Flexor Hallucis Longus Transfer And V-Y Plasty: An Effective Treatment Modality for Chronic Achilles Rupture - A Case Series

@#Introduction: To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy. Materials and methods: A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y plasty for Achilles tendon rupture. Patients were allowed full weight bearing at six weeks post-operatively, and were followed up at three months and six months post-operatively, when the range of motion of the ankle was examined, and the outcome was assessed using the EFAS score. Results: Of the 12 patients in the study, the majority were males; the mean age was 50.6±8.96 years. A significant improvement in dorsiflexion and plantarflexion was noted at the six-month follow-up compared to the three-month follow-up (P=<0.001 for both). When compared to the normal side, dorsiflexion and plantarflexion of the affected ankle were significantly less at three months but were comparable at six months post-operatively. A significant improvement was noted in the mean EFAS score at the sixmonth follow-up (25.5±5.71) compared to three months (18.6±0.90) post-surgery (P=0.001). Males were also noted to have significantly higher EFAS scores at their six-month follow-up than females (P=0.022). In contrast, a negative correlation was noted between the European Foot and Ankle Society (EFAS) score at the final follow-up and age (P=0.011). Conclusion: FHL tendon transfer with V-Y plasty in chronic Achilles rupture due to insertional Achilles tendinopathy is an effective procedure resulting in the restoration of the ankle range of motion and improvement in functional scores.

Demographic, Clinical, Laboratory and Management Profile in Patients of Amoebic Liver Abscess from Northern India

Background: Amoebic liver abscess (ALA) is a serious extra-intestinal manifestation of amoebiasis and a major problem in developing countries. Due to rapid urbanization, improved sanitation and hygiene in India, there has been a shift in disease epidemiology towards non-communicable disease, but recent changes in epidemiological and clinical pattern in ALA are not well studied. Aim: To evaluate recent demographic, clinical, laboratory and management profile in patient with ALA. Methods: It is a prospective observational study conducted in the Department of Gastroenterology, SMS medical college, Jaipur, Rajasthan from June 2018 to December 2020. A predesigned semi structured questionnaire consisting of socio-demographic factors, risk factors, clinical, laboratory and management profile was used to collect data. Result: A total 508 patients of amoebic liver abscess were analysed. Median age of presentation was 40 years, majority were males (90.4%) with chronic alcoholism (44.1%) and belonging to lower socio-economic class. Abdominal pain, fever and anorexia were the most common symptoms. A majority had right lobe involvement (77.6%) and solitary abscess in 67.5%. Most of the small liver abscesses (68%) were managed by medical treatment alone. Percutaneous needle aspiration was done in 62.6% patients, mostly for abscess size 5-10 cm (93%) with 90% success. A total of 24.6% patients underwent percutaneous catheter drainage, all successfully done. Intraperitoneal rupture was seen in 10% patient. Mortality was 1.5%. Conclusion: This is one of the largest cohorts of ALA which shows that a majority of cases are males from lower socioeconomic status with history of significant alcohol intake. Early initiation of a combined therapeutic approach leads to early symptomatic improvement, fewer complications and better outcomes.

The validity of the self-directed learning readiness instrument with the academic achievement among the Saudi medical students

Background: Self-directed learning (SDL) is very crucial for continuous professional development for all health-care professionals. Objectives: This study aims to measure the SDL readiness of the first clinical year medical students and its relation with their academic achievement. In addition, to examine the reliability and validity of SDL rating scales. Materials and Methods: This is a quantitative cross-sectional study involving the 3rd year medical students at a Saudi medical school. The level of SDL readiness was measured by a validated Fisher’s scale which includes three subscales: Self-control (SC), self-management (SM), and desire for learning (DL), and student’s academic achievement by their grade point average (GPA). The data were collected through a self-administered questionnaire and were analyzed using the Statistical Package for the Social Sciences. Results: High SDL scores were found to have a positive relationship with students’ academic achievement. The overall mean score of Fisher’s scale was 156.73 ± 15.85. The mean score of SC was 61.2 ± 6.4 followed by the DL 48.4 ± 5.6 and SM skills 47.1 ± 6.6. Factor analysis revealed that all three-factor models and individual subscales have an average to poor fit. Conclusion: The study results showed that the high SDL readiness score is directly proportional to students’ academic achievement. The students were highly self-directed learners, but the study could not confirm that the current SDL model had a strong level of reliability and validity when tested with undergraduate level medical student’s achievement by the GPA. Although the study confirmed that our students are self-directed learners, their time management skills need to be improved.

