Meta-analysis and meta-regression analysis of iliac limb occlusion after endovascular aneurysm repair.

OBJECTIVE: Our objective was to investigate the incidence, interventions and outcomes of iliac limb occlusion after endovascular aneurysm repair (EVAR). METHODS: We performed a systematic review that conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines using a registered protocol (CRD42017064375). We considered studies reporting patients with iliac limb occlusion after EVAR. We interrogated electronic information sources and bibliographic reference lists using a combination of free text and controlled vocabulary searches. We conducted a proportion meta-analysis of outcomes applying a random effects model. We used mixed effects (methods of moments) regression models to investigate whether the incidence of iliac limb occlusion changed over time. RESULTS: We identified 13 studies reporting a total of 5454 patients who underwent EVAR from 1995 to 2014. The pooled incidence estimate of primary iliac limb occlusion was 5.6% (95% confidence interval [CI], 4.0-7.8). The incidence of iliac limb occlusion was more pronounced in old studies and declined in more recently published studies (slope P = .022; Q=5.279). Forty-four percent (95% CI, 36%-52%) had an acute presentation. One-half of the patients (48%; 95% CI, 41%-56%) presented within 30 days of EVAR. Seventeen percent (95% CI, 13%-23%) underwent endovascular treatment, 8% (95% CI, 5%-13%) received hybrid procedures, and 61% (95% CI, 54%-67%) had open surgery. The 30-day mortality was 0.036 (95% CI, 0.018-0.070; heterogeneity: P = .999, I2 = 0%). The rate of limb loss within 30 days and during follow-up was 0.031 (95% CI, 0.015-0.063; heterogeneity: P = .999; I2 = 0%) and 0.045 (95% CI, 0.024-0.083; heterogeneity: P = .978; I2 = 0%), respectively. Reintervention was undertaken in 0.080 (95% CI, 0.048-0.130; heterogeneity P = .919; I2 = 0%) over a follow-up ranging from 7 to 39 months. The mortality during follow-up was 0.056 (95% CI, 0.031-0.099; heterogeneity: P = .866; I2 = 0%). CONCLUSIONS: Iliac limb occlusion occurred in 5.6% of patients after EVAR. One-half of these patients presented early. Even though surgical treatment has been used more frequently, there is insufficient evidence to suggest its superiority over endovascular/hybrid repair. A considerable number of patients will require reintervention. Future research is needed in identifying patients at risk of iliac limb occlusion.

Bowel ischaemia after endovascular aneurysm repair.

The aim of this review was to investigate presentation, aetiology, management, and outcomes of bowel ischaemia following EVAR. We present a case report and searched electronic bibliographic databases to identify published reports of bowel ischaemia following elective infra-renal EVAR not involving hypogastric artery coverage or iliac branch devices. We conducted our review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. In total, five cohort studies and three case reports were included. These studies detailed some 6,184 infra-renal elective EVARs, without procedure-related occlusion of the hypogastric arteries, performed between 1996 and 2014. Bowel ischaemia in this setting is uncommon with an incidence ranging from 0.5 to 2.8 % and includes a spectrum of severity from mucosal to transmural ischaemia. Due to varying reporting standards, an overall proportion of patients requiring bowel resection could not be ascertained. In the larger series, mortality ranged from 35 to 80 %. Atheroembolization, hypotension, and inferior mesenteric artery occlusion were reported as potential causative factors. Elderly patients and those undergoing prolonged procedures appear at higher risk. Bowel ischaemia is a rare but potentially devastating complication following elective infra-renal EVAR and can occur in the setting of patent mesenteric vessels and hypogastric arteries. Mortality ranges from 35 to 80 %. Further research is required to identify risk factors and establish prophylactic measures in patients that have an increased risk of developing bowel ischaemia after standard infra-renal EVAR.

Arterial Injury in the Upper Limb Resulting from Dog Bite.

