Detectability and surgical outcomes in parathyroid surgery - a single-centre experience.

The incidence of primary hyperparathyroidismand referrals for the removal of parathyroid adenomas are increasing. Factors that improve the detectability, and ultimately the surgical outcome, are the focus of this retrospective study. We included 117 patients who had parathyroid operations with intraoperative monitoring of parathyroid hormone (PTH). Sestamibi, ultrasound and, in selected cases, fusion with computed tomograms (CT), were done to locate the lesion preoperatively. Concentrations of calcium and PTH before and after operation, specimen weight, and preoperative vitamin D concentrations, were assessed. The sensitivity of sestamibi and ultrasound for the preoperative location of adenomas was 92% and 80%, respectively. Sestamibi located them more accurately in patients with low preoperative concentrations of vitamin D (p = 0.037) and with heavier adenomas (p < 0.001). We found no significant association between the preoperative concentrations of PTH and detectability on preoperative scans (p = 0.058). Postoperative follow up showed that 97% of the 117 patients were biochemically cured. Accurate location helps to lower morbidity as it facilitates a targeted approach. Further studies are needed to explore the role of vitamin D in the location of parathyroid adenomas before parathyroidectomy.

Anastomosis between the transverse cervical nerve and marginal mandibular nerve: how often does it occur?

Anastomoses in the neck between the sensory transverse cervical nerve (C2,3) and the cervical branch of the facial nerve are common, but communications with more superior branches of the facial nerve are rare. After we had identified a case where the transverse cervical nerve joined the marginal mandibular branch of the facial nerve in the submandibular triangle during a selective neck dissection, we searched for this variant in 86 neck dissections to see if it occurs more often than expected. We found it in one further patient. As this anastomosis of the nerve could easily be confused with the marginal mandibular branch itself, particularly during a more limited exposure (such as excision of a submandibular gland), our findings remind surgeons to be vigilant when dissecting in this area to minimise the risk of weakness of the lower lip postoperatively.

The 'bother' of obstructed defecation.

OBJECTIVE: To examine the relationship of visual analog scale (VAS) 'bother' scores for obstructed defecation (OD) with demographic data, physical examination and sonographic findings of the posterior compartment. METHODS: All patients seen at a urogynecology clinic between January and October 2013 were included. Patients were diagnosed with OD if they had any of the following: incomplete bowel emptying, straining with bowel movement or need for digitation. Patients used a VAS to rate OD bother on a scale of 0-10 (0, no bother; 10, worst imaginable bother). For each patient, a comprehensive history was obtained, the International Continence Society Pelvic Organ Prolapse Quantification was performed and four-dimensional translabial ultrasound volumes were recorded on maximal Valsalva maneuver. Linear and multiple regression models were used to correlate bother VAS scores with demographic, clinical and sonographic findings. RESULTS: Among 265 patients included in the analysis, 61% had OD symptoms with a mean VAS bother score of 5.6. OD bother scores were associated with a history of previous prolapse surgery (P = 0.0001), previous hysterectomy (P = 0.0006), descent of the posterior compartment (Bp; P = 0.004) and hiatal dimensions (Pb and Gh + Pb; P = 0.006 and P = 0.004). OD bother was associated with the following sonographic findings: true rectocele (P = 0.01), depth of rectocele (P = 0.04), descent of rectal ampulla (P = 0.02), enterocele (P = 0.03) and rectal intussusception (P < 0.0001). CONCLUSIONS: VAS bother scores are associated with both clinical and sonographic measures of posterior compartment descent. Rectal intussusception was most likely to result in highly bothersome symptoms of OD. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Division of the spinal accessory nerve in the anterior triangle: a prospective clinical study.