Stress in medical undergraduates; its association with academic performance.

Objectives: To explore the difference in level of perceived stress among medical undergraduates of various classes and its association with their academic performance. Methodology: This observational study was conducted by the faculty members at University Medical & Dental College Faisalabad, Pakistan during six months period from October 2012 to March 2013. All the regular medical undergraduate students of five academic years MBBS from 2007 to 2012 were included in the study. The stress level of the students was determined by PSS 14 and the factors leading to stress were evaluated by a predesigned questionnaire. Data was analyzed using SPSS version 19. ANOVA and chi-square tests were used to compare the level of stress among various classes and its causative factors. Results: Mean PSS was highest for final year students. Third year MBBS had significant difference in stress level both with first year (p=0.042) and final year MBBS (p=0.004). High achievers were less stressed as compared to low achievers (p=0.006). Consecutive boring lectures, lack of time for recreation, gap between students and teacher followed by difficulty selecting the reading material turned out to be the major stressors. Conclusion: Students of all the five academic years experience stress and the final year MBBS is the most stressed one. On the other hand low academic achievement group is more stressed as compared to high academic achievers from all the five classes. Student support programs to combat stress may be planned to improve their quality of life and their academic scores as well.

Lipid profile and glycosylated hemoglobin status of gestational diabetic patients and healthy pregnant women.

Aim: Lipid profile and glycosylated hemoglobin level changes in gestational diabetes. The extent to which this alteration takes place is still not clearly documented. Materials and Methods: To add a clear answer to this question, lipid profile parameters, and glycosylated hemoglobin status were determined in patients with gestational diabetes mellitus and compared to healthy pregnant women (controls). Results: Fasting plasma glucose levels, plasma glucose levels 1 hour, and plasma glucose levels 2 hours after 75 gm oral glucose administration (oral glucose tolerance test) were significantly higher in patients with gestational diabetes as compared to controls. Glycosylated hemoglobin was significantly higher in gestational diabetes than in controls. It was observed that there was a significant increase in serum cholesterol and serum triglyceride level in cases with gestational diabetes when compared to healthy pregnant women. Conclusion: The results of our study suggest that abnormal glucose levels, glycosylated hemoglobin, serum cholesterol, and serum triglycerides play an important role in pathophysiology of gestational diabetes, and therefore, extensive studies are required. Early diagnosis of gestational diabetes will decrease adverse neonatal and maternal outcomes.

Central neuropsychiatric complications of hepatitis C virus infection in Egyptian patients

Central neuropsychiatric hepatitis C virus [HCV]-associated disorders have been described with increasing frequency in the literature. Anticardiolipin antibodies [aCL] associated with HCV may be an important marker for the central neurological complications. furthermore, cryoglobulinemia could be an important genic factor for such complications. To study various central neuro-psychiatric complications of chronic hepatitis C infection and their possible pathogenetic mechanisms. This study was conducted upon 160 Egyptian patients with chronic hepatitis C infection. They were subdivided into 2 subgroups: Group I which included 80 chronic hepatitis C patients with clinically apparent neuropsychiatric complication [s] and group II which included 80 chronic hepatitis C patients neuropsychiatric asymptomatic. The control group included 30 healthy volunteers as a control group for the neuropsychological evaluation. Patients were subjected to clinical neuropsychological evaluation, estimation of hepatitis markers, cryoglobulins, anticardiolipin antibodies, antinuclear antibodies, EEG, MRI brain. In neuropsychiatric manifested HCV patients, the most commonly encountered disorders were memory impairment and mood disorders each affected 11.7% of patients red by fatigue which affected 10% of patients then cerebrovascular complications and tension-type headache each.affected 8.3% of patients and in less frequency, late onset idiopathic intracranial hypertension and CNS infections There was highly statistical significant difference between both groups regarding the presence of cryoglobulin, anticardiolipin antibody, antinuclear antibody, EEG changes and MRL lesions being more common in group I. Cognitive impairment, mood disorders, fatigue, cerebrovascular complications are common with HCV infection especially when associated with+ve cryoglobulins, ACL and antinuclear antibodies

Fibula Osteocutaneous Flap for Mandible Reconstructionafter Ameloblastoma Resection: Amending Technique toReduce Ischaemic Time

A 27 year old patient with ameloblastoma of the mandible underwent anterior mandibulectomy and reconstruction with left fibula osteocutaneous flap. The bone was shaped at the lower limb before cutting the pedicle. Vascularised free fibula flap provides a good alternative to other bone grafts in mandible reconstruction as it is relatively easy to perform, carries a low complication rate, and mandibular shaping with intact pedicle cuts down on ischaemic as well as total operative time.

