Recovery of severe motor deficit secondary to herniated lumbar disc prolapse: is surgical intervention important? A systematic review.

INTRODUCTION: The natural history of motor deficit due to lumbar disc herniation has been thought to be favourable. However, on closer analysis of seminal articles on this topic, this is not the case for patients with severe motor deficits (MRC grade ≤3). The aim of this study is to answer the following questions: (1) Is surgical intervention beneficial in patients with severe motor weakness (defined by MRC grade of 3 or less) due to herniated lumbar nucleus pulposus? (2) Does time to surgery from onset of motor weakness influence the outcome? (3) Are there any other prognostic factors? MATERIALS AND METHODS: A comprehensive search was conducted in MEDLINE and EMBASE from 1970 upto July 2013. Inclusion criteria for studies are: (1) minimum of three patients aged 18 and older, who had symptomatic herniated lumbar disc prolapse and underwent surgery, (2) description of pre and post-operative muscle weakness utilising the Medical Research Council (MRC) muscle power grade or equivalent, such that both reviewers could confidently identify a cohort of patients with at least grade three motor weakness or worse, (3) a minimum of 6 months follow-up. RESULTS: Seven studies were identified with a total of 354 patients. Complete recovery was seen in 38.4% of patients following surgery and 32% following non-operative treatment. Age and grade of motor deficit were identified as significant prognostic factors in some of the studies. CONCLUSION: The current available evidence is not robust enough to address the questions posed. We have proposed a framework for future studies.

Intra-operative neurophysiological prediction of upper trunk recovery in obstetric brachial plexus palsy with neuroma in continuity.

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively. In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively. Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

The impact of routine histopathological examination on cholecystectomy specimens from an Asian demographic.

INTRODUCTION: Most gallbladder carcinoma cases are suspected pre-operatively or intra-operatively. In Malaysia histopathological examination of cholecystectomy specimens has become routine practice. The aim of this study was to assess the impact of routine histological examinations on cholecystectomy specimens from an Asian demographic, which may differ from a Caucasian demographic. METHODS: A retrospective study was performed of all histopathology reports for cholecystectomies (laparoscopic and open) undertaken over a period of 12 years (1997-2008) in a single teaching hospital. RESULTS: A total of 1,375 gallbladder specimens were sent for histopathological analysis, with 7 (0.5%) being reported as malignant while only three (0.2%) were found to contain primary gallbladder carcinoma. Other premalignant findings included two specimens with dysplastic changes of the mucosa and one tubulovillous adenoma with a dysplastic epithelium. From the ten malignant and premalignant specimens, seven were diagnosed pre-operatively, two were suspected intra-operatively and one was diagnosed with dysplastic changes on the histopathology report post-operatively. CONCLUSIONS: This study supports earlier research carried out in the UK and the demographic difference does not affect the impact of the histology examination on cholecystectomy specimens in diagnosing this disease. A selective policy is recommended in Malaysia.

Subacute physeal abscess: case report to illustrate treatment with a minimally invasive incision and drainage technique.

INTRODUCTION: Brodie's abscess is a form of subacute osteomyelitis characterised by a low grade pyogenic abscess found most commonly in the metaphysis. One rare form found in children crosses the physeal growth plate and into the epiphysis. Due to the rarity of this subtype and apprehension associated with treatment of the transphyseal abscess, no clear guidance exists on its management. CASE HISTORY: We present a case of delayed diagnosis of Brodie's abscess crossing the physis in a 14-year-old boy. He gave a one-year history of pain in the right knee and early x-rays had shown lucent areas in the tibia. However, these were only noted to be significant at presentation one year later. We also describe an improvised minimally invasive and atraumatic technique of modifying a laminar suction catheter for accessing and draining the abscess. CONCLUSIONS: From our experience and reports in the literature it is clear that antibiotic treatment is generally advocated with varying degrees of surgical intervention. Outcomes are largely favourable. Nevertheless, initial drainage allows samples to be sent for microbiological and histological assessment to aid subsequent management and may prevent subsequent leg length discrepancy from failed conservative treatment. We believe that management of a transphyseal abscess must include early drainage and a prolonged course of antibiotics. The antibiotic choice and duration will be governed by culture results and local policy but is commonly given for up to six weeks in the literature and must include one antistaphylococcal drug.

Glenoplasty for complex shoulder subluxation and dislocation in children with obstetric brachial plexus palsy.

