Effect of Diluted Dakin's Solution Versus Standard Care on Diabetic Foot Ulcer Management: A Randomized Controlled Trial.

BACKGROUND: Diabetic foot ulcers (DFUs) are the main cause of hospitalizations and amputations in diabetic patients. Failure of standard foot care is the most important cause of impaired DFU healing. Dakin's solution (DS) is a promising broad-spectrum bactericidal antiseptic for management of DFUs. Studies investigating the efficacy of using DS on the healing process of DFUs are scarce. Accordingly, this is the first evidence-based, randomized, controlled trial conducted to evaluate the effect of using diluted DS compared with the standard care in the management of infected DFUs. METHODS: A randomized controlled trial was conducted to assess the efficacy of DS in the management of infected DFUs. Patients were distributed randomly to the control group (DFUs irrigated with normal saline) or the intervention group (DFUs irrigated with 0.1% DS). Patients were followed for at least 24 weeks for healing, reinfection, or amputations. In vitro antimicrobial testing on DS was performed, including determination of its minimum inhibitory concentration, minimum bactericidal concentration, minimum biofilm inhibitory concentration, minimum biofilm eradication concentration, and suspension test. RESULTS: Replacing normal saline irrigation in DFU standard care with 0.1% DS followed by soaking the ulcer with commercial sodium hypochlorite (0.08%) after patient discharge significantly improved ulcer healing (P < .001) and decreased the number of amputations and hospitalizations (P < .001). The endpoint of death from any cause (risk ratio, 0.13; P = .029) and the amputation rate (risk ratio, 0.27; P < .001) were also significantly reduced. The effect on ulcer closure (OR, 11.9; P < .001) was significantly enhanced in comparison with the control group. Moreover, DS irrigation for inpatients significantly decreased bacterial load (P < .001). The highest values for the in-vitro analysis of DS were as follows: minimum inhibitory concentration (MIC), 1.44%; minimum bactericidal concentration (MBC), 1.44%; minimum biofilm inhibitory concentration (MBIC), 2.16%; and minimum biofilm eradication concentration (MBEC), 2.87%. CONCLUSIONS: Compared with standard care, diluted DS (0.1%) was more effective in the management of infected DFUs. Dakin's solution (0.1%) irrigation with debridement followed by standard care is a promising method in the management of infected DFUs.

Assessing potential impact of 2015 American Thyroid Association guidelines on community standard practice for I-131 treatment of low-risk differentiated thyroid cancer: case study of Jordan.

OBJECTIVES: The 2015 American Thyroid Association (ATA) guidelines called for significantly more selective 131I therapy in patients with low-risk differentiated thyroid cancer (DTC). We hypothesized that application of these guidelines would significantly reduce the 131I activity utilized by an academic tertiary hospital in Jordan. METHODS: All DTC patients managed at Jordan University Hospital (JUH) between 1/2009 and 6/2019 were classified according to the 2015 ATA risk category and 131I activity was assigned accordingly. The actual 131I activity administered was compared with that recommended by the 2015 ATA guidelines. RESULTS: In total, 135/182 DTC patients (74.2%) managed at JUH underwent 131I therapy. Of those, 58 (43%) had ATA low-, 58 (43%) intermediate-, and 19 (14%) high-risk disease. The low-, intermediate-, and high-risk DTC patients received an average (±SD) initial 131I activity of 3.53 ± 0.95, 4.40 ± 1.49, and 5.06 ± 2.52 GBq, respectively. Withholding 131I therapy altogether in the 2015 ATA low-risk patients would result in decreasing the 131I activity in the overall patient population by 37%. Withholding 131I therapy only in low-risk papillary thyroid microcarcinomas while administering 1.11 GBq of 131I to other low-risk patients would result in 28% reduction of 131I. CONCLUSION: This study demonstrates a significant reduction in 131I therapeutic activity that would be given to DTC patients in an academic tertiary setting in Jordan, following acceptance of the 2015 ATA recommendations. Institutions that adopted the 2015 ATA guidance should measure outcomes in comparison to their historical controls and report those findings, while long-term results of randomized controlled trials are forthcoming.

Contemporary considerations in adjuvant radioiodine treatment of adults with differentiated thyroid cancer.

