Outcomes of AV fistula formation for dialysis patients using interrupted sutures one-year single center study.

Objectives: To document the Outcomes of AV fistula formation for dialysis patients using interrupted sutures. Methods: In this Cross-sectional study conducted at PNS Shifa Karachi, from June 2022 to June 2023, patients above 18 years of age, male or female, with ESRD/CKD were included. After clinical screening and ultrasound doppler, the distal most part of wrist was considered as a site for radio cephalic AVF. Operation was performed under surgical loupe with 4.5x magnification. Standard incision of about 4-5 cm oblique proximal to the wrist crease was given at the volar surface on the radial side of Distal forearm, extending till the lateral side up to the snuffbox. Subcutaneous tissue was incised and dissection was done to identify the cephalic vein and radial artery. Distal most end of the cephalic vein was ligated using vicryl 4-0 suture and cephalic vein dissected free from the underling tissue to mobilize it up to the radial artery. Results: During the study N=35 patients who required AVF creation visited the department. The mean age of the study participants was 59.34±15.48. If thrill at the site of AVF and backflow at cut end of cephalic vein were present the surgeons were satisfied, higher satisfaction among the surgeon was achieved in the AVF created at brachiocephalic artery while the diameter of vessels didn't contribute in surgeon satisfaction. Conclusion: Presence of thrill at the site of AVF and backflow at cut end of cephalic vein have strong association with good prognosis of AVF.

The Outcome Of Pedicled Medial Sural Artery Perforating Flap For Proximal Leg Reconstruction.

BACKGROUND: Reconstruction of defects around the knee and proximal leg are difficult to reconstruct. Out of the multiple flaps described for reconstruction, the pedicled Medial Sural Artery Perforating Flap (MSAP) has recently gained popularity. We conducted this study to assess the clinical outcomes of pedicled MSAP for this purpose at our hospital. METHODS: A descriptive case series was conducted from April 2022 to March 2023. All patients above 18 years with defects around the knee and proximal leg were included. Patients with tissue loss in the calf area were excluded. RESULTS: A total of 14 patients were included. Twelve (86%) were males, while only 2 were females (14%). The mean age was 33.5 years (±8.76). The most common cause of the defect was trauma (n=11, 85%). The Mean distance of the distal-most perforator from the popliteal crease was 12.714 (±1.990) cm (range 9-16 cm). It was observed that the most distal perforator is usually present in a 2 cm radius of the medial musculo-tendinous junction of the gastrocnemius. Complications were seen in 2 (14%) patients. The mean duration of hospital stay was 4.2 (±0.96) days. Patients were followed up weekly for the first two weeks and then at 1, 3 and 6 months. CONCLUSIONS: MSAP Flap is a reliable thin, long pedicled fasciocutaneous flap with low donor site morbidity and aesthetically good results for reconstruction around the knee and proximal leg.

The impact of COVID-19 pandemic on hand hygiene adherence among pediatric physicians, in Saudi Arabia.

