Haustral rhythmic motor patterns of the human large bowel revealed by ultrasound.

Effective and widely available strategies are needed to diagnose colonic motility dysfunction. We investigated whether ultrasonography could generate spatiotemporal maps combined with motor pattern frequency analysis, to become a noninvasive method to characterize human colon motor patterns. Abdominal colonic ultrasonography was performed on healthy subjects (N = 7), focusing on the detailed recording of spontaneous haustral activities. We developed image segmentation and frequency analysis software to analyze the motor patterns captured. Ultrasonography recordings of the ascending, transverse, and descending colon identified three distinct rhythmic motor patterns: the 1 cycle/min and the 3 cycles/min cyclic motor pattern were seen throughout the whole colon, whereas the 12 cycles/min cyclic motor pattern was identified in the ascending colon. The rhythmic motor patterns of the human colon that are associated with interstitial cells of Cajal-associated pacemaking activity can be accurately identified and quantified using ultrasound.NEW & NOTEWORTHY Ultrasonography in the clinical field is an underutilized tool for assessing colonic motility; however, with the addition of frequency analysis techniques, it provides a method to identify human colonic motor patterns. Here we report on the 1, 3, and 12 cpm rhythmic motor patterns. Ultrasound has the potential to become a bedside assessment for colonic dysmotility and may reveal the health of interstitial cells of Cajal (ICC) pacemaker activities.

Root mean square of successive differences is not a valid measure of parasympathetic reactivity during slow deep breathing.

Deep breathing exercises are the second most used complementary health approach in the United States. Two heart rate variability (HRV) parameters, the root mean square of successive differences (RMSSD) and the respiratory sinus arrhythmia (RSA), are used to assess parasympathetic reactivity to deep breathing, but they are often not in agreement. Our purpose was to determine the cause of the disagreement. We investigated HRV parameters in 38 subjects during baseline, deep breathing, and recovery. Here we show that RMSSD as a measure of parasympathetic reactivity is unreliable; it does not reflect the increase in HRV during deep breathing as determined by RSA. We observed a decrease in RMSSD values despite a marked increase in HRV as determined by RSA and the standard deviation of normal heartbeat interval (SDNN) in healthy subjects and patients with functional bowel disorders. We show that RSA captures all aspects of HRV, whereas successive differences in heart rate intervals are only a small part of HRV, with decreasing variability during deep breathing in most subjects. We present a new measure of calculating RSA during deep breathing that may become an essential tool for researchers and clinicians. We also provide a unique visualization of the increased heart rate variability during deep breathing. Hence, RMSSD cannot be used to assess parasympathetic reactivity during deep breathing; using RSA is recommended. The use of RMSSD in previous influential studies may have led to erroneous conclusions about parasympathetic reactivity during deep breathing. Its continued use may undervalue the effects of the autonomic nervous system in slow deep breathing.

Generation of Gut Motor Patterns Through Interactions Between Interstitial Cells of Cajal and the Intrinsic and Extrinsic Autonomic Nervous Systems.

The musculature of the gastrointestinal tract is a vast network of collaborating excitable cell types. Embedded throughout are the interstitial cells of Cajal (ICC) intertwined with enteric nerves. ICC sense external stimuli such as distention, mediate nerve impulses to smooth muscle cells, and provide rhythmic excitation of the musculature. Neural circuitry involving both the intrinsic and extrinsic autonomic nervous systems, in collaboration with the ICC, orchestrate an array of motor patterns that serve to provide mixing of content to optimize digestion and absorption, microbiome homeostasis, storage, transit, and expulsion. ICC are specialized smooth muscle cells that generate rhythmic depolarization to the musculature and so provide the means for peristaltic and segmenting contractions. Some motor patterns are purely myogenic, but a neural stimulus initiates most, further depolarizing the primary pacemaker cells and the musculature and/or initiating transient pacemaker activity in stimulus-dependent secondary ICC pacemaker cells. From stomach to rectum, ICC networks rhythmically provide tracks along which contractions advance.

Interstitial cells of Cajal and human colon motility in health and disease.

