Management and Novel Treatment of Degloving Soft Tissue Injuries: A Case Report.

Degloving soft tissue injuries (DSTIs) are injuries usually due to trauma sustained parallel to the body, shearing off skin and soft tissue from the underlying muscle and bone. Most commonly due to workplace and traffic accidents, DSTIs can occur due to a variety of traumas, resulting in a wide spectrum of clinical presentations. Treatment is often prolonged and complex, which requires the intervention of a multidisciplinary healthcare team to provide the most optimal outcomes. In this case, we report an 89-year-old male presenting with a lower left leg degloving injury due to a single motor vehicle accident (MVA). Initial surgery and observation were performed to determine the vascular structure, and subsequent debridement was performed to assess the viability of the tissue. Aggressive weekly debridement with stem cell injections and membrane wraps were used to stimulate healing in the patient. Once completed, a skin flap was grafted, which led to the patient completing his healthcare plan within six months. This case serves as an example of an effective healthcare team providing unified care to their patients to increase their mobility and quality of life.

An analysis of risk factors for pancreatic fistula after robotic pancreaticoduodenectomy: outcomes from a consecutive series of standardized pancreatic reconstructions.

BACKGROUND: Proponents of the robotic platform site its potential advantages in complex reconstructions such as the pancreaticojejunal anastomosis; however, the incidence and risk factors for postoperative pancreatic fistula (POPF) after robotic pancreaticoduodenectomy (RPD) have not been characterized. OBJECTIVE: To identify independent risk factors for POPF after RPD. METHODS: A prospectively maintained database of patients that underwent RPD (2008-2013) with a standardized pancreaticojejunostomy was analyzed. Univariate and multivariate analyses (UVA/MVA) were used to identify independent predictors for POPF. The POPF prognostic scores developed by Braga and Callery for open pancreaticoduodenectomy were then applied with logistic regression analysis on this RPD cohort. RESULTS: One hundred and fifty consecutive RPDs were analyzed. POPF occurred in 26 (17.3%); 13 (8.6%) of which were ISGPF category B and C. On UVA, patients with POPF had larger body mass index (BMI), smaller pancreatic duct diameter, smaller tumor size, longer OR time, larger estimated blood loss (EBL) and RBC transfusion (all p < 0.05). Higher EBL, duct size <4 mm, larger BMI and small tumor size remained the best independent risk factors for POPF on MVA. Increased Callery (OR 1.46, 95% CI, p = 0.001) and Braga (OR 1.2, 95% CI, p = 0.005) scores predicted an increased risk of POPF in this RPD cohort. CONCLUSIONS: Larger BMI, higher EBL, smaller tumor size and smaller duct diameter are the main predictors of POPF in RPD.

The learning curve for robotic distal pancreatectomy: an analysis of outcomes of the first 100 consecutive cases at a high-volume pancreatic centre.

BACKGROUND: Robotic distal pancreatectomy (RDP) is performed increasingly, but knowledge of the number of cases required to attain procedural proficiency is lacking. The aim of this study was to identify the learning curve associated with RDP at a high-volume pancreatic centre. METHODS: Metrics of perioperative safety and efficiency for all consecutive RDPs were evaluated. Outcomes were followed to 90 days. Cumulative sum (CUSUM) analysis was used to identify inflexion points corresponding to the learning curve. RESULTS: Between 2008 and 2013, 100 patients underwent RDP. There was no 90-day mortality. In two patients (2.0%), surgery was converted to laparotomy. Thirty procedures were performed for pancreatic adenocarcinoma. Precipitous operative time reductions from an initial operative time of 331 min were observed after the first 20 and 40 cases to 266 min and 210 min, respectively (P < 0.0001). The likelihood of readmission was significantly lower after the first 40 cases (P = 0.04), and non-significant reductions were observed in incidences of major (Clavien-Dindo Grade II or higher) morbidity and Grade B and C leaks, and length of stay. CONCLUSIONS: In this experience, RDP outcomes were optimized after 40 cases. Familiarity with the platform and dedicated training are likely to contribute to significantly shorter learning curves in future adopters.

The chemokine receptors CXCR4/CXCR7 and their primary heterodimeric ligands CXCL12 and CXCL12/high mobility group box 1 in pancreatic cancer growth and development: finding flow.