Evaluation of the effect of aging on intracellular free potassium, magnesium and calcium: relation to hypertension and diabetes

Elevated cytosolic free calcium [Cai], potassium [Ki], magnesium [Mgi] and reciprocally disturbed, extracellular ionized calcium, potassium and magnesium levels are observed in both hypertension and non-insulin-dependent diabetes mellitus [NIDDM]. Because the changes of vascular function and insulin sensitivity in these conditions resemble the changes associated with [normal] ageing, we wondered to what extent similar alterations in calcium, potassium and magnesium metabolism occur with aging per se in the absence of hypertension or diabetes. We therefore measured platelet Cai, Ki and Mgi levels by spectrofluorometry and serum Ca, K, Mg-ion levels in normotensive, nondiabetic, healthy, elderly subjects, mean age 68.5 +/- 3.5 years old [n=11]; in healthy, normal, young adults, 43.2 +/- 3.4 years old [n=13]; in 11 young adult hypertensives, 41.3 +/- 3.7 years old; and in 9 normotensive NIDDM subjects, 43,8 +/- 2.1 years old. Platelet Cai levels were higher [125.9 +/- 8.1 versus 98.9 +/- 1.4nmol/L] and Ca-ion levels lower [8.9 +/- 0.2 versus 10.3 +/- 0.28mg/dl] in normal elderly compared with young control subjects. Furthermore, platelet Ki and Mgi levels were lower [131 +/- 2.4 versus 146 +/- 3.8mmol/l; 218.4 +/- 9.4micro mol/l versus 326.3 +/- 9.8 micro mol/l] in normal elderly compared with young control subjects. K-ion and Mg-ion levels were also lower [4.4 +/- 0.18 versus 5.4 +/- 0.15mmol/l; 1.86 +/- 0.08 versus 1.92 +/- 0.3mg/dl] in normal elderly compared with young control subjects. These ionic changes mimic those occurring in young hypertensive and young diabetic subjects. We conclude that ageing is associated with alterations of Cai, Ki, Mgi and Ca-ion, K-ion, Mg-ion levels resembling those changes present at any age in hypertension and diabetes. We hypothesize that these alterations of ionic concentrations underlie the predisposition to the alterations of blood pressure and insulin sensitivity characteristic of [normal] ageing

Intercostobrachial nerve preservation during axillary clearance for cancer breast is: it a must?

Axillary clearance has been an integral part of breast cancer surgery. However, it can present sequela and complications including: limitation of shoulder movement, paresthesia and chronic pain in the arm and axilla, which are related to the nerve injuries. This study aimed at evaluating the feasibility of preservation of Intercostobrachial nerve [ICBN] during complete axillary dissection and to compare the impact of preservation or sacrifiction on postoperative axillary and inner aspect of the arm symptoms and sensation. The study was carried out on 58 consecutive patients with operable carcinoma of the breast, admitted to Alexandria Surgical Oncology Unit during 2003. Preservation of ICBN during complete axillary dissection was attempted in all patients. Accordingly they are divided into: thirty patients in whome the ICBN was preserved [Group A] and 28 patients, in whome the ICBN was sacrificed [Group B]. Clinical examination of the patients revealed that 34 cases were N[0] [58.6%]: 18 in group A and 16 cases in group B. During surgery, the nerve was found to be easily preserved in slim patients and when the axillary lymph nodes were not heavily involved. After 3 and 6 months; improvement of sensory symptoms was found both subjectively and objectively in group A. This was significantly noticed after 3 months postoperative. On the other hand persistence of anesthesia and hyposthesia was manifested in group B patients. Although patients who had preservation of ICBN were symptomatic in the immediate postoperative period, yet resumption of normal axillary and inner arm sensation was attained with longer follow up. It is recommended to preserve the ICBN wherever feasible as it has a positive impact on maintaining the axillary and inner arm sensation with a subsequent improvement in the quality of life in these patients

Clinical characteristics and autonomic dysfunction in hypotension

This study aimed to describe hypotension, its associated symptoms, important laboratory findings, cardiovascular autonomic functions and echocardiographic findings. This descriptive cross sectional study was done to survey hypotension in 1128 patients. Only 5.2% [59/1128] of patients were hypotensives, i.e. BP=100/60 mmHg. Hypotensives [n=50] are compared to age [mean 28.5 years] and sex [male/female ratio 0.85] matched normotensives [n=50]. From the results obtained, it was concluded that hypotension may be considered as a disease entity. It may present with different symptoms and signs including abnormal cardiovascular autonomic functions which should be performed in routine examination