Our understanding of human colonic motility, and autonomic reflexes that generate motor patterns, has increased markedly through high-resolution manometry. Details of the motor patterns are emerging related to frequency and propagation characteristics that allow linkage to interstitial cells of Cajal (ICC) networks. In studies on colonic motor dysfunction requiring surgery, ICC are almost always abnormal or significantly reduced. However, there are still gaps in our knowledge about the role of ICC in the control of colonic motility and there is little understanding of a mechanistic link between ICC abnormalities and colonic motor dysfunction. This review will outline the various ICC networks in the human colon and their proven and likely associations with the enteric and extrinsic autonomic nervous systems. Based on our extensive knowledge of the role of ICC in the control of gastrointestinal motility of animal models and the human stomach and small intestine, we propose how ICC networks are underlying the motor patterns of the human colon. The role of ICC will be reviewed in the autonomic neural reflexes that evoke essential motor patterns for transit and defecation. Mechanisms underlying ICC injury, maintenance, and repair will be discussed. Hypotheses are formulated as to how ICC dysfunction can lead to motor abnormalities in slow transit constipation, chronic idiopathic pseudo-obstruction, Hirschsprung's disease, fecal incontinence, diverticular disease, and inflammatory conditions. Recent studies on ICC repair after injury hold promise for future therapies.

Pancreatic Duct Stones.

pancreatitis appears to exist in the presence of such calculi upon radiology. Having said that, pancreatic ductal stone due to biliary causes (origin), in face of acute pancreatitis, is rare. To the best of our knowledge this was the first case of its kind presented to our hospital in recent past. A 25-year-old female presented to the emergency department of our hospital with an acute episode of pancreatitis. Computerized tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP) & magnetic resonance cholangiopancreatography (MRCP) concluded acute pancreatitis (AP) with dilated main pancreatic duct left side branches and intra ductal calculi. The findings were not suggestive of any chronic pancreatitis. Conservative treatment was given for the episodic attack of AP. After the episode resolved, an exploration and extraction of the pancreatic ductal calculus was performed successfully. The pancreatic duct stones were removed by lateral pancreaticojejunostomy (partington-rochelle procedure). The patient made a remarkable recovery after the procedure and was perfectly healthy and well-oriented in time and space at 4-months follow up. Acute pancreatitis is an inflammatory condition of pancreas, when, associated with pancreatic duct stones a lateral pancreaticojejunostomy is done, which, results in better outcomes decreasing the mortality and morbidity. Acute pancreatitis due to ductal calculi is rare for which extraction is safe after resolution of the episode of AP. Studies need to be carried out to look for the outcome and the effectiveness of the procedure, when, specifically and specially done for this condition.

Eales Disease.

Eales disease is an eponym after a British ophthalmologist Henry Eales. The aetiology behind Eales disease is ill-understood and stands controversial. Various systemic diseases associated with peripheral retinal revascularization and Retinal vasculitis could imitate the proliferative and inflammatory phases of Eales' disease, respectively. We present a case of a 30 years old female patient with Eales disease and discuss the clinical features, treatment plan and its outcome in our patient. Tuberculosis appears to be the cause of Eales disease but the relation is yet to be established and clinically proven. Steroid therapy is usually the main stay of treatment with tapering doses of systemic corticosteroids. Other interventions are vitrectomy, photocogulation or cryotherapy.

Pleomorphic Adenoma Of Minor Salivary Glands.

Pleomorphic adenoma is the most common benign tumour of salivary glands which is Known for its wide pleomorphic architecture. It accounts for 45-75% of all salivary gland neoplasm. It can involve major as well as minor salivary glands. Among minor salivary glands (5-10% of cases) the palate lip, nasal cavity, pharynx, larynx and trachea are the most common sites. Diagnosis is made with biopsy along with histopathology. Wide excision with biopsy and removal of underlying extension of tumour is the treatment of choice. Sixty years old farmer presented with painless swelling in the upper lip for the last 8 years. History revealed recurrent mass in the midline of upper lip with no other complaints. He was operated 3 times for this complaint in the past. Belonging to poor socioeconomic status no biopsy records were found. On examination 3×4 cm hard and mobile mass was found. Lymph nodes of head and neck and parotid gland revealed no enlargement. Surgery by wide excision was planned. After baseline investigation surgery was done and the mass sent for histopathology. Biopsy reports showed pleomorphic adenoma on unusual site. Dissection of salivary gland tumour is important as they have propensity to metastasize. Wide local excision along with biopsy is the method of choice. Proper surgical techniques are required to avoid recurrence.