Dog bites in the upper limbs have particular significance, because despite the small size of the puncture wounds, penetration is deep, causing serious injuries to deeper structures. There is currently very little data relating to upper extremity dog bite arterial injury. We present the case of a 32-year-old man who sustained a dog bite injury to his right arm, leading to direct puncture and spasm of the brachial artery. He was successfully treated with a jump bypass graft to the right brachial artery, with the use of the reversed ipsilateral cephalic vein as a conduit. We identified 34 cases in the literature reporting upper limb arterial injury secondary to dog bite. Twenty-two cases in the literature detailed axillobrachial artery damage (65%), 24% radial artery, 3% ulnar artery, and 9% combined. Presentation was most commonly with diminished pulses found in at least 45% of the patients. Arterial thrombosis occurred in 29% of cases of single artery injury, transection in 15%, intimal tear in 9% of cases, and undisclosed in 44%. Management most commonly included interposition graft (47%) and primary repair (20%), while 15% did not undergo surgical intervention, 9% underwent ligation, and 3% were treated with thromboembolectomy. Follow-up data for these patients are scarce, with some experiencing residual neurological deficit. This report highlights the importance of prompt recognition and treatment of vascular injury following dog bite to attain an optimal outcome and minimize complications.

Newborn with meroanencephaly: Surviving all odds.

Neural tube defects are a group of congenital anomalies of brain development that carry a significant risk of morbidity and mortality. Anencephaly is a serious form of this defect with a very poor prognosis. It can present in three forms - meroanencephaly, holoanencephaly, and craniorachischisis. Meroanencephaly is considered to be the classic form of anencephaly. It manifests as a lack of cranial vault bones and exposed dorsal neural tissue resulting from defective neural tube closure in the very early period of gestation. Antenatally, the diagnosis may be suggested by ultrasound examination and by elevated maternal alpha-fetoprotein level. Here, we describe a case of meroanencephaly who was discharged from the hospital in fair condition despite the life-threatening anomaly.

Analysis of dye degradation products and assessment of the dye purity in dye-sensitized solar cells.

RATIONALE: For commercialization of dye-sensitized solar cells (DSSCs), improvement of their long-term stability and efficiency is important. A key component in solar cells is the dye, its high purity and high stability. Here, methods for dye extraction and purification, and for determination of dye purity and dye degradation in DSSCs, were developed. METHODS: A method was developed for extraction of the dye Z907 from intact solar cells using a water/ethanol mixture containing tetrabutylammonium hydroxide. The N719 dye synthesized in our laboratory was purified by gel filtration on Sephadex LH20. These dyes, along with the dyes N3 and RuL2 (NC)2, were analyzed using nuclear magnetic resonance (NMR) spectroscopy and liquid chromatography coupled to an electrospray ionization quadrupole-time-of-flight mass analyzer (LC/MS) operating in negative ionization mode. RESULTS: Purification of the synthesized N719 removed several impurities, including its undesired isomer with the thiocyanate ligand attached to ruthenium through sulfur instead of nitrogen. The dyes N719 and Z907 were successfully extracted from solar cells and together with N3 and RuL2 (NC)2 analyzed by LC/MS, although N719 isomerized almost immediately in basic aqueous solution. The [M-H](-1) ions were observed and the measured mass was within a ±6 ppm range from the exact mass. CONCLUSIONS: LC/MS in combination with NMR spectroscopy was shown to provide useful information on dye structure, purity, and on the efficiency of the purification methods. These methods allow for further studies of solar cell dyes, which may provide the detailed information needed for the improvement and eventual commercialization of the solar cell technology.

Prevalence and pattern of congenital malformations among neonates in the neonatal unit of a teaching hospital.

