers and CEA, showing an area under the receiver operator characteristic (ROC) curve of 0.855 with a positive predictive value of 81.1% for polyps and cancer diagnosis. CONCLUSION: These circulating markers in combination with other markers offer the prospect of a simple blood test as a possible secondary screen for colorectal cancers and polyps in patients with positive faecal occult blood tests.