Internal mammary perforator vessels as recipient for microvascular breast reconstruction: Technique and outcomes in 161 flaps.

BACKGROUND: The use of internal mammary perforator (IMP) vessels as recipients for free flap breast reconstruction was first described in 1999. Despite numerous advantages over the internal mammary (IM) and thoracodorsal recipient vessels, their widespread use remains mired in concern. This paper describes our method of IMP vessel preparation and outcomes with regard to safety and reliability. METHODS: To support the reliability of the IMP vessel preparation, a retrospective study on prospectively collected data of all free flap breast reconstruction patients between 1 July 2016 and 31 July 2019 was performed. Data were collected on patient demographics, type of reconstruction operative details and complications. RESULTS: Out of the 450 flaps performed, the IMP vessels were used in 36% of the cases. Of these cases, 18% had received neo-adjuvant chemotherapy and 15% had a history of radiotherapy to the chest wall. In total, 161 flaps were performed to reconstruct 138 breasts (115 single and 23 stacked flaps). Three patients required a return to theatre, with one needing recipient vessel revision from the IMP to the IM vessels due to calibre mismatch. No mastectomy skin flap necrosis, free flap loss or significant fat necrosis were encountered. CONCLUSION: This article describes an IM vessel preparation method that results in predictable outcomes in both single and stacked flap reconstructions with a low complication rate. Due to their reliability and versatility, we consider the IMP vessels a valuable attribute to the recipient vessel arsenal of any breast reconstruction microsurgeon.

Innovative Approaches to Safe Surgery: A Narrative Synthesis of Best Practices.

By encompassing a wide range of best practices within the ever-changing realm of modern surgical care, this exhaustive narrative compendium attempts to unravel the complex tapestry of novel approaches to safe surgery. Within the context of a dynamic surgical environment, this research endeavors to illuminate and integrate state-of-the-art methods that collectively methodically improve patient safety. The narrative elucidates a diverse array of practices that seek to revolutionize the paradigm of safe surgery, emphasizing technological progress, patient-centric approaches, and global viewpoints. The combined effectiveness of these methods in fostering an all-encompassing culture of safety, improving surgical precision, and decreasing complications is revealed by the results obtained from their implementation. The recognition of the dynamic interplay among multiple components, including the active participation of patients, the integration of cutting-edge technologies, and the establishment of comprehensive quality improvement programs, is fundamental to this narrative. By their collective composition, these components support the notion that secure surgical practices are intricate and interrelated. The present synthesis functions as a fundamental resource for healthcare professionals, policymakers, and researchers, providing an enlightening examination of the current condition of secure surgical practices. By emphasizing the promotion of innovation, continuous development, and the utmost quality of patient care, it offers a strategic guide for navigating the complex terrain of safe surgery. In the ever-evolving landscape of surgical care, this narrative synthesis serves as a guiding principle for stakeholders striving to understand better and implement safe surgical procedures in various healthcare environments.

A UK consensus statement on thromboprophylaxis for autologous breast reconstruction.

Microsurgical breast reconstruction accounts for 22% of breast reconstructions in the UK. Despite thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 4% of cases. Using a Delphi process, this study established a UK consensus on VTE prophylaxis strategy, for patients undergoing autologous breast reconstruction using free-tissue transfer. It captured geographically divergent views, producing a guide that reflected the peer opinion and current evidence base. METHODS: Consensus was ascertained using a structured Delphi process. A specialist from each of the UK's 12 regions was invited to the expert panel. Commitment to three to four rounds of questions was sought at enrollment. Surveys were distributed electronically. An initial qualitative free-text survey was distributed to identify likely lines of consensus and dissensus. Each panelist was provided with full-text versions of key papers on the topic. Initial free-text responses were analyzed to develop a set of structured quantitative statements, which were refined via a second survey as a consensus was approached. RESULTS: The panel comprised 18 specialists: plastic surgeons and thrombosis experts from across the UK. Each specialist completed three rounds of surveys. Together, these plastic surgeons reported having performed more than 570 microsurgical breast reconstructions in the UK in 2019. A consensus was reached on 27 statements, detailing the assessment and delivery of VTE prophylaxis. CONCLUSION: To our knowledge, this is the first study to collate current practice, expert opinion from across the UK, and a literature review. The output was a practical guide for VTE prophylaxis for microsurgical breast reconstruction in any UK microsurgical breast reconstruction unit.

