Hypothalamic hamartoma surgery in a setting with limited resources.

BACKGROUND: Three years ago (in 2020), we at the epilepsy center in Shiraz, Iran, started an endeavor to initiate a surgical program for patients with hypothalamic hamartoma (HH). We discussed that although minimally invasive techniques are desired, they are not available in the nation. We decided to proceed with open disconnection and resection surgery techniques. The current manuscript presents the results of the HH surgery program at our center as a case series. METHODS: This study included all patients with a diagnosis of HH who were referred to Shiraz Epilepsy Center with drug-resistant epilepsy and who underwent HH surgery from October 2020 to January 2023 at our epilepsy center, Namazi Hospital, Shiraz, Iran. RESULTS: Seven patients were included. All patients had gelastic seizures. Four patients (57%) underwent total resection of HH, and the lesions were disconnected and partially resected in three other patients (43%). Three patients (43%) became seizure-free after surgery, and three patients (43%) had more than 50% reduction in their seizure frequencies. Three patients (43%) had no post-operative complications. Only one patient (14.3%) suffered from a permanent postoperative complication (right hemiparesis). The mortality rate was zero. Five parents (71%) were satisfied with the surgery outcomes. CONCLUSION: Hypothalamic hamartoma surgery is feasible even in centers with limited resources if a close collaboration exists between the epileptology and neurosurgery teams. Careful planning based on the expertise of the team members and the available resources is required to foster success.

Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes.

BACKGROUND: Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation. METHODS: From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery. RESULTS: The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations. CONCLUSION: Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.

Role of the Neutrophil to Lymphocyte Ratio in Guillain Barré Syndrome: A Systematic Review and Meta-Analysis.

In this study, we conducted a systematic review and meta-analysis regarding the role of the neutrophil to lymphocyte ratio (NLR) in Guillain Barré syndrome (GBS). The most recent update to the search was on July 18, 2022, through the databases of Web of Science, PubMed, Embase, and Scopus. The Newcastle-Ottawa scale was used for quality assessment of included studies. Finally, 14 studies were included in the review, and among them, ten studies were included in the meta-analysis. Our results showed that NLR levels were significantly increased in the patients with GBS compared with healthy controls (SMD = 1.05; 95%CI = 0.59 to 1.50, P < 0.001). After treatment, NLR levels were decreased to the extent that they became similar to healthy controls (SMD = -0.03, 95%CI = -0.29 to 0.22, P = 0.204). Moreover, NLR was a stable predictor of outcome or response to treatment in such patients (SMD = 1.01, 95%CI = 0.65 to 1.37, P < 0.001); the higher the NLR, the worse the outcome. In addition, patients who underwent mechanical ventilation had higher levels of NLR compared to those who did not (SMD = 0.93, 95%CI = 0.05 to 1.82, P = 0.03). However, NLR levels were not different among distinct GBS subtypes, so it could not distinguish among them. In conclusion, our analysis indicates that the NLR levels are highly elevated in patients with GBS. Therefore, the NLR has the potential to be used as a biomarker to inform diagnosis, prognosis, or treatment responses in GBS, and future studies are warranted.

Subperiosteal hematoma as a rare complication of neurofibromatosis 1: A case report and review of the literature.

INTRODUCTION: Subperiosteal hematoma (SPH) is a rare complication of neurofibromatosis type 1 (NF-1) which can be presented spontaneously or after a minor trauma a painful or painless growing lesion. PRESENTATION OF CASE: Here, we presented a 10-year-old boy, a known case of NF-1, who presented with a painless growing leg lesion. The bony wall cystic lesion was suggested based on radiologic and pathologic investigation. During the operation, an SPH was detected and excised completely. DISCUSSION: Consistent with previous reports, our case of subperiosteal hematoma in an NF-1 patient predominantly presented with well-established subperiosteal bone proliferation on plain radiographs, with the hematoma most commonly affecting the tibia. CONCLUSION: The SPH in NF-1 and differentiating it from a malignant transformation should be considered for the rapidly enlarging bony mass.

Nano-hydroxyapatite structures for bone regenerative medicine: Cell-material interaction.

