Validating low-fidelity arthroscopic simulation in medical students: a feasibility trial.

INTRODUCTION: With surgical opportunities becoming increasingly restricted for orthopaedic trainees, simulation training is a valuable alternative at providing sufficient practice. This pilot study aims to assess the potential effectiveness of low-fidelity simulation in teaching medical students basic arthroscopic skills and the feasibility of its incorporation into formal student training programmes. METHODS: Twenty-two medical students completed pre- and post-training tests on the Probing (Task 1) and Maze (Task 2) exercises from the Sawbones 'Fundamentals of Arthroscopy Surgery Training' (FAST) programme. Training consisted of practising horizon control, deliberate linear motion and probing within 25min over a period of days. Completion time and error frequency were measured. The difference in performance was assessed using a paired two-tailed t-test. Qualitative data were collected. RESULTS: Test completion time decreased significantly by a mean of 83s (±46s, 95% confidence intervals [CI] 37 to 129) for Task 1 (p=0.001) and 105s (±55s, 95% CI 50 to 160) for Task 2 (p=0.0007). Frequency of direct visualisation errors decreased significantly by a mean of 1.0 errors (±1.0 errors, 95% CI 0.1 to 2.0) for Task 1 (p = 0.04) and 0.8 errors (±0.8 errors, 95% CI 0.1 to 1.6) for Task 2 (p = 0.04). At post-training, 82% of participants were willing to incorporate FAST into formal training. CONCLUSIONS: Low-fidelity simulators such as FAST can potentially teach basic arthroscopic skills to medical students and are feasible for incorporation into formal training. They also give students a cost-effective and safe basic surgical training experience.

The impact of time to surgery after hip fracture on mortality at 30- and 90-days: Does a single benchmark apply to all?

INTRODUCTION: Delays to surgery after hip fracture have been associated with mortality Uncertainty remains as to what timing benchmark should be utilized as a marker of quality of care and how other patient factors might also influence the impact of time to surgery on mortality. The goal of this study was to determine how time to surgery affects 30- and 90-day mortality by age and to explore the impact of preoperative comorbid burden and sex. PARTICIPANTS: We used population-based administrative data from a Canadian province collected from 01April2008 to 31March2015. Of 12,713 Albertans 50-years and older who experienced a hip fracture and underwent surgery within 100 h of admission, 11,996 (94.8%) provided data. METHODS: Time to surgery was analyzed in hours from admission to surgery. Age and the interaction between age and time to surgery were evaluated using logistic regression. Charlson co-morbidity score and sex were also considered in the analysis. Survival was evaluated at 30-and 90-days post hip fracture using a provincial registry. RESULTS: The average age of the cohort was 79.6 ± 11.2 years and 8,412 (70.1%) were female. Overall, 586 (4.9%) patients died within 30-days and 1,023 (8.5%) died within 90-days of hip fracture. Mortality increased significantly with increasing time to surgery (30-day mortality odds ratio [OR] = 1.03; 95%CI 1.01-1.05: 90-day mortality OR = 1.03; 95% CI 1.01-1.04). Mortality also increased substantially with increasing age; those ≥85 years were 19.63 (95% CI 6.83-67.33) and 15.66 (95%CI 7.20-37.16) times the odds more likely to die relative to those between 50-64 years of age at 30-days and 90-days postoperatively respectively. Further, those who were ≥85 years were more significantly affected by increasing time to surgery than those who were 50-64 years of age at both 30-days (p = 0.04) and 90-days (p = 0.025) post-fracture. Males and those with a higher comorbid burden also had higher odds of dying after controlling for time to surgery (p < 0.001) CONCLUSION: Time to surgery following hip fracture may have a differential effect on 30- and 90-day survival dependent on age. Older patients appear to be at higher risk of dying with surgical delays than younger patients.

Successful treatment of chronic hepatitis C infection with crushed elbasvir/grazoprevir administered via a percutaneous endoscopic gastrostomy tube.