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy with a growing incidence worldwide. The initial conventional management is surgery, followed by consideration of 131 I treatment that includes three options. These are termed remnant ablation (targeting benign thyroid remnant), adjuvant (targeting presumed microscopic DTC) and known disease (targeting macroscopic DTC) treatments. Some experts mostly rely on clinicopathologic assessment for recurrence risk to select patients for the 131 I treatment. Others, in addition, apply radioiodine imaging to guide their treatment planning, termed theranostics (aka theragnostics or radiotheragnostics). In patients with low-risk DTC, remnant ablation rather than adjuvant treatment is generally recommended and, in this setting, the ATA recommends a low 131 I activity. 131 I adjuvant treatment is universally recommended in patients with high-risk DTC (a primary tumor of any size with gross extrathyroidal extension) and is generally recommended in intermediate-risk DTC (primary tumor >4 cm in diameter, locoregional metastases, microscopic extrathyroidal extension, aggressive histology or vascular invasion). The optimal amount of 131 I activity for adjuvant treatment is controversial, but experts reached a consensus that the 131 I activity should be greater than that for remnant ablation. The main obstacles to establishing timely evidence through randomized clinical trials for 131 I therapy include years-to-decades delay in recurrence and low disease-specific mortality. This mini-review is intended to update oncologists on the most recent clinical, pathologic, laboratory and imaging variables, as well as on the current 131 I therapy-related definitions and management paradigms, which should optimally equip them for individualized patient guidance and treatment.

Role of Preoperative Dexamethasone Nebulization in Reducing Bougie Complications Encountered After Sleeve Gastrectomy: a Prospective Double-Blind Control Interventional Study.

INTRODUCTION: The usage of bougie devices in guiding the extent of sleeve gastrectomies has been associated with several laryngeal and pharyngeal complications. Despite these being distressing for patients, they draw little attention in current literature. OBJECTIVES: To study the role of preoperative nebulized dexamethasone in relieving the symptoms related to bougie insertion during laparoscopic sleeve gastrectomy postoperatively. MATERIALS AND METHODS: A prospective interventional study that included 80 patients. The patients were assigned to two groups, 40 patients in each group: the dexamethasone group (D) which received nebulized dexamethasone 8 mg 1 h before surgery and the control group (S) which received saline nebulizer instead. Assessment of postoperative sore throat, nausea and vomiting, odynophagia, and change of voice was used as an outcome comparative tool. RESULTS: The patient's age ranged from 17 to 61 years, and the mean age of patients was 34.51 (± 9.5) years. Patients were composed of 13 (16.3%) males and 67 (83.8%) females. The study found a significant preference of outcome values in the dexamethasone group. Sore throat mean and medians were less at all-time intervals: 0 h (p < 0.001), 1 h (p < 0.001), 6 h (p < 0.004), and 24 h (p < 0.001). Nineteen patients of the saline group suffered from a change of voice (p < 0.001), compared to only 4 patients in the dexamethasone group. On the contrary, no significant differences are noted in the incidences of PONV and odynophagia. CONCLUSION: Preoperative nebulized dexamethasone was found to be an effective measure in reducing bougie insertion complications in laparoscopic sleeve gastrectomy.

Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study.

OBJECTIVES: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS).  Methods: A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results: No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations.  Conclusion: Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.

Helicobacter pylori Does not Affect Postoperative Outcomes After Sleeve Gastrectomy.

BACKGROUND: The effect of Helicobacter pylori (HP) colonization of the stomach of patients undergoing laparoscopic sleeve gastrectomy (LSG) is unclear. OBJECTIVE: The objective of this study is to evaluate the effect of HP colonization on postoperative outcomes of LSG. SETTING: The setting of this study is in University Hospital. METHODS: This study was a retrospective cohort study of prospectively maintained database of all patients who underwent LSG at Jordan University Hospital from 2008 to 2015. RESULTS: Five hundred patients were included (362 females and 138 males). The mean preoperative weight was 124.5 ± 23.8 kg. The mean preoperative body mass index (BMI) was 45.5 ± 6.9 kg/m2. Two hundred sixteen (43.2%) patients were found to be HP positive. The differences between the HP positive and negative groups in respect of sex, baseline weight, and BMI were not statistically significant. However, patients who were HP positive were significantly older. All patients were followed for at least 3 months. We had an overall complication rate of 2.6%. Differences in the complication rate between the two groups were not statistically significant. Follow-up was 61% at 1 year. The mean percent total weight loss (%TWL) was 32.9 ± 7.9, and the mean percent excess weight loss (%EWL) was 76.9 ± 21.1. The decrease in BMI was 15.2 ± 5.2. The difference between the two groups was not statistically significant. CONCLUSION: There is no clear association between HP infection at the time of surgery and postoperative complications, especially leaks.