The Cycling of Intracellular Calcium Released in Response to Fluid Shear Stress Is Critical for Migration-Associated Actin Reorganization in Eosinophils.

The magnitude of eosinophil mobilization into respiratory tissues drives the severity of inflammation in several airway diseases. In classical models of leukocyte extravasation, surface integrins undergo conformational switches to high-affinity states via chemokine binding activation. Recently, we learned that eosinophil integrins possess mechanosensitive properties that detect fluid shear stress, which alone was sufficient to induce activation. This mechanical stimulus triggered intracellular calcium release and hallmark migration-associated cytoskeletal reorganization including flattening for increased cell-substratum contact area and pseudopodia formation. The present study utilized confocal fluorescence microscopy to investigate the effects of pharmacological inhibitors to calcium signaling and actin polymerization pathways on shear stress-induced migration in vitro. Morphological changes (cell elongation, membrane protrusions) succeeded the calcium flux in untreated eosinophils within 2 min, suggesting that calcium signaling was upstream of actin cytoskeleton rearrangement. The inhibition of ryanodine receptors and endomembrane Ca2+-ATPases corroborated this idea, indicated by a significant increase in time between the calcium spike and actin polymerization. The impact of the temporal link is evident as the capacity of treated eosinophils to move across fibronectin-coated surfaces was significantly hampered relative to untreated eosinophils. Furthermore, we determined that the nature of cellular motility in response to fluid shear stress was nondirectional.

Identification of operative dose of NPK on yield enhancement of desi and kabuli chickpea (Cicer arietinum L.) in diverse milieu.

The effect of fertilizer on yield and yield related traits studied in two consecutive years at two different locations. Three different doses of fertilizer (NPK) applied at the rate of 9:23:0, 18:46:12 and 27:69:25 respectively on sixteen chickpea, genotypes (Desi and Kabuli advance lines and commercial varieties). Data recorded for days to 50% flowering, plant height, primary and secondary branches, pods per plant, 100-grain weight and grain yield (kg/ha). In Desi chickpea highest grain yield (kg/ha) in both years was produced by advance line D-12026 and in Kabuli advance line K-70005 at Faisalabad location. Grain yield kg/ha had significant positive correlation with all the considered parameters except days to 50% flowering and days to 50% maturity. The treatment comparison manifested that fertilizer doses 9:23:0 enhanced grain yield. The high dose of fertilizer is not recommendable. The grain yield of Desi and Kabuli chickpea at two locations Pulses Research Institute (PRI) Faisalabad and GBRSS (Gram Breeding Research Sub Station) Kallurkot had significant variation. The grain yield (kg ha-1) was significant high in research area of PRI, Faisalabad in both years. The NPK 9:23:0 found operative dose of fertilizer for chickpea.

Bilateral Hydronephrosis Secondary to Giant Cell Tumor of the Sacrum.

Sacral giant cell tumors (GCTs) are rare entities that exhibit slow progressive growth and become clinically apparent when they reach a considerable size. The current case report discusses the presentation, investigation, and management of a young male patient diagnosed with a large sacral mass. A 17-year-old male patient presented with uremia, bilateral lumbar pain, and severe weakness of his lower extremities. Imaging revealed a midline sacral mass causing bilateral upper tract obstruction. The patient underwent bilateral nephrostomies followed by a partial en bloc sacrectomy and curettage of the tumor bulk. Histopathology revealed a giant cell tumor of the sacrum. Postoperatively, the patient received adjuvant radiotherapy and rehabilitation for his neurological symptoms. Sacral GCTs are essentially benign but behave like a malignant tumor in view of frequent recurrences and reports of malignant transformation. Surgery with wide local excision remains the ideal modality for complete clearance of sacral tumors. Nevertheless, limitations include their large size, difficult operative access, risk of fatal intraoperative bleeding, and inevitable high postoperative morbidity.