Prevalence of human T-lymphotropic virus type I and type II antibody among blood donors in Eastern Saudi Arabia

Human T-cell leukemia/lymphoma virus type I and type II [HTLV-I/II] infections can be transfusion associated, leading to tropical paraparesis, myelopathy and other neurological disorders. The aim of this study is to circumvent the risk of transmission through blood transfusion and to describe the prevalence of HTLV-I/II antibody among blood donors of Al-Hasa region and the cost effectiveness of screening blood donors. The study was conducted at the Department of Laboratory and Blood Bank, King Fahad Hospital, Al-Hofuf, Al-Hasa, Kingdom of Saudi Arabia during the period of 1997 to 2003. A total of 47426 blood donors were screened for HTLV-I/II antibody by enzyme-linked immunosorbent assay test, during the 7 years of study period. The positive samples were confirmed by western blot analysis. Overall, HTLV-I antibody positivity [confirmed by western blot] was 3/47426 [0.006%]. Out of 3 donors positive for HTLV-I antibody during 1997 to 1998, 2 were expatriates [Indian] and one was native Saudi donor. Human T-cell leukemia/lymphoma virus type I antibody positivity among the native Saudi donors was 1/47426 [0.002%] [2/100000 blood donors]. None of the donor were positive for HTLV-II antibody. During the last 5 consecutive years of the study period [1999-2003], none of the donor was positive for HTLV-I/II antibody. Al-Hasa region is non-endemic for HTLV-I/II virus infections. Screening of native Saudi blood donors for these viruses does not appear to be cost effective

Relapsing polychondritis in an elderly male.

A 65 years patient presented with left ear swelling, swelling of the nasal bridge with congestion of the eyes. Clinically there was evidence of left auricular chondritis, nasal chondritis and conjunctivitis with a history of multiple similar episodes in the past, features suggestive of relapsing polychondritis. The patient improved with oral prednisolone.

technique to improve results in colon replacement of the oesophagus

This study aimed to present a simple method to improve the results of colon replacement of the oesophagus in children with post-corrosive oesophageal stricture or long gap oesophageal atresia. At the operation to establish a gastrostomy, the abdomen and colon are explored and the segment of colon to be used for replacement is chosen. The trunk of the middle colic artery supplying the transverse colon is ligated and divided proximal to the marginal artery or if another segment of the colon is chosen, the corresponding vessel is ligated. Between November 1999 and October 2002, 11 children [6 boys and 5 girls] had the middle colic vessels ligated during the gastrostomy operation. Five neonates had long gap oesophageal atresia with or without fistula. The other 6 had long segment oesophageal stricturedue to swallowing caustic potash. Their ages ranged from one day to 40 months. The hospital stay ranged from 10 to 14 days. The interval between vascular ligation and the replacement was one to 3 months depending on the general condition of the patient. The follow up period is 9 to 44 months. The results revealed that after the definitive operation of colon replacement of the oesophagus, the children resumed feeding through the gastrostomy on day 5. They were fed by mouth from day 8 and all were home by day 15. There was no wound infection, no fistula, or chest complications. One patient developed stricture at the colo-oesophageal anastomosis two months after surgery. The oesophageal anastomosis was excised six months after the colon interposition surgery and reanastomosis performed through the same neck incision and the patient was sent home 7 days later. The study concluded that ligation of the middle colic vessels during the gastrostomy operation increases the blood supply to the transverse colon through the left upper colic and marginal vessels. This adds extra ten minutes to the operation of gastrostomy. This technique has increased the success rate in colonic replacement and minimized morbidity in the unit. The principle is commonly used in plastic surgery in pedicled flap reconstruction and in pediatric surgery in high abdominal testis

Ewing's sarcoma, primitive neuroectodermal tumour and neuroblastoma: morphological, immunohistochemical and electron microscopic study

