The influence of Javanese turmeric (Curcuma xanthorrhiza) on the pharmacokinetics of warfarin in rats with single and multiple-dose studies.

CONTEXT: Co-administration between warfarin (WF) and Curcuma xanthorrhiza Roxb. (Zingiberaceae) (CX) is found in Indonesian patients and need to be evaluated. OBJECTIVE: This study assesses the effect of concomitant administration of CX extract on the pharmacokinetics of WF in rats. MATERIALS AND METHODS: Wistar rats were divided into 4 groups (n = 6) and administered with 2% Pulvis Gummi Arabicum (PGA, control), fluconazole (FZ, 6 mg/kg), CX-1 (6 mg/kg) or CX-2 (18 mg/kg BW) for 7 days. For the single-dose study, at the 8th day, WF (1 mg/kg) was administered to all groups and blood samples were taken from 0.25 to 72 h. For the multiple-dose study, daily dose of WF was administered to all groups of rats and at the 7th to 9th day, the rats were treated with PGA, CX-1, CX-2 and FZ. Blood samples were withdrawn daily at 4 h after administration of WF from the 1st to 11th day. RESULTS: The area under the curve (AUC) of R- and S-WF in the CX-2 group was a significantly higher value compared to the control (77.54 vs. 35.27 mg.h/L for R-WF and 316.26 vs. 40.16 mg.h/L for S-WF; p < 0.05; Kruskal-Wallis method). The CX-2 administration also caused the increasing in the concentration level of R-WF (16%) and S-WF (27%) from the 7th to 9th day of administration. DISCUSSION AND CONCLUSIONS: The CX administration in a higher dose caused alteration on WF pharmacokinetics suggesting the need for clinical evaluation of the interaction between CX and WF.

Feasibility study of an online modifiable Enhanced Recovery After Surgery protocol with specific focus on opioid avoidance.

BACKGROUND: The high and increasing rate of opioid use is a serious issue in the Western world affecting the population's physical and mental health. In most cases, opioid dependency starts with prescriptions by medical professionals, so efforts aimed at reducing in-hospital opioid use should result in less long-term dependency. The aim of the current study was to evaluate the feasibility of implementing an opioid-scarce protocol as part of a new online modifiable Enhanced Recovery After Surgery (mERAS) programme. METHODS: A single-centre retrospective study was conducted comparing a cohort treated under the new opioid-scarce mERAS protocol (n = 96; May 2018-Nov 2018) to those treated under the original ERAS protocol (n = 84; November 2017-April 2018). The primary outcome was the quantity and duration of opioid use. RESULTS: Fewer patients used fentanyl via intravenous patient-controlled analgesia in the mERAS group (54% versus 70%; P = 0.03). The mERAS group was also less likely to use oral oxycodone (80% versus 99%; P < 0.0001) and for a shorter duration (median 3 versus 5 days; P = 0.0002). More local anaesthetic transversus abdominis plane catheters were used in the mERAS group (34% versus 6% in the control group; P < 0.0001). CONCLUSION: Opioid use can be significantly reduced after elective colorectal surgery by employing an opioid-scarce ERAS protocol. Further data is required to confirm the clinical benefits of this approach.

COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

Efficient bidirectional piezo-optomechanical transduction between microwave and optical frequency.

Efficient interconversion of both classical and quantum information between microwave and optical frequency is an important engineering challenge. The optomechanical approach with gigahertz-frequency mechanical devices has the potential to be extremely efficient due to the large optomechanical response of common materials, and the ability to localize mechanical energy into a micron-scale volume. However, existing demonstrations suffer from some combination of low optical quality factor, low electrical-to-mechanical transduction efficiency, and low optomechanical interaction rate. Here we demonstrate an on-chip piezo-optomechanical transducer that systematically addresses all these challenges to achieve nearly three orders of magnitude improvement in conversion efficiency over previous work. Our modulator demonstrates acousto-optic modulation with [Formula: see text] = 0.02 V. We show bidirectional conversion efficiency of [Formula: see text] with 3.3 µW  red-detuned optical pump, and [Formula: see text] with 323 µW blue-detuned pump. Further study of quantum transduction at millikelvin temperatures is required to understand how the efficiency and added noise are affected by reduced mechanical dissipation, thermal conductivity, and thermal capacity.

Evaluation of indirect decompression of the lumbar spinal canal following minimally invasive lateral transpsoas interbody fusion: radiographic and outcome analysis.

BACKGROUND: The surgical treatment of lumbar stenosis traditionally includes laminectomy for direct decompression of the spinal canal. Selected patients with spinal stenosis may also require lumbar fusion. Minimally invasive lateral transpsoas interbody fusion has the ability of placing a large interbody cage that can increase disc height and distract the spinal level. The purpose of this study was to examine the concept of indirect decompression of the spinal canal in patients with co-existing lumbar spinal stenosis undergoing lateral transpsoas interbody fusion. MATERIALS AND METHODS: We reviewed 25 consecutive spinal stenosis patients with instability undergoing lateral transpsoas interbody fusion without laminectomy. All patients had relevant symptoms of back pain, leg pain, and/or spinal claudication and met standard criteria for lumbar fusion. Patients were evaluated by outcome analysis scales (VAS scores, Oswestry disability index and treatment intensity scale). Postoperative MRI scans, when available, were evaluated for change in canal dimensions. Statistical significance was assessed by paired t-test, which compares the mean change. There were 25 patients in the study (mean age 61 years). 15 patients had grade I spondylolisthesis. VAS for back pain intensity improved from 7.74 to 2.07 and for frequency from 7.91 to 2.22. VAS for leg pain intensity improved from 7.24 to 1.87 and frequency from 7.41 to 2.35. All improvements were statistically significant (P<0.0001). The Oswestry disability index improved from 55.1 to 16.4 (P<0.0001), and treatment intensity scale improved from 14.6 to 3.7 (P<0.0001). Radiographic evaluation in 20 treated levels (15 patients) found an increase in dural sac dimension of 54% in the anterior-posterior plane and 48% in the medial-lateral plane (P<0.0001). The calculated area of the dural sac increased an average of 143% (range of - 10.4% to + 495%). CONCLUSION: Indirect decompression of spinal stenosis can be achieved with lateral transpsoas interbody fusion with improved clinical outcomes. Pre-op and post-op MRI scans showed a significant increase in dural sac dimensions. The mechanism for this indirect decompression may relate to stretching and unbuckling of the spinal ligaments and a decrease in intervertebral disc bulging. Further studies are needed to determine which stenosis patients undergoing this surgery are most appropriate for indirect decompression alone over laminectomy.