Upper airway obstruction by a fragmented tracheostomy tube: Case report and review of the literature.

INTRODUCTION: Many objects were described in the literature as causes of upper airway obstruction including seeds, nuts and household particles but fragmented tracheostomy tube is a rarely reported cause of airway obstruction. We report a case of foreign body aspiration in the tracheobronchial tree due to a fragmented and migrated tracheostomy tube. PRESENTATION OF CASE: We report a 4.5 year old female patient who had upper airway obstruction due to a fragmented and migrated tracheostomy tube. She was diagnosed by chest X-ray and the tube was removed by rigid bronchoscopy. DISCUSSION: Several factors contribute to fragmentation of the tracheostomy tube including repeated removal and reinsertion, cleaning, boiling or chemicals. Early breakage is most often due to manufacturing defects. The occurrence of a fractured tracheostomy tube in children is rare. Nevertheless, tracheobronchial foreign bodies in children can be life threatening and pose a dire emergency. CONCLUSION: Based on our experience, the doctors and other staff should check for any manufacturing defects before the first use of a tracheostomy tube, which should reduce the occurrence of this rare, but life threatening.

The Magnitude of Antral Resection in Laparoscopic Sleeve Gastrectomy and its Relationship to Excess Weight Loss.

BACKGROUND: The objective of this study was to evaluate the effect of antral resection on weight loss and complications after laparoscopic sleeve gastrectomy (LSG). METHODS: This was a retrospective study of the prospectively collected data of patients who underwent LSG at Jordan University Hospital from February 2011 to February 2012. Patients were divided into two groups based on antral resection: group A underwent a 6-cm antral resection, and group B underwent a 2-cm antral resection. The percentage of excess weight loss (%EWL) was calculated at 3, 6, 12, and 24 months postoperatively. RESULTS: One hundred and ten patients were included in the study, all of whom completed at least 24 months of follow-up (mean follow-up, 33 months). Their mean body mass index was 46.1 ± 7.9 kg/m(2). In group A, the mean %EWL was 38.1 ± 14.1, 54.9 ± 19.9, 65.6 ± 22.8, and 66.8 ± 28.4% at 3, 6, 12, and 24 months, respectively. However, in group B, the mean %EWL was 42.1 ± 13.4, 63.8 ± 19.8, 80.0 ± 22.1, and 81.5 ± 22.9% at 3, 6, 12, and 24 months, respectively. Patients in group B experienced statistically significant greater weight loss than patients in group A. Statistically significant greater weight regain was seen in group A. Group A had a higher incidence of reflux symptoms (six patients; 11%) than group B (four patients; 7.1%). CONCLUSIONS: Radical antral resection in association with LSG safely potentiates the restrictive effect achieved and may result in greater and better maintained weight loss.

Volume of resected stomach as a predictor of excess weight loss after sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of obesity. The objective of this study was to evaluate the volume of the resected stomach (VRS) as a predictor of the percentage of excess weight loss (%EWL) 1 year after LSG. METHODS: This was a single-surgeon study of prospectively collected data of patients who underwent LSG at Jordan University Hospital (February 2009 to February 2012). The VRS was measured using a standardized technique. The %EWL was calculated at 3, 6, and 12 months postoperatively. The correlation between the VRS and %EWL was statistically evaluated. RESULTS: Ninety patients underwent LSG during the study period. Of these, 73 patients (57 female) completed at least 1 year of follow-up and were analyzed; their body mass index was 45 ± 7.6 kg/m(2) (33-81). The VRS was 1,337.4 ± 435.2 ml (600-2,800). The %EWL was 33.6 ± 11.1 % at 3 months, 48.6 ± 15.5 % at 6 months, and 56.8 ± 18.9 % at 12 months. A significant correlation was observed between the VRS and %EWL at 1 year (p = 0.003). Patients with a VRS of >1,100 ml (n = 43) achieved significantly greater %EWL at 12 months than did those with a VRS of ≤ 1,100 (n = 30). Removal of >1,100 ml of gastric volume was associated with a sensitivity and specificity of 75.5 and 46.2 %, respectively, for achieving a %EWL of ≥ 50 %. CONCLUSION: The VRS can be used as an indicator of excess weight loss 1 year after LSG.