Introduction: The hand hygiene practice (HHP) is the most effective and simplest preventive measure to reduce the risk of infection. HHP is more relevant among pediatric physicians in the context of the COVID-19 pandemic since, children are more vulnerable to infection. Therefore, assessment of the COVID-19 impact on HHP could be useful in minimizing lethal virus transmission from pediatric physicians to patients and vice versa. Method: The present cross-sectional, electronically self-administered supplement based survey study was conducted among different professional levels of pediatric physicians involving consultants, specialists, and residents. The supplement includes information related to demography, knowledge, awareness, preventive measures, demonstration and practice of HHP. The information was collected and summarized on a Microsoft excel sheet before being imported to SPSS for statistical analysis. Results: Of the total (N = 404) pediatric physicians, 56.68% male, 43.06% belongs to 25-35 years, 42.32% were consultants, 98.01% respondents were familiar with five moments of HHP. Further, HHP immediately before touching patients (99.26%), clean/aseptic procedure (95.04%), after body fluid exposure (72.28%), after touching patients (98.01%), after touching surrounding of patients (74.75%) may prevent germ transmission to patients whereas HHP after touching patients (98.27%), before clean/aseptic procedure (67.57%), after exposure to immediate surroundings of patients (97.02%) may prevent germ transmission to pediatric physicians. Rubbing hands is preferred before palpation of abdomen (74.25%), before giving injection (56.68%), after removing gloves (61.88%), after making a patient's bed (47.80%), while washing of hands preferred after emptying bedpan (67.82%) and after visible exposure to blood (84.40%), 92.57% believed gloves can't replace HHP, posters display at point of care as reminders (95.30%), received frequent HHP education (82.92%), 50.49% do not need HHP reminder, 51.73% preferred alcohol based sanitizer, 53.46% facilitate daily morning huddle, HHP >10 times per day before COVID-19 (24.62%) while in COIVID-19 (56.44%). HPP is the most effective way to prevent the spread (98.01%) of microbes because it kills germs (90.35%), health care associated infections is the major (38.06%) cause of germ transmission, 86.88% will be remains committed to HHP even after pandemic. In comparison to residents and specialists, consultants gave more importance (p = 0.02) to HHP and were more adherent during (p = 0.007) and even after (p = 0.001) COVID-19 pandemic. Conclusion: Assessing knowledge of pediatric physician, awareness, and adherence to hand hygiene measures could be helpful to reduce the contact transmission of lethal viruses to patients and vice versa. Further increase in the awareness, knowledge and education of HHP are required in order to maximize its utilization.

A novel multi-criteria decision-making approach for prioritization of elective surgeries through formulation of "weighted MeNTS scoring system".

Background: Publicly funded healthcare system has long non-manageable elective surgery waiting lists due to the non-existence of systematic mathematical modelling that can assess the relative priority of patients on elective surgery waiting lists thus denying the provision of surgical support to the patients with higher urgency. Mostly the patients of general surgery are entertain with highly subjective "time-honoured" methods that are inadequate to measure and compare the urgency of surgical procedure. Objective: A methodology of assigning priorities to patients on elective surgery waiting lists has been presented in this paper using weighted criteria objectives. The objectives hve been chosen and assigned weights based on hospital conditions, and in consultation with the surgeons in hospital in Pakistan. Methods: The proposed methodology presents two working contributions; first, a scoring mechanism based on MeNTS scoring system with weighted criterion that objectively translate the condition of patient prior to the surgical procedure; and second, a patient prioritization methodology to select patients for surgeries according to the corresponding scores. Detailed simulation results from actual patient data have been presented to evaluate the effectiveness of the proposed methodology, and its applicability and ease of use has been tested in real-time by surgeons while providing consultations to their patients. Results: The proposed methodology outperforms the traditional "first-come-first-serve" methodology as there was a 30% reduction in average waiting time in elective surgery waiting lists (from 4.246 to 2.956 days) with 103 (90%) of patients being entertained before or within the unprioritized surgeries time span, with 94 patients having surgery within 1 day of being on waiting list (an increase of 47 patients). Moreover, transparency and equity were also found in the adaptation of this strategy to prioritize the elective surgery patients. Conclusions: Prioritizing patients on elective surgery waiting lists is an important concern in surgical field. In most of the methodologies presented in earlier research, prioritization of patients for surgery is carried out subjectively. This study shows that the proposed technique has the potential to decrease the waiting times for patients on elective surgery waiting lists, as well as be presented as an objective methodology for preparing the elective surgery waiting lists to increase the transparency in waiting list.

Preparation and Characterization of Novel Schiff Base Derived From 4-Nitro Benzaldehyde and Its Cytotoxic Activities.