WHAT IS KNOWN AND OBJECTIVE: Elbasvir/grazoprevir is an all-oral regimen approved for patients with hepatitis C virus (HCV) genotypes 1 and 4, and in renal insufficiency. However, to date, no data exist on the efficacy of this regimen when it is crushed and administered through a percutaneous endoscopic gastrostomy (PEG) tube. Here, we illustrate the case of a 63-year-old man who is the only known patient with HCV infection in the English literature to have successfully achieved a sustained viral response (SVR) when elbasvir/grazoprevir oral combination was administered through a PEG tube. CASE SUMMARY: A 63-year-old man with worsening HCV-associated membranoproliferative glomerulonephritis was referred to the gastroenterology clinic for prompt HCV treatment. He had history of high-grade mucoepidermoid carcinoma of the parotid status post-resection and was expected to develop severe mucositis and dysphagia during radiation precluding typical oral therapy of his HCV. He received a PEG tube for nutrition and underwent a 16 week course of crushed Elbasvir/Grazoprevir for HCV treatment through the PEG. At the end of the therapy he achieved SVR and his kidney function also improved. WHAT IS NEW AND CONCLUSION: We present the first known clinical case of a non-cirrhotic patient with HCV genotype 1A with HCV-related MPGN treated successfully with crushed Elbasvir/Grazoprevir administered through a PEG tube. With the prevalence of PEG tube insertion and HCV on a rise, we expect these 2 population cohorts to intersect in the future. Our report may serve as a guidance in such clinical scenario.

Characteristics and Impacts of Venous Thromboembolism in Patients with Hepatocellular Carcinoma.

INTRODUCTION: Venous thromboembolism (VTE) is a common complication in cancer patients, and is associated with worse prognosis in such population. Hepatocellular carcinoma (HCC) poses high risk for VTE; however, data is scarce regarding the characteristics and consequences of VTE in HCC patients. METHOD: We retrospectively reviewed the electronic medical records (EMR) of 270 patients diagnosed with HCC from 2000 to 2015 in Cook County Health and Hospitals System. We report the cumulative incidence of VTE in the present cohort, and identified through multivariate logistic regression the independent risk factors of the development of VTE. Overall prognosis of patients with and without VTE were presented and compared. RESULTS: Sixteen cases (5.93%) of VTE were documented in the present study. In multivariate analysis, obesity, Child B cirrhosis, intra-hepatic lesions more than 3, and multi-organ extrahepatic metastasis were significantly associated with VTE development (p < 0.05). The presence of VTE was an independent risk factor for mortality in multivariate analysis (HR = 3.62, p = 0.021), together with male gender, Child C cirrhosis, and extrahepatic metastasis. CONCLUSIONS: Obesity, Child B cirrhosis, more intra-hepatic lesions, and multi-organ extrahepatic metastasis are associated with cancer-associated VTE. VTE will adversely affect the prognosis of patients with HCC; therefore, primary thromboprophylaxis may be warranted in such population.

Acute liver failure with amiodarone infusion: A case report and systematic review.

WHAT IS KNOWN AND OBJECTIVE: Amiodarone, a commonly used class III antiarrhythmic agent notable for a relatively long half-life of up to 6 months and its pronounced adverse effect profile, is used for both acute and chronic management of cardiac arrhythmias. Chronic use of amiodarone has been associated with asymptomatic hepatotoxicity; however, acute toxicity is thought to be uncommon. There are only six reported cases of acute liver failure (ALF) secondary to amiodarone. In all these cases the outcome of death during the same hospitalization resulted. We aimed to report the only case of acute liver failure secondary to amiodarone infusion in the existing literature where the patient survived. CASE SUMMARY: A 79-year-old woman admitted with atrial flutter was being treated with intravenous (IV) amiodarone when she abruptly developed coagulopathy, altered mental status and liver enzyme derangement. She was diagnosed with acute liver failure (ALF) secondary to an amiodarone adverse drug reaction, with a calculated score of seven on the Naranjo adverse drug reaction probability scale. Amiodarone was immediately withheld, and N-acetylcysteine (NAC) was initiated. Clinical improvement was seen within 48 hours of holding the drug and within 24 hours of initiating NAC. On post-hospital follow-up visit she was reported to have complete recovery. WHAT IS NEW AND CONCLUSION: This report emphasizes the importance of monitoring liver enzymes and mental status while a patient is being administered IV amiodarone. N-acetylcysteine administration may have possibly contributed to the early and successful recovery from ALF in our patient. To date, she is the only patient in the existing literature who has been reported to survive ALF secondary to amiodarone administration.

Physicochemical properties and release characteristics of starches from seeds of Indian Shahi Litchi.

Many conventional sources of starches are from staple foods. Non-conventional and cheap sources of starch are being explored. Starch was isolated from Shahi Litchi seeds using two extraction media; acidic (citric acid 0.3%, w/w; LC) and alkaline (NaOH 0.5%, w/w; LN). Each starch was investigated for various properties such as structural, morphological and functional. The percentage yield of LN and LC was 11% and 12.6%, respectively. Morphological properties of both starches show same structural makeup, but compound granules were in LN starch. Moisture content, amylose content was found to be higher LC starch than in LN starch, which indicates that extraction media affects the properties of starch. FTIR confirmed the carbohydrate nature of the both isolated starches. TGA data of both starches reveal slight difference in stability with temperature. In vitro release of both starches shows the release up to 58.95±0.04% and 67.184±0.07% in 5h for LN and LC, respectively, that indicates that these starches can be used in delayed drug delivery and targeting drugs to the colon.