Ascending infection of foot tendons in diabetic patients.

Bone and soft tissue infection in the foot of diabetic patients is a well-described issue in the literature. A sound anatomical knowledge of the foot anatomy and compartments is mandatory to understand the mechanisms of infection spread. We describe four cases of diabetic foot infection complicated by long ascending infection. All did not respond initially to antibiotic treatment and the usual surgical debridement and were cured only after excision of the infected tendons. We highlight a rare but serious complication of the diabetic foot disease not commonly seen by the surgical community. We hope that this report raises the awareness of this condition so that a prompt diagnosis is made and appropriate treatment started, thereby reducing the risk of major lower limb amputations.

Performance of chloride/phosphate test in patients with primary hyperparathyroidism. Is it related to calcium level?

OBJECTIVE: To examine the sensitivity of the chloride/phosphate (Cl/PO4) ratio with a cut-off point of >33 as a diagnostic test for primary hyperparathyroidism (pHPT) in surgically proven patients, and its performance at different calcium levels. METHODS: This is a retrospective medical records based study. Data of 120 patients diagnosed with pHPT, already operated in the Department of Surgery, Cisanello Hospital, Pisa, Italy between March 2010 and June 2011 were reviewed. They were divided into 4 subgroups according to their calcium levels. The Cl/PO4 ratio was measured for each patient, with a cut-off point of 33, sensitivity of Cl/PO4 test was measured. Test sensitivity was calculated for each subgroup, and a correlation with the parathyroid hormone (PTH) level was investigated. Performance of the equation was tested for the normocalcemic patients with a suitable control group. RESULTS: The sensitivity of Cl/PO4 ratio for the whole group was 0.883 (0.809-0.932). The sensitivity was 0.9340 (0.857-0.973) for patients with serum calcium above normal levels. A similar result of 0.933 (0.830-0.978) was demonstrated for the subgroup with hypercalcemia <1 (mg/dL) above normal level. Normocalcemic patients constituted 24%; for this subgroup, the sensitivity test was 0.724 (0.562-0.887), specificity was 0.763 (0.628-0.898), positive predictive value was 0.700 (0.536-0.864), and negative predictive value was 0.784 (0.651-0.916). No correlation was identified between the performance of formula and serum PTH level. CONCLUSION: The Cl/PO4 test seems to be a good tool to anticipate pHPT and showed a fair performance in normocalcemic patients.

Underlay mesh repair for spontaneous lumbar hernia.

INTRODUCTION: Lumbar hernia is a rare condition with fewer than 300 cases reported in the literature. It arises through posterolateral abdominal wall defects, named the inferior triangle (Petit) and superior triangle (Grynfelt). It can be congenital or acquired, primary or secondary, peritoneal or extraperitoneal, reducible or complicated. PRESENTATION OF CASE: We report a 63 year old female patient who presented to our hospital with a reducible right superior lumbar hernia. She underwent repair with underlay mesh after inversion of the sac and had a smooth postoperative course. DISCUSSION: In contrast to the classical procedure the underlay mesh modification saved us from enlarging the defect, and was quick and associated with minimal tissue injury. CONCLUSION: Underlay mesh repair for spontaneous lumbar hernia is feasible when the defect is small.

Gastric perforation secondary to metastasis from ovarian cancer: Case report.

INTRODUCTION: Metastasis from ovarian cancer occurs frequently through the peritoneal cavity in the form of peritoneal carcinomatosis; isolated gastric metastasis is rarely reported in literature. PRESENTATION OF CASE: We present a case of 43-year-old infertile lady, who developed a picture of acute abdomen four days post total abdominal hysterectomy and salpingoopherectomy for ovarian cancer. Further contrast-enhanced CT scan demonstrated massive free gas and fluid in the abdomen. She underwent antrectomy with truncal vagotomy due to 3cm×4cm prepyloric gastric ulcer. Final pathology proved the presence of metastatic serous cystadenocarcinoma of ovarian origin. DISCUSSION: Our patient had a gastric perforation secondary to ovarian metastasis. Being isolated, the absence of ascites and the transmural nature of the gastric metastasis suggest haematogenous spread .To the best of our knowledge perforated gastric metastasis secondary to ovarian cancer was not reported in literature before. CONCLUSION: Gastric metastasis should be kept in mind in patients with a well-known ovarian cancer who present with gastric lesions, ulcers, bleeding or perforation.