We describe the early results of glenoplasty as part of the technique of operative reduction of posterior dislocation of the shoulder in 29 children with obstetric brachial plexus palsy. The mean age at operation was five years (1 to 18) and they were followed up for a mean of 34 months (12 to 67). The mean Mallet score increased from 8 (5 to 13) to 12 (8 to 15) at final follow-up (p < 0.001). The mean passive forward flexion was increased by 18° (p = 0.017) and the mean passive abduction by 24° (p = 0.001). The mean passive lateral rotation also increased by 54° (p < 0.001), but passive medial rotation was reduced by a mean of only 7°. One patient required two further operations. Glenohumeral stability was achieved in all cases.

Vitamin D deficiency in patients with osteoarthritis undergoing total hip replacement: a cause for concern?

We measured the plasma 25-hydroxyvitamin D(3) (25(OH)D(3)) levels in 62 consecutive Caucasian patients undergoing total hip replacement for osteoarthritis. The patients were divided into two groups based on whether they were vitamin D sufficient or deficient. The groups were matched for age, gender and the American Society of Anaesthesiologists (ASA) grade. The prevalence of vitamin D deficiency in our patients was comparable with recent population-based studies performed in the United Kingdom. Patients with vitamin D deficiency had lower pre-operative Harris hip scores (Mann-Whitney test, p = 0.018) and were significantly less likely to attain an excellent outcome from total hip replacement (chi-squared test, p = 0.038). Vitamin D levels were found to positively correlate with both pre- and post-operative Harris hip scores. These results warrant further study of vitamin D deficiency in patients undergoing joint replacement as it is a risk factor for a suboptimal outcome which is relatively simple and cheap to correct.

A rare case of giant cutaneous horn.

Cutaneous horn, a clinical manifestation of hyper-proliferation of compact keratin, can represent a wide array of underlying benign and malignant pathologies. Here we report a unique case of a giant cutaneous horn (7x4x3 cm) that developed on a chronic ulcer in a non sun-exposed area. This case presented challenges in terms of diagnosis and treatment. We also review the literature about this rare condition.

An anatomic study of flexor tendon sheaths: a cadaveric study.

Previous descriptions of the pattern of communication between the digital flexor tendon sheaths have been largely based on imaging studies. An anatomic study on 12 cadaveric hands was conducted using water soluble dye and directly observed patterns of communication between the digital flexor tendon sheaths and the radial and ulnar bursae. Four out of twelve specimens (33%) demonstrated a communication between the radial and ulnar bursae. The ulnar bursa communicated with the ring finger flexor sheath in two specimens, and the index finger flexor sheath in two specimens. One hand (8.3%) showed communication between the middle finger tendon sheath and radial bursa and between the index finger flexor tendon sheath and radial bursa. These findings show a considerable level of variation in communicating patterns between the synovial sheaths of the hand and wrist. Clinicians should be aware of the possibility of variations to the classical presentation of spread of infection through the digital flexor sheaths.

Symptoms experienced during 24-h pH monitoring and their relationship to outcome after laparoscopic total fundoplication.

Some patients having a 24-h pH monitoring test prior to laparoscopic fundoplication experience no symptoms at all in spite of having a positive test, and other patients experience only atypical symptoms in spite of having a positive test. This study investigates the postoperative outcome of such patients. All patients underwent esophageal manometry and 24-h esophageal pH monitoring before laparoscopic total fundoplication. Patients were divided into three groups based on their symptom profile recorded during a positive 24-h pH monitoring: those with typical symptoms (n = 104), those with atypical symptoms (n = 28) and those who experienced no symptoms at all (n = 23). The outcomes measured were heartburn score (0-10), dysphagia composite score (0-45) and satisfaction score (0-10) at 12 months after surgery. Outcome analysis reveals the heartburn scores were significantly reduced postoperatively for all groups of patients. At 1 year after surgery, there was no difference among the three groups of patients in terms of heartburn score and dysphagia composite scores, nor the experience of bloating, belching, or their willingness to repeat surgery. Despite one group experiencing no symptoms, and another group atypical symptoms during a positive pH study, the postoperative satisfaction scores for these two groups was good, but significantly less (P = 0.03, P = 0.02, respectively) than the group of patients with a typical symptom index. In conclusion, patients who experience only atypical symptoms or no symptoms at all during their preoperative positive 24-h pH monitoring may still obtain a good result from antireflux surgery. However, these symptom profiles should alert the surgeon that such patients may have an outcome which is not as good as patients who experience only typical symptoms during a pH study.

Vestibular schwannomas with fluid-fluid level.