Bone tissue engineering holds great promise for the regeneration of damaged or severe bone defects. However, several challenges hinder its translation into clinical practice. To address these challenges, interdisciplinary efforts and advances in biomaterials, cell biology, and bioengineering are required. In recent years, nano-hydroxyapatite (nHA)-based scaffolds have emerged as a promising approach for the development of bone regenerative agents. The unique similarity of nHA with minerals found in natural bones promotes remineralization and stimulates bone growth, which are crucial factors for efficient bone regeneration. Moreover, nHA exhibits desirable properties, such as strong chemical interactions with bone and facilitation of tissue growth, without inducing inflammation or toxicity. It also promotes osteoblast survival, adhesion, and proliferation, as well as increasing alkaline phosphatase activity, osteogenic differentiation, and bone-specific gene expression. However, it is important to note that the effect of nHA on osteoblast behavior is dose-dependent, with cytotoxic effects observed at higher doses. Additionally, the particle size of nHA plays a crucial role, with smaller particles having a more significant impact. Therefore, in this review, we highlighted the potential of nHA for improving bone regeneration processes and summarized the available data on bone cell response to nHA-based scaffolds. In addition, an attempt is made to portray the current status of bone tissue engineering using nHA/polymer hybrids and some recent scientific research in the field.

Application of artificial intelligence in trauma orthopedics: Limitation and prospects.

The varieties and capabilities of artificial intelligence and machine learning in orthopedic surgery are extensively expanding. One promising method is neural networks, emphasizing big data and computer-based learning systems to develop a statistical fracture-detecting model. It derives patterns and rules from outstanding amounts of data to analyze the probabilities of different outcomes using new sets of similar data. The sensitivity and specificity of machine learning in detecting fractures vary from previous studies. AI may be most promising in the diagnosis of less-obvious fractures that are more commonly missed. Future studies are necessary to develop more accurate and effective detection models that can be used clinically.

Joint replacement and human immunodeficiency virus.

The incidence of human immunodeficiency virus (HIV)-infected cases that need total joint replacement (TJR) is generally rising. On the other hand, modern management of HIV-infected cases has enabled them to achieve longevity while increasing the need for arthroplasty procedures due to the augmented dege-nerative joint disease and fragility fractures, and the risk of osteonecrosis. Although initial investigations on joint replacement in HIV-infected cases showed a high risk of complications, the recent ones reported acceptable outcomes. It is a matter of debate whether HIV-infected cases are at advanced risk for adverse TJR consequences; however, the weak immune profile has been associated with an increased probability of complications. Likewise, surgeons and physicians should be aware of the complication rate after TJR in HIV-infected cases and include an honest discussion of the probable unwelcoming complication with their patients contemplating TJR. Therefore, a fundamental review and understanding of the interaction of HIV and arthroplasty are critical.

Constant current or constant voltage deep brain stimulation: short answers to a long story.

PURPOSE: Recently, the feature of generating constant current output has been added to the implantable pulse generators (IPGs). The efficacy of the conventionally used constant voltage (CV) stimulation has been proved in different movement and psychiatric disorders. In this systematic review, we aimed to discuss the effect of constant current (CC) and constant voltage stimulation on patients with Parkinson's disease (PD) who had subthalamic nucleus deep brain stimulation implantation; we also compared these methods of stimulation with each other. METHODS: Using the words "Deep brain stimulation", "constant current" and "constant voltage", we developed a broad search strategy and a systematic search was conducted in PubMed, Scopus, Web of Science and Cochrane electronic bibliographic databases. Studies on the Parkinson's disease patients with subthalamic deep brain stimulation, which mentioned constant current or/and constant voltage setting stimulation were included. RESULTS: After screening of 284 articles, 10 reports were found eligible for this study. The score of unified Parkinson's disease rating scale part 3 was improved compared to the baseline, whether the stimulation was CV at baseline or CC. No significant change in non-motor outcomes was found. CONCLUSIONS: Although CC stimulation has shown a significant improvement in both motor and non-motor symptoms of PD, switching from CV to CC did not result in a significant change in the score of these items based on UPDRS. To sum up, implantation of constant current devices is safe and significantly improves motor function; it also maintains an acceptable safety profile in patients with PD.

Metabolic effects of dopamine-agonists treatment among patients with prolactinomas.