Novel therapies need to be developed for patients with pancreatic cancer because of the poor outcomes of current regimens. Pancreatic cancer cells respond to the C-X-C chemokine receptor type 4 (CXCR4)/C-X-C chemokine receptor type 7 (CXCR7)/C-X-C motif chemokine 12 (CXCL12)/high-mobility group box 1 signaling axis and this axis presents a novel target for therapy. C-X-C motif chemokine 12 stimulates CXCR4/CXCR7-bearing cells in a paracrine manner. C-X-C chemokine receptor type 4 and CXCR7 are transmembrane G protein-coupled receptors that, upon interaction with ligand CXCL12, activate downstream protein kinases that promote a more aggressive behavior. C-X-C chemokine receptor type 4 is expressed on most pancreatic cancer cells, whereas CXCR7 is primarily expressed on tumor-associated endothelium. High-mobility group box 1 promotes the CXCR4 and CXCL12 interaction, promoting angiogenesis and lymphangiogenesis. Hypoxia-inducible factor 1 is a potent stimulator of CXCR4 and CXCL12 expression, promoting more aggressive behavior. This receptor/ligand interaction can be disrupted by CXCR4 antagonists available and in clinical use to harvest bone marrow stem cells. Novel imaging strategies are now being developed at several centers to evaluate response to therapy and identify early recurrence. Thus, the CXCR4/CXCR7/CXCL12 interaction plays a critical role in cancer cell progression, proliferation, invasion, as well as metastasis and is a suitable target for therapy, imaging, as well as development of novel diagnostics.

Anterior mediastinal paraganglioma: a case for preoperative embolization.

BACKGROUND: Paraganglioma is a rare but highly vascular tumor of the anterior mediastinum. Surgical resection is a challenge owing to the close proximity to vital structures including the heart, trachea and great vessels. Preoperative embolization has been reported once to facilitate surgical treatment. CASE PRESENTATION: We report a case of anterior mediastinal paraganglioma that was embolized preoperatively, and was resected without the need for cardiopulmonary bypass and without major bleeding complications. CONCLUSION: We make a case to further the role of preoperative embolization in the treatment of mediastinal paragangliomas.

The effect of clinical clerkship on students' attitudes toward psychiatry in Karachi, Pakistan.

OBJECTIVE: Attitudes of medical students toward a specialty is strongly related to their future choice of specialty. In developing countries like Pakistan, where there is a shortage of psychiatrists, there is a need to assess the effect of exposure to psychiatry on medical students. METHODS: The authors conducted a survey of fourth-year medical students at Aga Khan University in Karachi, Pakistan. RESULTS: Psychiatry clerkship had an overall positive attitude toward psychiatric illness, patients, and psychiatrists, but no effect on students' choice of psychiatry as a career. CONCLUSION: Psychiatry teaching needs to be made more relevant to the rest of the medical curricula. This may improve students' interest and their future choice of psychiatry as an area of specialization.

Cardiovascular health knowledge and behavior in patient attendants at four tertiary care hospitals in Pakistan--a cause for concern.

BACKGROUND: Knowledge about coronary heart disease (CHD) and its risk factors is an important pre-requisite for an individual to implement behavioral changes leading towards CHD prevention. There is scant data on the status of knowledge about CHD in the general population of Pakistan. The objective of this study was to assess knowledge of CHD in a broad Pakistani population and identify the factors associated with knowledge. METHODS: Cross sectional study was carried out at four tertiary care hospitals in Pakistan using convenience sampling. Standard questionnaire was used to interview 792 patient attendants (persons accompanying patients). Knowledge was computed as a continuous variable based on correct answers to fifteen questions. Multivariable linear regression was conducted to determine the factors independently associated with knowledge. RESULTS: The mean age was 38.1 (+/- 13) years. 27.1% had received no formal education. The median knowledge score was 3.0 out of a possible maximum of 15. Only 14% were able to correctly describe CHD as a condition involving limitation in blood flow to the heart. Majority of respondents could identify only up to two risk factors for CHD. Most commonly identified risk factors were stress (43.4%), dietary fat (39.1%), smoking (31.9%) and lack of exercise (17.4%). About 20% were not able to identify even a single risk factor for CHD. Factors significantly associated with knowledge included age (p = 0.023), income (p < 0.001), education level (p < 0.001), residence (p < 0.001), a family history of CHD (p < 0.001) and a past history of diabetes (p = 0.004). Preventive practices were significantly lacking; 35%, 65.3% and 84.6% had never undergone assessment of blood pressure, glucose or cholesterol respectively. Only a minority felt that they would modify their diet, stop smoking or start exercising if a family member was to develop CHD. CONCLUSION: This is the first study assessing the state of CHD knowledge in a relatively diverse non-patient population in Pakistan. There are striking gaps in knowledge about CHD, its risk factors and symptoms. These translate to inadequate preventive behavior patterns. Educational programs are urgently required to improve the level of understanding of CHD in the Pakistani population.