OBJECTIVE: To determine the prevalence and pattern of congenital malformations among neonates in a teaching hospital. METHODS: The prospective hospital-based study was conducted over a period of 18 months in the neonatal unit of Combined Military Hospital, Kharian, from September 2011 to February 2013. All neonates from newborn to 28 days of age admitted to the unit irrespective of their condition comprised the study population. Neonatal examination was done by the Registrar at the time of admission followed by neonatologist/paediatrician. Information regarding gender, weight, gestational age, mode of delivery, consanguinity, maternal age, antenatal visit record and family history were recorded on a predesigned proforma. After clinical examination, if required, relevant investigations like ultrasonography, radiology, echocardiography, laboratory and genetic studies were done to confirm diagnosis. Data was statistically analysed by using SPSS 20. RESULTS: Out of 3,210 total admissions, 226 (7%) neonates were congenitally malformed. Of them, 130 (57.52%) were male and 96 (42.47%) females. Among different body systems affected, anomalies related to the central nervous system were 46 (20.35%) musculoskeletal 42 (18.58%), genitourinary 34 (15.04%), cardiovascular system 30 (13.27%), ear, eye, face, neck 27 (11.94%), digestive system 19 (8.40%), syndromes and skin 14 (6.19%) each. CONCLUSION: Congenital Malformations are not rare in our community and central nervous system is the most commonly affected system. Healthcare managers must stress upon primary prevention in the form of vaccination, nutrition and drugs to decrease preventable share of congenital malformations.

Coeliac disease--clinical presentation and diagnosis by anti tissue transglutaminase antibodies titre in children.

OBJECTIVE: To study the spectrum of clinical presentation of coeliac disease and the role of IgA anti-tissue transglutaminase antibodies titer in the diagnosis and effect of gluten-free diet on such titers in children. METHODS: The prospective study was conducted in the paediatric department of Combined Military Hospital, Kharian from Sep 2011 to Sep 2012. Children of 1-12 years of age presenting with chronic diarrhoea, malnutrition and failure to thrive were included regardless of gender, socioeconomic status, ethnicity and geographical distribution. Anti-tissue transglutaminase angibodies titers were done on enrolment. Patients with levels more than 30 u/ml were enrolled. They were advised strict gluten-free diet for six months. These titers were repeated after six months to document the effect of gluten-free diet on these titers. Paediatric endoscopy and duodenal biopsy facilities were not available at the study site, so the response was monitored through titers. Data was analysed using SPSS-20. RESULTS: Out of 61 patients with IgA levels more than 10 u/ml, 52 (85.24%) were found to have a positive (> 30u/ml) anti-tissue transglutaminase antibodies titers with a mean value of 42.67 +/- 7.60 U/ml. These 52 patients were then put on a trial of gluten-free diet for six months after which significant reduction in titer was noticed, with a mean value of 13.25 +/- 2.59 U/ml. This reduction in titer was associated with marked clinical improvement and regression of symptoms. Frequency of different clinical features in descending order revealed that chronic diarrhoea, abdominal distension, iron deficiency anaemia, failure to thrive, pallor and rickets were present in 38 (73.1%), 30 (57.7%), 29 (55.8%), 29 (53.8%), 28 (53.8%) patients respectively. CONCLUSION: Chronic diarrhoea, failure to thrive, pallor, abdominal distention and iron deficiency anaemia were common modes of presentation. The antibodies were strongly positive in most of the cases. All children showed significant improvement in clinical features and reduction in antibody titers after six-month trial of gluten free diet.

Incidence of congenital heart disease among neonates in a neonatal unit of a tertiary care hospital.