Laparoscopic Versus Open Pyeloplasty for Primary Pelvic Ureteric Junction Obstruction: A Prospective Single Centre Study.

Introduction The aim of the study was to compare the clinical and patient-reported outcomes among open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) patients. Materials and methods This was a prospective single centre, case-cohort study conducted in a tertiary care hospital with 62 patients. In both techniques, dismembered Anderson-Hynes pyeloplasty were undertaken. Post-operatively patients underwent visual analogue scale (VAS) assessment for pain, days to ambulation and comparison of the short- and long-term outcomes of the two procedures. Results There was no difference in the physical and functional outcomes between the two surgical approaches at 12 months period after surgery. However, patients in the laparoscopic group did report a higher rate of satisfaction at six weeks and six months' postoperatively. Likewise, patients in LP experienced less pain during the postoperative period (p-value <0.001), with decreased analgesic requirements. This translated into an early patient ambulation in the laparoscopic group (p-value <0.001), and a shorter hospital stay for the LP group (p-value <0.001). Moreover, follow-up ultrasound showed equal improvement of hydronephrosis among the two groups. Conclusion Laparoscopic and open pyeloplasty are equally effective in treating pelvic ureteric junction obstruction (PUJO), with comparable patient-reported outcomes at 12-month follow-up. However, the laparoscopic technique merits over open surgery with faster rehabilitation, a decreased postoperative pain experience and shorter hospital stay.

Plasma Cell Leukaemia: A Rare Yet Aggressive Plasma Cell Dyscrasia With A Very Poor Response To Conventional Therapy.

Plasma cell leukaemia (PCL) is a very rare plasma cell dyscrasia with a significant number of monoclonal plasma cells in the peripheral blood. It is diagnosed by the presence of ≥ 2x109 /L plasma cells in the blood or by plasma cells making up ≥20% of the leukocyte count. It can arise from a leukemic transformation of multiple myeloma, or more commonly it can be primary. Regardless of its origin, it carries a very dire prognosis. It responds very poorly to the traditional chemotherapy regimens used for multiple myeloma. We present the case of a 50 years old female who presented to our hospital with a complicated UTI and severe generalized body aches. She was diagnosed as a case of plasma cell leukaemia and was treated with cyclophosphamide and dexamethasone, however she failed to go into remission. Her condition deteriorated and she ultimately passed away 1.5 months after diagnosis. The recommended treatment for PCL is aggressive combination chemotherapy followed by stem cell transplantation. However, there is no consensus regarding the treatment of plasma cell leukaemia, and treatment should be individualized based on the patient profile. Once diagnosed, the prognosis is poor.

Burn related mortality in Greater Manchester: 11-year review of Regional Coronial Department Data.

INTRODUCTION: The Coroners Department (CD) records hold important demographic, injury and death details for victims of burn injuries derived from various sources yet this rich source of data has been infrequently utilised previously in describing the epidemiology of burn related mortality. The aim of this study was to use CD data to comprehensively investigate burn related mortality in the Greater Manchester region of United Kingdom. MATERIALS AND METHODS: A retrospective study design was used to collect data for deceased demographics, injury details, site of death and cause of death from four CD offices in GM over an 11-year period (2000-2010 inclusive). Office of National Statistics (ONS) population metrics were used to calculate age- and gender-specific population denominators and mortality rates. Index of Multiple Deprivation (IMD) was used to correlate mortality with deprivation. Linear regression and Pearson's/Spearman's rank correlation were used to calculate trends and correlations. Poisson regression was used to calculate relative risk (IRR) between age- and gender groups. RESULTS: There were 314 recorded deaths in the region over the study period and thermal injury was 3-times less likely to result in death in 2010 compared to 2000. The largest proportion of these deaths (24.8%) was comprised of individuals ≥75 years in age. The relative risk of mortality in males was nearly 1.5-times higher and a significant majority of victims (77%) sustained their burn injury at their own home/residence. Inhalation injury without cutaneous burns was the most frequent type of injury (33%) and accidental house fires caused nearly half (49%) the injuries resulting in death. Sixty-five percent of deaths during this period were recorded to have occurred outside of regional burn service (RBS) hospitals and the commonest cause of immediate death on the death certificates was "inhalation of products of combustion" (32.1%). Within the >75 years age group the risk of death significantly increased with every quintile reduction in deprivation. CONCLUSION: Our data shows that despite reducing overall mortality, certain age groups and causation patterns are associated with significantly higher risks of mortality in our region. Further reduction in burn mortality should focus on the use of prevention efforts with established effectiveness in these high-risk groups. In addition, as a significant proportion of deaths occur outside a burn service environment hence epidemiology data based solely on mortality statistics from burn services will underestimate true burn related mortality.