Normal drugs exhibit activities against both normal and cancer cells. Furthermore, cancer cells may develop resistance to these drugs that alternative treatment must be explored. The main objective of this study was to examine the anticancer activity of Schiff base against Tongue Squamous Cell Carcinoma Fibroblasts (TSCCF) and normal human gingival fibroblasts (NHGF) and to propose its mechanism. A Novel Schiff base ligand was synthesized from the reaction of 5-C-2-4-NABA (5-chloro-2-((4-nitrobenzylidene) amino) benzoic acid). These Schiff bases possessed azomethine group (-HC=N-) and aromatic group (CH) as analyzed by Fourier transforms infrared (FTIR) spectroscopy and UV-Vis spectra. The in vitro cytotoxicity screening assay suggested promising activity against TSCCF with IC50 of 446.68 µg/mL, but insignificant activity against NHGF cells (IC50 of 977.24 µg/mL) after 72 h. The evidence of apoptotic induction was supported by DAPI staining of apoptotic nuclei with reduced cell numbers, suggesting that Schiff base could induce apoptotic bodies in cancer cells being observed. Based on the Schiff base structure, the anti-cancer mechanism may be attributed to the -HC=N- azomethine group. For the first time, our findings highlighted the anticancer activities of the new Schiff base against oral cancer cell lines.

A Community Pharmacy-Based Intervention in the Matrix of Type 2 Diabetes Mellitus Outcomes (CPBI-T2DM): A Cluster Randomized Controlled Trial.

INTRODUCTION: Egypt has the ninth highest diabetes mellitus (DM) prevalence in the world. There is a growing interest in community involvement in DM management. AIM OF THE STUDY: The aim of the study was to evaluate the tailored diabetes care model (DCM) implementation in Alexandria governorate by community pharmacy-based intervention (CPBI) from a clinical, humanistic, and economic aspect. METHODS: This is a 6-month period cross-over cluster randomized control trial conducted in Alexandria. Ten clusters owing 10 community pharmacies (CPs) recruited 100 health insurance-deprived T2DM patients with >7% HbA1c in 6-months. The study was divided into 2 phases (3 months for each period) with a 1-month washout period in between. After CPs training on DCM, the interventional group received pictorial training for 45 minutes in first visit, and 15 minutes in weekly visits, whereas the control group patients received the usual care (UC). At baseline and end of each phase (3 months), patients had clinical and physical activity assessments, filled all forms of study questionnaire (knowledge, self-management, satisfaction, and adherence) and did all laboratory investigations (Fasting Blood Glucose [FBG]), HbA1c, protein-creatinine clearance (PCR), creatine clearance (GFR), and lipid profile. RESULTS: There was no significant difference in the basal systolic and diastolic blood pressure between patients in the CBPI and UC groups, but the CBPI had significantly decreased the mean SBP and DBP by (P = .008, .040, respectively). Also, significant waist circumference and BMI reductions (-5.82 cm and -1.86 kg/m2, P = .001) were observed in the CBPI. The CBPI patients achieved a greater reduction in FBG and HbA1C than the UC patients (102 mg/dL and 1.9%, respectively P < .001). Also, significant reductions in total cholesterol, LDL, and triglyceride (-6.4, -15.4, and -6.3 mg/dL respectively, P = .001) were achieved in the CBPI group. No significant differences were found in HDL, GFR, and PCR. Moreover, significant improvements of behavior, score of knowledge, self-management, satisfaction, and adherence were observed in CBPI patients. After multivariate analysis, HbA1C readings were significantly influenced by baseline HbA1C and eating habits. The cost saving for CPBI was -1581 LE per 1% HbA1c reduction. CONCLUSION: This is the first study in Egypt that illustrated the positive impact of pictorial DCM delivered by CPBI collaborative care on clinical, humanistic, laboratory, and economic outcomes to local T2DM patients.

COVID 19 pandemic: Effect on management of patients with breast cancer; single center retrospective cohort study.