A less energy intensive process for dehydrating onion.

Onion powder has an extensive demand and wide application worldwide as flavour additive in convenience foods and medicinal products. Conventionally onion powder is prepared by hot air drying of onion slices followed by grinding. Convective air drying when used alone demands longer drying time and thus has a high expense of energy. As bulk of onion is water (82-87 %), removal of moisture prior to drying can reduce moisture loading on dryer and hence the energy consumption. Keeping this in view, onions were partially dewatered using centrifugal force before convective drying. The effect of partial mechanical dewatering and drying air temperature was studied on drying time, specific energy consumption and onion powder quality (colour and flavour). The combination process was also optimized to achieve increased drying rate and product quality comparable to products obtained using convective drying alone. Onions subjected to 60 % partial mechanical dewatering and hot air drying at 70 °C exhibited significantly (p ≤ 0.5) shortened drying time, decreased energy consumption and maintained colour and flavour of the dried product.

The adverse effect of elevated body mass index on outcome after autologous chondrocyte implantation.

We analysed whether a high body mass index (BMI) had a deleterious effect on outcome following autologous chondrocyte implantation (ACI) or matrix-carried autologous chondrocyte implantation (MACI) for the treatment of full-thickness chondral defects of the knee from a subset of patients enrolled in the ACI vs MACI trial at The Royal National Orthopaedic Hospital. The mean Modified Cincinnati scores (MCS) were significantly higher (p < 0.001) post-operatively in patients who had an ideal body weight (n = 53; 20 to 24.9 kg/m(2)) than in overweight (n = 63; 25 to 30 kg/m(2)) and obese patients (n = 22; > 30 kg/m(2)). At a follow-up of two years, obese patients demonstrated no sustained improvement in the MCS. Patients with an ideal weight experienced significant improvements as early as six months after surgery (p = 0.007). In total, 82% of patients (31 of 38) in the ideal group had a good or excellent result, compared with 49% (22 of 45) of the overweight and 5.5% (one of 18) in the obese group (p < 0.001). There was a significant negative relationship between BMI and the MCS 24 months after surgery (r = -0.4, p = 0.001). This study demonstrates that obese patients have worse knee function before surgery and experience no sustained benefit from ACI or MACI at two years after surgery. There was a correlation between increasing BMI and a lower MCS according to a linear regression analysis. On the basis of our findings patient selection can be more appropriately targeted.

Association of death receptor 4, Caspase 3 and 5 gene polymorphism with increased risk to bladder cancer in North Indians.

PURPOSE: Perturbed apoptosis due to missense alterations in candidate tumor suppressor gene Death receptor 4 (DR4) and in caspases (Casp) lead to deregulated cell proliferation and cancer predisposition. Some data indicate that normal variations within the sequence of apoptotic genes may lead to suboptimal apoptotic capacity and therefore increased cancer risk. To test our proposal we examined whether six single nucleotide polymorphisms (SNPs) of the DR4 and Casp3, 5 genes contrive the risk of bladder cancer (BC) in a North Indian population. MATERIALS AND METHODS: Genotyping was performed in 200 BC patients and 225 controls by Allele-specific PCR and by polymerase chain reaction-restriction fragment length polymorphism. RESULTS: In DR4 Arg141His, BC patients having AA genotype (p = 0.036; OR = 2.51. In Casp5Leu13Phe G > C, significant association was observed with GC (p = 0.025; OR = 1.78) and also in GC + CC (p = 0.026; OR = 1.68). C allele carriers in Casp5Ala90Thr T > C showed low risk of BC (p = 0.036; OR = 0.83). While in Casp3 G > A, AG (p = 0.003; OR = 2.11), GG (p = 0.050; OR = 2.18), G allele (p < 0.001; OR = 1.85) and its carrier AG + GG (p = 0.001; OR = 2.12) have shown significant BC risk. Significant association between DR4 Ala228Glu polymorphism and smoking was observed in BC risk. Haplotype analysis demonstrated that DR4 (Thr209Arg-Arg141His-Ala228Glu) C-G-C is associated with 1.8 folds (OR = 1.85; p = 0.033) risk. GG genotype of Casp3 G > A polymorphism showed increased risk of recurrence (p = 0.009; HR = 5.20). CONCLUSION: This study provided new support for the association of DR4 and Casp3, 5 in BC development, the tumorigenic effect of which was observed to be more enhanced in case of smoking exposure.