Rizatriptan RPD for severe migraine in the emergency department--a multicenter study.

Many patients with severe migraine come to the Emergency Department (ED) due to failure of different drug regimens to stop their headache. We treated 98 patients with severe migraine who were seen in three different EDs. We used rizatriptan RPD wafers 10 mg and observed the patients for 2 h. We found that at 2 h, 92.9% (91/98) of the patients had pain relief, and 73.5% were pain free. The mean time to pain relief was 26.9 +/- 29.6 min with a median of 15 min, and the time to pain free was 70.2 +/- 47.3 min with a median of 75 min. Eighty-five percent of the patients were free of associated symptoms, such as nausea and vomiting, at 2 h with a mean time to symptom free of 55 +/- 47.5 min and a median of 45 min. Rizatriptan was reported to be much better than other drugs by 74.4% of the patients. Side effects were minor and transient. Recurrence of migraine occurred part of the day in 17.1% of the patients and all day or almost all day in 8.6% of the patients only. The results were consistent in all three EDs. We conclude that rizatriptan RPD is very effective and reliable as a first-line therapy for acute migraine in the ED. It dissolves immediately in the mouth without the inconvenience of an injection. It works fast and has few side effects and low headache recurrence.

Accuracy of commercial reporting systems to monitor quality of care in burns.

INTRODUCTION: Capse Healthcare Knowledge Systems (CHKS) is a global commercial organisation that operates health benchmarking programmes in the UK and internationally. In absence of a specialty-specific quality monitoring programme for burn services, CHKS has been producing comparative quality data for burn services for a number of years. The major quality indicator reported by CHKS is mortality as a Risk Adjusted Mortality Index (RAMI). The accuracy of RAMI is unknown in comparison to published burn-specific mortality prediction models. METHODS: A retrospective study design was used to collect data for patients admitted to the Adult Burn Service at University Hospital South Manchester (UHSM) between January 2006 and December 2010. Data was collected from two sources, CHKS and Manchester Burn Injury Database (MBID). The demographic and injury characteristics of survivors and non-survivors were compared and Receiver Operator Curve (ROC), equivalence and non-inferiority analyses were used to assess accuracy of RAMI in comparison to Abbreviated Burn Severity Index (ABSI), Belgian Outcome of Burn Injury (BOBI) score, Baux score (Baux) and McGwin score (McGwin). RESULTS: The accuracy of RAMI to discriminate between survivors and non-survivors (area under curve=0.79, 95% CI 0.50-0.81) was significantly inferior to that of ABSI, BOBI, Baux and McGwin scores. Equivalence and non-inferiority testing of ROC curves also showed RAMI score to be inferior to ABSI, BOBI, Baux and McGwin scores at 5% significance level. CONCLUSION: CHKS RAMI provides an inaccurate and inferior monitoring of mortality as a quality indicator in burn patients compared to burn specific mortality prediction models. This study raises concerns about the ability of commercially reported systems to accurately monitor quality indicators of relevance to burn care.

To cool or not to cool: evolution of the treatment of burns in the 18th century.

The 18th century represents a transitional period in evolution of surgery and burn treatment, a time just before major advances such as asepsis, burn excision and skin grafting, were to revolutionise surgical practice. The medical minds of this era first began to question the centuries of dogma and speculation that were at the heart of medicine. The evolution of the treatment of burns in this crucial time is reviewed from the perspective of two of the exceptional medical minds of that era John Hunter and James Earle. Many of their observations are still valid today and their influence would prove inspirational in ushering in modern era of burn management.