BACKGROUND: (SARS-COV-2) infection, led to a pandemic affecting many countries, resulting in hospitals diverting most of their resources to fight the pandemic. Breast cancer, already a healthcare dilemma, is also affected in this scenario. Our aim was to find out the impact of COVID-19 on presentation of breast cancer stage and its effects on overall onco-surgical management. METHODS: This cohort single-centered retrospective review was carried out at our hospital, over a period of 18 months. Females with known breast cancer were included in the study. Data was collected on performas by a single researcher. Effect of COVID pandemic on presentation stage and its impact on overall management was studied. SPSS 23.0 used for data analysis. A 95% CI was used. Descriptive statistics were presented as range/means. Categorical data was analyzed by Fisher exact test, t-test was applied to numerical data, p value ≤ 0.05 was considered significant. RESULTS: Out of 87 patients presenting with suspicious lump, 69 who had malignancy on histo-pathology were included in study. Twelve out of 69 were COVID positive. Sixty patients presented with advanced stage (≥stage 2b) out of which 21 underwent upstaging of disease due to delay in presentation/management. We found that 9 out of 12 (majority) Covid positive patients had disease upstaging. Overall main reason for delay in presentation was found to be unawareness of disease. CONCLUSION: We concluded that COVID-19 pandemic had no impact on presentation delay, breast cancer management/treatment and disease upstaging as compared to figures available for our population before the pandemic. However, our study showed significant correlation between disease upstaging and COVID status. This led us to reconsider our preformed protocols for COVID positive breast cancer patients. Our results can be used by future researchers to investigate if COVID itself can contributes in patho-physiology of upstaging in breast cancer or not.

Hydrogen peroxide inhibition of bicupin oxalate oxidase.

Oxalate oxidase is a manganese containing enzyme that catalyzes the oxidation of oxalate to carbon dioxide in a reaction that is coupled with the reduction of oxygen to hydrogen peroxide. Oxalate oxidase from Ceriporiopsis subvermispora (CsOxOx) is the first fungal and bicupin enzyme identified that catalyzes this reaction. Potential applications of oxalate oxidase for use in pancreatic cancer treatment, to prevent scaling in paper pulping, and in biofuel cells have highlighted the need to understand the extent of the hydrogen peroxide inhibition of the CsOxOx catalyzed oxidation of oxalate. We apply a membrane inlet mass spectrometry (MIMS) assay to directly measure initial rates of carbon dioxide formation and oxygen consumption in the presence and absence of hydrogen peroxide. This work demonstrates that hydrogen peroxide is both a reversible noncompetitive inhibitor of the CsOxOx catalyzed oxidation of oxalate and an irreversible inactivator. The build-up of the turnover-generated hydrogen peroxide product leads to the inactivation of the enzyme. The introduction of catalase to reaction mixtures protects the enzyme from inactivation allowing reactions to proceed to completion. Circular dichroism spectra indicate that no changes in global protein structure take place in the presence of hydrogen peroxide. Additionally, we show that the CsOxOx catalyzed reaction with the three carbon substrate mesoxalate consumes oxygen which is in contrast to previous proposals that it catalyzed a non-oxidative decarboxylation with this substrate.

Isothermal titration calorimetry uncovers substrate promiscuity of bicupin oxalate oxidase from Ceriporiopsis subvermispora.

Isothermal titration calorimetry (ITC) may be used to determine the kinetic parameters of enzyme-catalyzed reactions when neither products nor reactants are spectrophotometrically visible and when the reaction products are unknown. We report here the use of the multiple injection method of ITC to characterize the catalytic properties of oxalate oxidase (OxOx) from Ceriporiopsis subvermispora (CsOxOx), a manganese dependent enzyme that catalyzes the oxygen-dependent oxidation of oxalate to carbon dioxide in a reaction coupled with the formation of hydrogen peroxide. CsOxOx is the first bicupin enzyme identified that catalyzes this reaction. The multiple injection ITC method of measuring OxOx activity involves continuous, real-time detection of the amount of heat generated (dQ) during catalysis, which is equal to the number of moles of product produced times the enthalpy of the reaction (ΔHapp). Steady-state kinetic constants using oxalate as the substrate determined by multiple injection ITC are comparable to those obtained by a continuous spectrophotometric assay in which H2O2 production is coupled to the horseradish peroxidase-catalyzed oxidation of 2,2'-azinobis-(3-ethylbenzthiazoline-6-sulfonic acid) and by membrane inlet mass spectrometry. Additionally, we used multiple injection ITC to identify mesoxalate as a substrate for the CsOxOx-catalyzed reaction, with a kinetic parameters comparable to that of oxalate, and to identify a number of small molecule carboxylic acid compounds that also serve as substrates for the enzyme.