Rediscovering cyanobacteria as valuable sources of bioactive compounds.

Cyanobacteria are a simple, but primitive and diverse group of microorganisms, with characteristics in common to both bacteria and algae. Their success as a group in a wide range of habitats has been attributed to their unique physiological characters and high adaptive ability under a wide range of environmental conditions. The potential of cyanobacteria as a source of a variety of compounds such as polysaccharides, lipids, proteins, vitamins, sterols, enzymes, pharmaceuticals and other fine chemicals is well recognized, and their demand is now on an increasing trend. This compilation reviews the salient advances in the discovery of bioactive compounds from cyanobacteria and their significance in agriculture and industry.

Comprehensive analysis of the molecular basis of oculocutaneous albinism in Indian patients lacking a mutation in the tyrosinase gene.

BACKGROUND: Oculocutaneous albinism (OCA) refers to a group of inherited disorders where the patients have little or no pigment in the eyes, skin and hair. Mutations in genes regulating multi-step melanin biosynthesis are the basis of four 'classical' OCA types with overlapping clinical features. There are a few reports on defects in TYR and a single report on SLC45A2 in Indians affected with OCA but no report on OCA2 (a major locus related to the disease) and TYRP1. OBJECTIVES: To assess and describe a comprehensive picture of the molecular genetic basis of OCA among Indians with no apparent mutations in TYR. METHODS: Twenty-four affected pedigrees from 14 different ethnicities were analysed for mutations in OCA2, TYRP1, SLC45A2 and SLC24A5 using the polymerase chain reaction-sequencing approach. RESULTS: Two splice-site and four missense mutations were detected in OCA2 in seven unrelated pedigrees, including four novel mutations. Haplotype analysis revealed a founder mutation (Ala787Thr) in two unrelated families of the same ethnicity. A patient homozygous for a novel SLC45A2 mutation also harboured a novel OCA2 defect. No mutation was detected in TYRP1 or SLC24A5. CONCLUSIONS: Our results suggest that an OCA2 gene defect is the second most prevalent type of OCA in India after TYR. The presence of homozygous mutations in the affected pedigrees underscores the lack of intermixing between the affected ethnicities. Direct detection of the genetic lesions prevalent in specific ethnic groups could be used for carrier detection and genetic counselling to contain the disease.

Current cell-based strategies for knee cartilage injuries.

Cartilage is frequently damaged and shows little or no capacity for repair. Injuries that extend to the subchondral level show some capacity for repair due to the release of bone marrow derived mesenchymal stem cells. This technique is employed in techniques like the microfracture but they are only appropriate for smaller cartilage defects. Autologous Chondrocyte Implantation (ACI) and Matrix-carried Autologous Chondrocyte Implantation (MACI) are currently used in clinical practice to treat larger full thickness chondral defects in the knee with similar results. MACI does however have a number of advantages including its amenability to be performed arthroscopically or through a more limited approach without requiring arthrotomy. More definitive studies showing the long-term effects of the two cell-based treatments and comparing them are however awaited. There are a small number of studies using mesenchymal stem cells and further in vitro and in vivo studies are needed before this treatment is optimised. This review discussed these treatment options and provides an evidence-based approach to current clinical treatments.

Does smoking influence outcome after autologous chondrocyte implantation?: A case-controlled study.

Smoking is known to have an adverse effect on wound healing and musculoskeletal conditions. This case-controlled study looked at whether smoking has a deleterious effect in the outcome of autologous chondrocyte implantation for the treatment of full thickness chondral defects of the knee. The mean Modified Cincinatti Knee score was statistically significantly lower in smokers (n = 48) than in non-smokers (n = 66) both before and after surgery (p < 0.05). Smokers experienced significantly less improvement in the knee score two years after surgery (p < 0.05). Graft failures were only seen in smokers (p = 0.016). There was a strong negative correlation between the number of cigarettes smoked and the outcome following surgery (Pearson's correlation coefficient -0.65, p = 0.004). These results suggest that patients who smoke have worse pre-operative function and obtain less benefit from this procedure than non-smokers. The counselling of patients undergoing autologous chondrocyte implantation should include smoking, not only as a general cardiopulmonary risk but also because poorer results can be expected in smokers following this procedure.

Physiological characterization and electron microscopic investigation of cyanobacteria associated with wheat rhizosphere.