The anatomical relation between the spinal accessory nerve and internal jugular vein is well documented, but other variants of the nerve, including the contributions of the cervical plexus to supply motor fibres to the trapezius, are less well known. We have previously described an anatomical variant in which the spinal accessory nerve divided before entering the sternocleidomastoid, and the inferior trunk passed directly under it to supply the trapezius. We now present a prospective study of 133 neck dissections (excluding radical dissections) in which a meticulous search was made for the variant in the anterior triangle of the neck during operation. We found it in 3 necks (2%). One of the 3 patients had a bilateral neck dissection but it was found on one side only, and in 2 cases it communicated with the cervical plexus. In all 3, stimulation of the inferior division resulted in contraction of the trapezius while the upper division was found to supply the sternocleidomastoid only. The finding of this variant, which was more common than first thought, highlights the need for meticulous dissection of the nerve before it enters the sternocleidomastoid to ensure that, when present, the inferior branch is preserved to minimise potential postoperative shoulder dysfunction. Further research including a cadaveric study is needed to understand this important variant more fully.

Genetic relatedness of artichoke (Cynara scolymus L.) hybrids using random amplified polymorphic DNA (RAPD) fingerprinting.

The artichoke (Cynara scolymus L.) is an important food and medicinal crop that is cultivated in Mediterranean countries. Morphological characteristics, such as head shape and diameter, leaf shape, and bract shape, are mainly affected by environmental conditions. A molecular marker approach was used to analyze the degree of polymorphism between artichoke hybrid lines. The degree of genetic difference among three artichoke hybrids was evaluated using random amplified polymorphic DNA-PCR (RAPD-PCR). In this study, the DNA fingerprints of three artichoke lines (A13-010, A11-018, and A12-179) were generated, and a total of 10 decamer primers were applied for RAPD-PCR analyses. Polymorphism  (16.66 to 62.50%) was identified using eight arbitrary decamers and total genomic DNA extracted from the hybrids. Of the 59 loci detected, there were 25 polymorphic and 34 monomorphic loci. Jaccard's similarity index (JSI) ranged between 1.0 and 0.84. Based on the unweighted pair group method with arithmetic mean (UPGMA) similarity matrix and dendrogram, the results indicated that two hybrids (A13-010 and A11-018) were closely related to each other, and the A12-179 line showed more divergence. When identifying correct accessions, consideration of the genetic variation and genetic relationships among the genotypes are required. The RAPD-PCR fingerprinting of artichoke lines clearly showed that it is possible to analyze the RAPD patterns for correlation between genetic means and differences or resemblance between close accessions (A13-010 and A11- 018) at the genomic level.

A national analysis of the outcome of major head and neck cancer surgery: implications for surgeon-level data publication.

OBJECTIVES: To undertake a national outcomes analysis following major head and neck cancer surgery in order to identify risk factors for complications and in-hospital mortality, as well as areas whose closer examination and formal benchmarking in the context of local and national quality assurance audits may lead to improved results for this condition. DESIGN: An analysis using Hospital Episode Statistics data. SETTINGS: All units undertaking major head and neck cancer surgery in England. MAIN OUTCOME MEASURES: Cancer sites, co-morbidities, social deprivation, surgical and non-surgical treatments, complications, and in-hospital mortality were recorded. Regression analysis was used for casemix adjustment and for identifying independent predictors of complications and mortality. Funnel plots were used for data visualisation. RESULTS: We identified 10,589 major head and neck cancer operations performed in England between 2006 and 2011. There were 7312 males, and mean age at surgery was 63 ± 13 years. Oral cavity (42%) and the larynx (28%) were the commonest cancer sites. At least one complication occurred in 33.1% of patients, and there were 322 (3.05%) in-hospital deaths. Variables associated with in-hospital mortality were trust volume, age, co-morbidities, performing emergency major surgery and performing a tracheostomy or reconstructive surgery. Occurrence of major medical complications including pulmonary infections (7%), major acute cardiovascular events (4.7%) and acute renal failure (0.6%) also increased mortality risk. The analysis identified units that were outside of crude and risk-adjusted 99.8% limits of confidence for complications and mortality. CONCLUSION: Mortality following head and neck cancer surgery shows significant national variation and is associated with fixed risk factors like age and co-morbidities, but also with modifiable risk factors like performing major surgery during an emergency admission, tracheostomy, reconstructive surgery and medical complications. We propose that the quality of tracheostomy care, reconstructive surgery, emergency major surgery rate, and occurrence and treatment of major medical complications should be closely examined and formally benchmarked as part of loco-regional and national quality improvement audits.