THORACODORSAL ARTERY PERFORATOR FLAP FOR UPPER LIMB RECONSTRUCTION.

BACKGROUND: Thoracodorsal artery perforator flap (TAP) is a feasible option to reconstruct defects in upper limb where only skin and subcutaneous tissue is required. METHODS: This case series was carried out at department of Plastic and Reconstructive Surgery Combined Military Hospital Rawalpindi. A total of 5 patients with upper limb defects were reconstructed with thoracodorsal artery musculocutaneous perforator flaps. Among them, 3 were pedicled and two free TAP flaps. All flaps except one pedicled flap were raised on a single perforator pedicle. Recipient sites were one axilla, two shoulder regions and two hands. The soft tissue defects in the patients had resulted from burns, trauma, wide local excision of synovial sarcoma and surgery for hidradenitis suppurativa. Preoperative hand held Doppler ultrasound was used to locate and mark the perforator. RESULTS: All flaps survived without significant complications. All flaps were hyperemic in the immediate postoperative period. We designed and raised all the five flaps on eccentrically placed perforators. All the raised perforators originated from the descending branch of the thoracodorsal artery. The donor sites were closed primarily with linear scars in all cases except one, in which partial closure was accomplished with split thickness skin grafting (STSG). CONCLUSION: The thoracodorsal artery perforator flap has great potential for reconstructing large, relatively shallow, defects of upper limb because of its suitable skin quality, texture and appropriate thickness, as well as hidden donor site, a reliable pedicle and sparing of muscle unit.

Use of vascularised free fibula in limb reconstruction (for non-malignant defects).

The case series was conducted at the Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from June 2009 to May 2011, and comprised 19 patients in whom free fibula flap was performed for upper and lower limb reconstruction, using SPSS 16. Results showed that flap survival was 100%. One (5.2%) flap was re-explored for venous congestion and was salvaged. One (5.2%) patient of congenital pseudoarthrosis of tibia had a fracture of the fibula and was treated with external fixation. Average follow up was 8 months. Mean union time and full weight-bearing was 6.5 +/- 1.34 months (range 3-8 months) and 9 months, respectively. No recurrence of pseudoathrosis was observed until the last follow up, with only a 1.5 cm length discrepancy in one patient. The results proved that a microvascular free fibular flap heals rapidly, causes early functional recovery and it can be raised as an osteocutaneous flap.

Long-term morbidity of axillary lymph node dissection: implications for patients with carcinoma breast.

BACKGROUND: To assess the long term complications of level II Axillary Lymph Node Dissection (AXLND) in patients with breast cancer and to see if they are high enough to warrant a Sentinel Lymph Node (SLN) biopsy in all patients presenting with carcinoma breast in our setup in Pakistan. METHODS: This study was conducted at Surgical Unit IV, Department of Surgery, Combined Military Hospital, Rawalpindi. Upper, lower arm circumferences and body mass index were ascertained in post Modified Radical Mastectomy (MRM) with level II AXLND, in female patients who had undergone surgeries from 1992 to 2008. Patient's perception of degree of lymph oedema, arm function and other symptoms like pain, tingling and numbness was noted. The number of lymph nodes removed, number of positive nodes and post operative radiotherapy were also recorded from the hospital records. RESULTS: Thus upper arm circumference in 85.7% patients and lower arm circumference in 89.2% patients was within 2 Cm of the unaffected side. No, moderate and severe arm swelling was described by 83.35% of patients, 11.6% of patients and one patient respectively and 41.5% of patients describing some arm swelling had positive lymph nodes. Thus even if they had gone (SLN) biopsy, these patients would have had a subsequent AXLND. Over 94% of patients had either good or excellent arm function with most in the excellent range. CONCLUSION: The patients at significant risk for positive nodal may be better served with an AXLND rather than the SLN technique.