Physiological attributes of a set of cyanobacterial strains, isolated from the rhizosphere of wheat (var. HD 2687), identified as belonging to the genera Calothrix (n = 3), Westiellopsis (1), Hapalosiphon (2) and Nostoc (2), were axenized and evaluated. The concentrated culture filtrates of three cyanobacterial strains - C. ghosei, H. intricatus and Nostoc sp. were able to enhance germination percentage, radicle and coleoptile length in inhibition experiments with wheat seeds. Indole-3-acetic acid (IAA) production was recorded in light and dark (+0.5 % glucose) incubated cultures. Incubation in the presence of tryptophan significantly enhanced IAA production. Acetylene-reducing activity was higher in light incubated cultures of Nostoc sp. followed by C. ghosei, while in the dark, C. ghosei recorded highest values. TLC of the filtrates revealed the presence of several amino acids such as histidine, and auxin-like compounds. Co-culturing with selected strains recorded significant enhancement in plant chlorophyll. Root sections of wheat seedlings co-cultured with C. ghosei revealed the presence of short filaments inside the root hairs and cortical region. Such strains can be promising candidates for developing plant growth promoting associations for wheat crop, besides serving as model systems for understanding the metabolic interactions of cyanobacteria with host plant, such as wheat.

Peri-acetabular resection and endoprosthetic reconstruction for tumours of the acetabulum.

We treated 98 patients with peri-acetabular tumours by resection and reconstruction with a custom-made pelvic endoprosthesis. The overall survival of the patients was 67% at five years, 54% at ten years and 51% at 30 years. One or more complications occurred in 58.1% of patients (54), of which infection was the most common, affecting 30% (28 patients). The rate of local recurrence was 31% (29 patients) after a mean follow-up of 71 months (11 to 147). Dislocation occurred in 20% of patients (19). Before 1996 the rate was 40.5% (17 patients) but this was reduced to 3.9% (two patients) with the introduction of a larger femoral head. There were six cases of palsy of the femoral nerve with recovery in only two. Revision or excision arthroplasty was performed in 23.7% of patients (22), principally for uncontrolled infection or aseptic loosening. Higher rates of death, infection and revision occurred in men. This method of treatment is still associated with high morbidity. Patients should be carefully selected and informed of this pre-operatively.

Use of an 'internal proximal femoral replacement' with distal fixation in revision arthroplasty of the hip.

We have managed 27 patients (16 women and 11 men) with a mean age of 68.4 years (50 to 84), with failed total hip replacement and severe proximal femoral bone loss by revision using a distal fix/proximal wrap prosthesis. The mean follow-up was for 55.3 months (25 to 126). The mean number of previous operations was 2.2 (1 to 4). The mean Oxford hip score decreased from 46.2 (38 to 60) to 28.5 (17 to 42) (paired t-test, p < 0.001) and the mean Harris Hip score increased from 30.4 (3 to 57.7) to 71.7 (44 to 99.7) (paired t-test, p < 0.001). There were two dislocations, and in three patients we failed to eradicate previous infection. None required revision of the femoral stem. This technique allows instant distal fixation while promoting biological integration and restoration of bone stock. In the short term, the functional outcome is encouraging and the complication rates acceptable in this difficult group of patients.

Splenic Syndrome due to Sickle Cell Trait amongst Indian Soldiers Serving in Kashmir.

BACKGROUND: Heterozygous transmission of gene for Haemoglobin S leads to sickle cell trait. Mostly the trait remains silent with no additional morbidity or mortality. When these persons migrate to higher altitudes, in times of high oxygen demand, some of them develop splenic infarction. This is a rare phenomenon and only 47 such cases had been reported till 2005. METHODS: This study was conducted at an Indian military hospital serving the troops deployed in Kashmir valley at altitudes ranging from 5500 ft to 13000 ft. When two consecutive splenectomies for splenic abscesses, turned out to be sickling induced infarction histopathologically, we reviewed splenectomy specimens received in last six years for evidence of sickling. RESULT: Out of 33 splenectomies performed during the period of study, 22 were due to trauma (gun shot injury 11; splinter injury one and blunt injury 10). Of the rest eleven, who presented without any history of trauma, seven had evidence of vascular occlusion with aggregates of sickled red blood cells. In none, Gram stain or Periodic Acid Schiff stain revealed any bacterial or fungal colonies. One patient of splenic syndrome was found to have unrecognised sickle cell trait and he was managed conservatively. CONCLUSION: Sickle cell trait should be excluded before considering splenectomy in ethnically vulnerable patients presenting with splenic syndrome. An uncomplicated splenic infarction can be managed conservatively.