HPTLC densitometric analysis of arbutin in bulk drug and methanolic extracts of Arctostaphylos uva-ursi.

A high-performance thin layer chromatographic densitometric method for the analysis of arbutin was developed and validated in the present investigation. Arbutin was separated on aluminium-backed silica gel 60 F(254) plates with methanol : chloroform (3:7)% (v/v) as the mobile phase. This system was found to give a compact spot of arbutin at a retention factor (R(f)) value of 0.32 ± 0.02. The limit of detection and limit of quantification were found to be 35.42 and 106.26 ng/spot, respectively. The proposed method with a high degree of precision and accuracy was employed for the analysis of arbutin in the bulk drug and methanolic extract of Arctostaphylos uva-ursi.

A new HPTLC densitometric method for analysis of swertiamarin in Enicostemma littorale and commercial formulations.

A high-performance thin layer chromatographic densitometric method for the analysis of swertiamarin in 60% methanolic extract of Enicostemma littorale and commercial formulations has been developed and validated in this study. Swertiamarin was separated on aluminium-backed silica gel 60 F254 plates using ethyl acetate : methanol : water (77 : 15 : 8)% v/v as the mobile phase. This system was found to give a compact spot of swertiamarin at R(f) value 0.36 ± 0.01. The limit of detection and limit of quantification were found to be 31.25 and 103.12 ng spot⁻¹, respectively. The proposed method was employed with a high degree of precision and accuracy for the estimation of swertiamarin in methanolic extract of Enicostemma littorale and in commercial formulations.

Constitutive expression of high-affinity sulfate transporter (HAST) gene in Indian mustard showed enhanced sulfur uptake and assimilation.

Lycopersicon esculantum sulfate transporter gene (LeST 1.1) encodes a high-affinity sulfate transporter (HAST) located in root epidermis. In this study, the LeST 1.1 gene was constitutively expressed in Indian mustard (Brassica juncea cv. Pusa Jai Kisan). Transgenic as well as untransformed plants were grown in sulfur-insufficient (25 and 50 µM) and sulfur-sufficient (1,000 µM) conditions for 30 days. Two-fold increase was noticed in the sulfate uptake rate of transgenic plants grown in both sulfur-insufficient and -sufficient conditions as compared to untransformed plants. The transgenic B. juncea plants were able to accumulate higher biomass and showed improved sulfur status even in sulfur-insufficient conditions when compared with untransformed plants. Chlorophyll content, ATP sulfurylase activity and protein content were also higher in transgenic plants than untranformed plants under sulfur-insufficient conditions. Our results, thus, clearly indicate that constitutive expression of LeST 1.1 gene in B. juncea had led to enhanced capacity of sulfur uptake and assimilation even in sulfur-insufficient conditions. This approach can also be used in other crops to enhance their sulfate uptake and assimilation potential under S-insufficient conditions.

Pericardiectomy for constrictive pericarditis: is prolonged inotropic support a bad omen?

Sixty-seven patients who underwent pericardiectomy for constrictive pericarditis at JIPMER, Pondicherry between 1987 and 1998 were the subjects of the study. Pre-operatively 70% of cases were in the New York Heart Association classes III and IV categories with clinical signs suggestive of constriction ie, raised jugular venous pressure in 99%, pleural effusion in 77%, pedal oedema in 61% and ascites in 55% of the cases. Seventy-five per cent of the cases underwent pericardiectomy through a median sternotomy and the rest via left anterolateral thoracotomy. Low cardiac output was evidenced in 70% of cases postoperatively which was managed by early institution and prolonged use of inotropes. There was 9% mortality especially in the early part of the experience. Tuberculous pathology was confirmed histologically in 57% cases. Sixty-three per cent of cases are presenting in follow-up in New York Heart Association class I. Prolonged use of inotropes instituted early in postoperative period is recommended to prevent postoperative ventricular dysfunction with adrenaline being the preferred inotrope. It is concluded that postoperative New York Heart Association class and long term survival were not significantly influenced by pre-operative New York Heart Association class, operative approach or peri-operative low cardiac output syndrome requiring prolonged inotropic support.