PURPOSE: To evaluate the effect of cabergoline treatment on metabolic parameters including the Triglyceride-glucose (TyG) index in newly diagnosed patients with prolactinoma. METHODS: 71 consecutive nondiabetic patients with prolactinoma were enrolled. Anthropometric and laboratory tests including TyG index were measured at baseline, 3 and 6 months visits. Treatment with cabergoline at the dose of 0.25 mg twice weekly was started and increased according to prolactin levels and continued for 6 months. RESULTS: At the baseline examination, the mean (SD) age, body mass index (BMI), waist circumference (WC), systolic blood pressure (SBP), and diastolic blood pressure (DBP) of patients were 36.2 (10.5) years, 29.2 (5.0) kg/m2, 98.2 (13.7) cm, 115.3 (13.3) mmHg, and 71.4 (8.1) mmHg, respectively. Forty-one (57.7%) of patients were women and 46 (64.8%) had microadenoma. Cabergoline treatment significantly improved anthropometric and metabolic measures including BMI, WC, fasting plasma glucose, triglycerides, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, uric acid (only among women), TyG index, and hypogonadism. Blood pressure (both systolic and diastolic) levels remained steady except for a significant decrease in DBP after 6 months of treatment only among women. A declining trend in MetS prevalence was found from baseline to a 3-month evaluation in both genders which was statistically significant among men. CONCLUSION: Short-term treatment with cabergoline can significantly improve cardiovascular risk factors except for blood pressure. Moreover, the TyG index as a surrogate marker of insulin resistance decreased significantly after the reduction of prolactin by treatment. Generally, results were similar among both genders.

Investigation of litigation in trauma orthopaedic surgery.

BACKGROUND: It has been said that the number of orthopaedic claims has increased in the last few years. Investigation through the most prevalent cause would help to prevent further cases. AIM: To review the cases of medical complaints in orthopedic patients who had been involved in a traumatic accident. METHODS: A retrospective multi-center review of trauma orthopaedic-related malpractice lawsuits from 2010 to 2021 was conducted utilizing the regional medicolegal database. Defendant and plaintiff characteristics along with fracture location, allegations, and litigation outcomes were investigated. RESULTS: A total of 228 claims referred to trauma-related conditions with a mean age of 31.29 ± 12.56 were enrolled. The most common injuries were at hand, thigh, elbow, and forearm, respectively. Likewise, the most common alleged complication was related to malunion or nonunion. In 47% of the cases, the main problem that led to the complaint was the inappropriate or insufficient explanation to the patient, and in 53%, there was a problem in the surgery. Eventually, 76% of the complaints resulted in a defense verdict, and 24% resulted in a plaintiff verdict. CONCLUSION: Surgical treatment of hand injuries and surgery in non-educational hospitals received the most complaints. The majority of litigation outcomes were caused by a physician's failure to fully explain and educate the traumatic orthopedic patients and technological errors.

Electrocardiographic characteristics of cirrhotic patients and their association with Child-Pugh score.

BACKGROUND: Cardiac dysfunction is a serious complication of cirrhosis which is usually asymptomatic. We investigated the clinical and electrocardiographic (ECG)-related factors among patients with cirrhosis and our aim was to find any associations between ECG changes and the etiology of cirrhosis, as well as Child-Pugh score. HYPOTHESIS: We hypothesized that some ECG-related factors, particularly prolonged QT interval, are more common in patients with cirrhosis. Also, these factors are associated with the severity of cirrhosis, measured by the Child-Pugh score. METHODS: From April 2019 to December 2022, we reviewed admitted patients to Namazi and Abu-Ali Sina hospitals, Shiraz, Iran. Patients with confirmed diagnosis of cirrhosis and without concurrent disorders affecting the cardiovascular system were selected. Clinical and ECG-related data were then extracted for participants, and Child-Pugh score was calculated. RESULTS: A total of 425 patients were included; the median age was 36 years, and 245 patients (57.6%) were men. Cryptogenic and primary sclerosing cholangitis were the most common etiologies. Prolonged QT followed by early transitional zone were the most common ECG changes (24.7% and 19.8%, respectively), which were significantly associated with the etiology of cirrhosis and Child-Pugh class. CONCLUSIONS: Prolonged QT interval and presence of early transitional zone in patients with cirrhosis may indicate cardiac dysfunction, necessitating further evaluations.