Ewing's sarcoma [ES], primitive neuroectodermal tumour [PNET] and neuroblastoma [NB] are most commonly considered in the differential diagnosis of small blue round cell tumor of infancy and childhood. The differential diagnosis between these over- lapped tumours is of utmost importance for therapy and prognosis. The aim of this study was to assess the morphological, immunohistochemical and ultrastructural diagnostic features of these overlapping tumors. The study was done on 18 cases including eight cases of Ewing's sarcoma, ES [seven bone and one soft tissue], three cases of primitive neuroectodermal tumor [PNET] and seven cases of neuroblastoma, NB [all were primary tumors]. ES was diagnosed by its positivity for CD 99, the presence of glycogen either histochemically or by EM along with the classic morphology of ovoid cells lacking rosettes and spindle cell pattern. NB was diagnosed by its positivity for neuron specific enolase [NSE] and negativity for CD 99, the presence of neurites, neurosecretory granules and neuropils by EM along with the rosettes by light microscopy and the absence of glycogen both histochemically and by EM. PNET had some features of ES as the presence of glycogen and positivity for CD 99 as well as some features of NB as the positivity for NSE and the presence of neurosecretory granules and neurites as well as the occasional presence of rosettes by light microscopy

Bochdalek hernia in adulthood: an unusual presentation and diagnostic dilemma.

Bochdalek diaphragmatic hernia is one of the most important surgically correctable causes of respiratory distress in the newborn. Delayed presentation in adult life is uncommon. We present a case of a 46-year-old, multigravida Kashmiri woman, who was misdiagnosed earlier and treated for pulmonary tuberculosis. Diagnosis was established pre-operatively by plain chest radiograph and barium meal. A dorso-lateral defect was located on left side of diaphragm which was corrected by using a prolene mesh.

Histopathological and immunohistochemical study of Kikuchi-Fujimoto disease [Necrotizing Histiocytic Lymphadenitis]

In this work, 17 lymph node biopsies from 17 patients were studied. The cases showed a fragmentation of the lymph node [8/17], residual reactive germinal centers [11/17], focal paracortical necrosis [8/17] and large confluent areas of necrosis with disturbance of the normal architecture [9/17]. Karyorrhexis was a prominent feature [+++] in 10/17 cases, moderate [++] in 5/17 cases and mild [+] in 2/17 cases. The karyorrhectic process was intimately associated with coagulative necrosis. The present study showed that this disease has sufficient morphological and immunohistochemical characteristic features to allow for a precise histological diagnosis, in particular when these morphological features are seen within the right clinical context of a young female patient, a good general condition, localized cervical lymphadenopathy and fever of unknown origin

Langerhans cell histiocytosis: morphological, immunohistochemical and ultrastructural study

A total of 23 samples of 21 patients designated Langerhan's cell histiocytosis [LCH] or eosinophilic granuloma was collected for this study. Light microscopy showed that the picture of LCHs was a mixture of Langerhan's [LCs] and eosinophils in varying proportions along with the occasional giant cells of foreign body and Langerhan's giant cells, lymphocytes and neutrophils. The immunohistochemical study showed mostly negative staining for alpha-1-antitrypsin. Out of the 23 specimens, 19 were positive for S100. CD Ia was performed on all cases with 100% positivity. The macrophages were negative for CD Ia and S100, but were positive for alpha-1-antitrypsin. The staining for NSE was positive for 19 specimens, but it was nonspecific as the histiocytes showed also a positive staining. All the 21 cases studied by electron microscopy had the characteristic features of Langerhans' cell histiocytosis in the form of Birbeck granules along with the deeply cleaved or pseudo-multisegmented nuclei with finely dispersed, thinly marginated chromatin and inconspicuous nucleoli

melanotic melanoma of soft tissue [clear cell sarcoma]: immunohistochemical and electron microscopis comparative study with cutaneous melanoma

This study included 13 cases of amelanotic melanoma of soft tissue or clear cell sarcoma [CCS] compared with 24 cases of conventional malignant melanoma of skin. The immunohistochemistry of Melan A, HMB45, S100, EMA, CEA, vimentin and cytokeratin was done for both study groups. The malignant cells of CCS showed 100% positivity [13/13] cases for S100, vimentin and NSE; while, 8/13 and 7/13 cases were positive for HMB45 and Melan A, respectively. All cases were negative for CEA, EMA and cytokeratin [Pankeratin]. The conventional melanoma showed that all cases [24/24] were positive for S100, NSE and vimentin; while, Melan A positivity was seen in 19/23 cases and HMB45 positivity was found in 18/23 cases. All cases were negative for CEA and EMA, while 3/24 cases were positive for cytokeratin. The findings of electron microscopy observed in all cases of the amelanotic melanoma and conventional melanoma groups were the same. The most characteristic finding was the presence of premelanosomes which exhibited the typical lamellated striated or barrel-stone internal structure of premelanosomes