OBJECTIVES: To determine the incidence and pattern of various congenital heart disease in a neonatal unit of a tertiary care hospital. METHODS: The prospective study was carried out in the neonatal unit of Combined Military Hospital, Rawalpindi, from September 2008 to August 2011. All 5800 neonates admitted with gestational age of > 28 weeks irrespective of birthweight were included in the study. Neonatologist/Paediatrician carried out the neonatal examination during the first 12 hours of life. Neonates suspected of having congenital heart disease were further evaluated by pulse oxymetry, X-ray chest and echocardiography to ascertain final diagnosis and type of lesion. Data was collected on a predesigned proforma containing information regarding gender, mode of delivery, gestational age, weight at birth, family history, and associated malformations. SPSS 16 was used for statistical analysis. RESULTS: Of the 5800 neonates, 87 (1.5%) were found to have congenital heart disease with an incidence of 15/1000. There was a male preponderance. Most common lesion was ventricular septal defect 27 (31.3%), followed by atrial septal defect 20 (22.9%), patent ductus arteriosus 13 (14.94%), tetralogy of fallot 06 (6.89%), transposition of great arteries 04 (4.59%), Pulmonary stenosis 05 (5.79%) and 03 (3.44%) had atrioventricular canal defects. CONCLUSION: Congenital heart disease is a common congenital anomaly. Its incidence varies from centre to centre due to different factors like nature of the sample, method of detection and early examination by a neonatologist/paediatrician. In this study a higher incidence is reported because it was carried out in a tertiary care unit, which is a referral hospital and all the neonates admitted in the unit were included in the study.

Effect of electrolyte bleaching on the stability and performance of dye solar cells.

Degradation of dye solar cells (DSCs) under severe ageing conditions may lead to loss of the tri-iodide in the electrolyte - a phenomenon known as electrolyte bleaching. Monitoring changes in the tri-iodide concentration as a result of degradation mechanisms and understanding their causes and effects are fundamental for improving the long-term stability of DSCs. In this contribution a strongly accelerated ageing test (1 Sun visible light, 1.5 Suns UV light, T = 110 °C for 12 h) was performed on DSCs in a double-sealed masterplate configuration to purposely induce severe electrolyte bleaching, and its effects on the performance and stability of DSCs with different initial tri-iodide concentrations [I3(-)]0 were investigated. The cells with low [I3(-)]0 suffered a severe loss in short circuit current density JSC (up to 85%). Also a significant loss of open circuit voltage VOC was observed and this loss was proportional to [I3(-)]0 with the highest VOC drop observed with the highest [I3(-)]0. Non-destructive analysis techniques based on the limited current density, JSCvs. light intensity, and photographic image analysis, were used to quantify the [I3(-)] loss, which was found to be ca. 50 mM and independent of [I3(-)]0. Quantitative model based VOC analysis in terms of changing [I3(-)] revealed that the degradation responsible for the VOC drop was dominated by an unknown mechanism that is unrelated to [I3(-)]0. The methods and results reported here help separating and identifying different degradation mechanisms related to electrolyte bleaching in DSCs.

Antibiotic prophylaxis in clean general surgery.

OBJECTIVE: To find out the incidence of surgical site infection in clean general surgery cases operated without prophylactic antibiotics. DESIGN: A comparative study. PLACE AND DURATION OF STUDY: The study was carried out in Combined Military Hospital, Pano Aqil Cantonment, from July 2003 to December 2004. PATIENTS AND METHODS: One hundred and twenty-four clean surgical cases operated without antibiotic prophylaxis between July 2003 and December 2004, were studied and these were compared with similar number of cases who received antibiotics. The data was collected and analyzed using software SPSS (version 10.0). Chi-square and student "t" test were used to analyze the association between antibiotics and wound infection. RESULTS: The most frequent operation was repair of various hernias, 69.3% in group A and 75% in group B. More operations were carried out between 21-30 years, 38.7% in group A and 41.9% in group B. Surgical site infection occurred in one patient (0.8 %) in each group. Chi- square test (0.636) applied to group A and B showed no association of infection and administration/ no administration of antibiotics (p > 0.25). The "t" test applied on group A and B (t=0) also showed no significant difference between administration of antibiotics/ no antibiotics and infection (p > 0.25). CONCLUSION: The use of prophylactic antibiotic in clean, non implant and elective cases is unnecessary.