Vestibular schwannomas containing cystic parts are common, but it is extremely rare for a vestibular schwannoma to contain fluid-fluid levels. In this report, we present two cases of vestibular schwannoma with magnetic resonance imaging findings of a fluid-fluid level, and we discuss the radiological features and possible mechanism of fluid-fluid level formation.

Vascular endothelial growth factor and soluble Tie-2 receptor in colorectal cancer: associations with disease recurrence.

AIMS: A delicate balance exists between pro-angiogenic factors and anti-angiogenic factors to regulate the process of angiogenesis. To investigate the relationship of VEGF-A with other angiogenic factors and to determine their clinical usefulness. METHODS: Venous blood was obtained from 47 patients with CRC prior to curative resections. VEGF-A, sVEGFR-1, sTie-2 receptor, and TNF-alpha levels in serum were measured concurrently with quantitative ELISA. The median follow-up term for patients without cancer death was 29 months (range 20-35). RESULTS: Both serum TNF-alpha activity and sVEGFR-1 was detectable in 17% and 74% of CRC patients, respectively. Univariate analysis demonstrated that the disease free survival was significantly associated with the tumour location (P=0.031), T category (P=0.006), TNF-alpha activity (P=0.0008), sTie-2 receptor (P=0.012) and VEGF-A (P<0.00001). From the survival analysis, a higher serum VEGF-A and sTie-2 receptor level is associated with an earlier development of metastases. Using multivariate Cox's regression analysis, the only independent predictors of outcome were sTie-2 receptor (P=0.038) and VEGF-A (P=0.006). CONCLUSIONS: sTie-2 receptor and VEGF-A appear to associate independently with the development of metastases, with VEGF-A being the most powerful predictor of outcome. These data also suggest that measurement of pre-operative sTie-2 receptor and VEGF-A is superior to determining VEGF-A alone with regards to predictive value.

Pseudoaneurysms of the femoral artery: recommendation for a method of repair.

PURPOSE: Formation of an anastomotic aneurysm in the femoral artery is one of the major complications after femoral artery surgery. The aim of this study was to assess the method of repair of femoral anastomotic aneurysms and their outcome in a District General Hospital. METHODS: A retrospective consecutive cohort of anastomotic femoral aneurysms, operated between 1977 and 1998, were studied. RESULTS: Twelve patients with a total of 19 pseudoaneurysms were treated. Five of the aneurysms were repaired using a vein patch and two had re-suturing of the anastomosis. Twelve aneurysms were repaired with complete revision of the anastomoses using interposition grafts. There were no recurrences in the interposition graft group whilst two recurred in the seven aneurysms repaired using re-suturing/vein patch. CONCLUSION: Interposition grafting would appear to be the method of choice for repair of femoral pseudoaneurysms as the outcome was better than that with re-suturing or using a patch closure technique.

Pre-operative serum vascular endothelial growth factor can select patients for adjuvant treatment after curative resection in colorectal cancer.

We aim to determine the clinical usefulness of pre-operative serum vascular endothelial growth factor (VEGF) as a predictor of outcome in patients undergoing curative resection for colorectal cancer. Serum VEGF was assayed by quantitative ELISA in 81 patients prior to curative resection for node-negative (n = 53) and node-positive (n = 28) disease. Median follow-up for patients without cancer death was 27 months (range 21-37). Pre-operative serum VEGF was significantly higher in patients who went on to develop metastases than those who did not (median, 713 pg ml-1 vs. 314 pg ml-1, P < 0.0001). Using multivariate Cox regression analysis, pre-operative serum VEGF was the most important prognostic factor independent of nodal status and adjuvant chemotherapy, and was superior to nodal status in predicting outcome (P < 0.00001). At 575 pg ml-1, pre-operative serum VEGF was 64% sensitive and 89% specific in predicting the development of metastases in curative resections, with a positive predictive value of 73% and a negative predictive value of 85%. Pre-operative serum VEGF is a powerful predictor of outcome following curative surgery for colorectal cancer. These data support the measurement of pre-operative serum VEGF as a method for selecting patients who require adjuvant therapy.

Interferon treatment for multiple sclerosis patients in Hong Kong.

We report on nine patients with multiple sclerosis who had received interferon beta-1a treatment for 6 months or more. Seven patients were Chinese and two were Caucasian. Seven patients had the relapsing-remitting type of multiple sclerosis, one had the primary-progressive type, and one had the progressive-relapsing type. Among the six compliant patients with the relapsing-remitting type of disease, four had less frequent relapses after treatment. This study could not show whether or not the use of interferon beta-1a was beneficial to non-compliant patients, or patients with other types of multiple sclerosis.