A severe form of non-classic Pompe's disease with normal creatinine kinase level.

A 24-month-old boy was referred to our pediatric intensive care unit because of difficulty in weaning from artificial ventilation. He had 2 bronchopneumonia attacks in 2 months; the diagnosis of Pompe's disease was confirmed by low glucosidase activity in lymphocytes and cultured fibroblasts without abnormality in the serum creatine kinase level. Our patient's creatine kinase levels were permanently normal. To the best of our knowledge, our Pompe's case is the first in the literature who has normal creatinine kinase levels despite earlier onset and rapidly progressive disease.

Proximal interphalangeal joint release in Dupuytren's disease of the little finger.

We present a prospective study, with 3-year follow-up, of the role and outcome of fasciectomy plus sequential surgical release of structures of the proximal interphalangeal joint in Dupuytren's contracture of the little finger. Our treatment programme involves fasciectomy for all patients followed by sequential release of the accessory collateral ligament and volar plate as necessary. Of the 19 fingers in the study, eight achieved a full correction by fasciectomy alone, and in these cases there was a fixed flexion deformity of 6 degrees at 3 months and 8 degrees at 3 years. The remaining 11 fingers (initial mean deformity 70 degrees flexion) were left with a fixed flexion deformity of 42 degrees after fasciectomy which reduced to 7 degrees with capsulo-ligamentous release. This increased to 26 degrees at 3 months but then remained relatively stable, increasing only to 29 degrees at 3 years. In our experience sequential proximal interphalangeal joint release has led to consistently good results with few complications in the correction of severe Dupuytren's disease of the little finger.

Expression of the EGF receptor family members ErbB2, ErbB3, and ErbB4 in germinal zones of the developing brain and in neurosphere cultures containing CNS stem cells.

The epidermal growth factor receptor family consists of four related tyrosine kinases: the epidermal growth factor receptor (EGF-R or ErbB), ErbB2, ErbB3, and ErbB4. These receptors are capable of extensive cross-activation upon the binding of their ligands - the EGF family of peptides for EGF-R and the neuregulins for ErbB3 and ErbB4. Since EGF-R is expressed by proliferating cells in the central nervous system (CNS), including multipotent CNS stem cells, we examined the expression of ErbB2, ErbB3 and ErbB4 in the germinal epithelia of the developing rat brain using in situ hybridization. ErbB2 and ErbB4 mRNAs were widely distributed within the germinal zones as early as E12. However, as development proceeded, ErbB2 mRNA was mainly present within the layers of cells immediately adjacent to the ventricular surface - the ventricular zone, while ErbB4 mRNA was predominantly expressed by subventricular zone cells, in the regions where these specialized germinal epithelia were present. ErbB3 mRNA distribution within germinal epithelia was more restricted, primarily confined to the diencephalon and rostral midbrain. Cultured neurospheres, which contain CNS stem cells, expressed ErbB2, ErbB4 and, to a lesser extent, ErbB3 protein as demonstrated by Western blot analysis. This expression declined during following differentiation. Heregulin-beta1, a neuregulin, had no effect on the proliferative capacity of neurospheres. Overall, our results indicate that ErbB2, ErbB3 and ErbB4 may play important and distinct roles in the genesis of the CNS. However, our in vitro data do not support a role for neuregulins in proliferation, per se, of CNS stem cells.

The reversed Esmarch tourniquet technique for the retrieval of cut flexor tendons.

The problem of retrieving a retracted proximal end in a zone II flexor tendon injury in the hand is a common one. We describe our experience of applying an Esmarch tourniquet from the elbow distally to retrieve the proximal end of the cut tendon. Our technique succeeded in presenting the proximal end through the wound in eight out of thirteen patients. This technique does not compromise the tendon, flexor sheath, the vinculae or the blood supply. It obviated the need for further incisions while keeping open other options for tendon retrieval.

Fractures of the carpal scaphoid. A critical study of the standard splint.

The effect of the position of splintage on displacement of fractures of the waist of the scaphoid was studied during operations and in cadavers. We found that these fractures were best splinted in neutral or slight palmar flexion with no ulnar deviation. Providing the wrist was not ulnar deviated, the position of the thumb had no effect on displacement.

Remote arterial injury. Another cause of spurious arterial spasm.

The need for urgent diagnosis and treatment of arterial injury is fully accepted but surgical exposure of the injured vessel is often preferred to pre-operative diagnosis by arteriography. Exposure of the artery at the site of limb injury may reveal spasm or thrombosis without evidence of direct trauma to the vessel. In that case, traction injury of the artery remote from the surgical field is likely. Commonly this affects a proximal segment of the artery but it can occur at a distal fixed point also. Attempts at thrombectomy risk further disruption of the vessel and diagnostic arteriography is required for satisfactory management. An illustrative case is presented.