Transmission dynamics and estimates of malaria vectorial capacity for Anopheles balabacensis and An. flavirostris (Diptera: Culicidae) on Banggi island, Sabah, Malaysia.

Holoendemic malaria transmission in two small isolated forest communities and a coastal village was studied by (1) all night human bait collections of Anopheles species from inside and outside houses and (2) buffalo-biting and CDC light-trapping catches during March and November 1984. During the same period thick and thin blood films were collected from the human population, and spleen rates were determined in children from two to nine years of age. Using both the immunoradiometric assay (IRMA) and the dissection technique, more sporozoite-positive infections were detected in An. balabacensis and An. flavirostris in November than in March. IRMA confirmed the presence of Plasmodium falciparum sporozoites. An average of 76.2% of the An. balabacensis population lived long enough to have reached a point where infectivity with P. falciparum was possible in November. Although fewer than five adult females bit humans per night at any time, a resident could theoretically have received more than 160 infective bites in one year. A high frequency of feeding on humans, coupled with increased anopheline life expectancy, contributed to high estimates of falciparum malaria vectorial capacity (number of infections distributed per case per day); for An. balabacensis (1.44-7.44 in March and 9.97-19.7 in November) and for An. flavirostris (0.19-5.14 in March and 6.27-15.8 in November). These high values may explain the increased malaria parasite rates obtained from at least two forest communities. Correlation between actual and calculated rates of gametocytaemia was poorest in Kapitangan due to inadequate sampling of the human population. In Banggi island, malaria is stable and holoendemic, and the population enjoys a high degree of immunity.

The influence of permethrin-impregnated bednets and mass drug administration on the incidence of Plasmodium falciparum malaria in children in Sabah, Malaysia.

A small-scale trial was carried out in the Upper Kinabatangan district of Sabah, Malaysia, to determine the effect of using permethrin-impregnated bednets on malaria transmission. A total of 306 nylon bednets with cotton borders, impregnated at a dose estimated to have been 0.062 g permethrin/m2 of nylon netting, were distributed to 139 households in five villages. At the time of distributing bednets, mass drug administration with Fansidar plus primaquine was also administered to the human population to clear all parasitaemias due to Plasmodium falciparum Welch. In another village, for comparison, mass drug administration was the only intervention. After intervention measures in December 1984 and January 1985, the parasite rates in children declined in all villages during the first month, significantly more in the villages with impregnated bednets than in the control, thus proving that the nets had an impact on malaria. However, after about 2 months, parasite rates started to increase again. After 4-6 months, parasite rates in the villages with bednets approached the rate in the control village without nets. The increase in parasite rates was paralleled by a significant deterioration in the quality, physical condition and the degree of non-utilization of bednets. Entomological evaluation proved the efficacy of permethrin-impregnated nets for controlling Anopheles balabacensis Baisas and other anophelines. Bioassays (1 h exposure) of permethrin-impregnated bednets gave 100% mortality initially and 44-61% mortality after 85-106 days. Mosquito collections in treated bednets were significantly reduced for at least 217 days. The project failed to achieve prolonged suppression of malaria transmission for a combination of entomological, sociological and practical reasons which are discussed in relation to the objectives and implementation of future bednet studies.

Triple-in double-out optical parallel logic processing system.

A triple-in double-out optical logic operating system based on shadow-casting processing is described. All the 256 logic operations of three inputs can be performed, and the optical adder can be easily implemented. A real-time encoding method for the input patterns is also presented.

Spontaneous spinal epidural haematoma.

Two Chinese patients with spontaneous spinal epidural haematoma are presented. The clinical picture and the possible site of bleeding are discussed.

Anopheles flavirostris incriminated as a vector of malaria and Bancroftian filariasis in Banggi Island, Sabah, Malaysia.

Seven villages in Banggi Island, Sabah, Malaysia, were surveyed four times to evaluate the roles of local mosquitoes as vectors of malaria and Bancroftian filariasis. 11 species of Anopheles were found biting man. 53.9% of the anophelines caught were An. flavirostris, 27.1% An. balabacensis, 6% An. donaldi and 4.2% An. subpictus. Infective malaria sporozoites, probably of human origin, were found in two of 336 An. flavirostris and 12 of 308 An. balabacensis. Sporozoites, probably of a non-human Plasmodium, were found in An. umbrosus. Nine of 1001 An. flavirostris and four of 365 An. balabacensis harboured L2 or L3 filarial larvae identified as those of Wuchereria bancrofti. This is the first record of An. flavirostris as a natural vector of malaria and W. bancrofti in Sabah.