Things are not what they seem neurologically and radiologically: An apt descriptor for spinal dural arteriovenous fistula (SDAVF).

Spinal dural arteriovenous fistulas (SDAVF) are the most common vascular malformations affecting the spinal cord. It is infrequently encountered in clinical practice and is believed to be acquired, predominantly affecting middle-aged and elderly men with unknown etiology. It is usually misdiagnosed despite presenting with conventional clinical findings and radiological features. Insidious onset of myelopathic findings is seen in addition to pathognomonic findings of cord edema and intrathecal flow voids on MRI. We present a case of SDAVF that was missed by the treating orthopedic surgeon and underwent spinal decompression with subsequent persistence of myelopathic symptoms. Angiography is required to confirm the diagnosis location of the fistula. Treatment is with embolization using liquid embolic agents or surgical through ligation of the draining vein. Endovascular techniques are minimally invasive, safe, and effective. Knowledge of the characteristics and advantages/disadvantages of each agent helps in planning and appropriate selection of agents for the patient. We report successful embolization with improved clinical outcomes for the patient using precipitating hydrophobic injectable liquid (PHIL) embolic agent. The outcome and prognosis of SDAVF depend on the duration of symptoms, severity of neurological symptoms, and successful occlusion of the fistulous draining vein. Awareness of this rare condition amongst clinicians and radiologists, would enable an earlier diagnosis and avoid morbid outcomes of this treatable condition.

Efficacy and Safety of Stempeucel in Osteoarthritis of the Knee: A Phase 3 Randomized, Double-Blind, Multicenter, Placebo-Controlled Study.

BACKGROUND: Osteoarthritis is a chronic, progressive, and degenerative condition with limited therapy options. Recently, biologic therapies have been an evolving option for the management of osteoarthritis. PURPOSE: To assess whether allogenic mesenchymal stromal cells (MSCs) have the potential to improve functional parameters and induce cartilage regeneration in patients with osteoarthritis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 146 patients with grade 2 and 3 osteoarthritis were randomized to either an MSC group or placebo group with a ratio of 1:1. There were 73 patients per group who received either a single intra-articular injection of bone marrow-derived MSCs (BMMSCs; 25 million cells) or placebo, followed by 20 mg per 2 mL of hyaluronic acid under ultrasound guidance. The primary endpoint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score. The secondary endpoints were WOMAC subscores for pain, stiffness, and physical function; the visual analog scale score for pain; and magnetic resonance imaging findings using T2 mapping and cartilage volume. RESULTS: Overall, 65 patients from the BMMSC group and 68 patients from the placebo group completed 12-month follow-up. The BMMSC group showed significant improvements in the WOMAC total score compared with the placebo group at 6 and 12 months (percentage change: -23.64% [95% CI, -32.88 to -14.40] at 6 months and -45.60% [95% CI, -55.97 to -35.23] at 12 months P < .001; percentage change, -44.3%). BMMSCs significantly improved WOMAC pain, stiffness, and physical function subscores as well as visual analog scale scores at 6 and 12 months (P < .001). T2 mapping showed that there was no worsening of deep cartilage in the medial femorotibial compartment of the knee in the BMMSC group at 12-month follow-up, whereas in the placebo group, there was significant and gradual worsening of cartilage (P < .001). Cartilage volume did not change significantly in the BMMSC group. There were 5 adverse events that were possibly/probably related to the study drug and consisted of injection-site swelling and pain, which improved within a few days. CONCLUSION: In this small randomized trial, BMMSCs proved to be safe and effective for the treatment of grade 2 and 3 osteoarthritis. The intervention was simple and easy to administer, provided sustained relief of pain and stiffness, improved physical function, and prevented worsening of cartilage quality for ≥12 months. REGISTRATION: CTRI/2018/09/015785 (National Institutes of Health and Clinical Trials Registry-India).

Critical medical ecology and intersectionality perspectives in schistosomiasis prevention and control in selected communities in Mindanao, the Philippines.

Schistosomiasis japonica remains a public health concern in many areas of the Philippines. Periodic Mass Drug Administration (MDA) to at-risk populations is the main strategy for morbidity control of schistosomiasis. Attaining MDA coverage targets is important for the reduction of morbidity and prevention of complications due to the disease, and towards achieving Universal Health Care. The study employed a qualitative case study design. Key informant interviews and focus group discussions were conducted to provide in-depth and situated descriptions of the contexts surrounding the implementation of MDA in two selected villages in known schistosomiasis-endemic provinces in Mindanao in the Philippines. Data analysis was done using the Critical Ecology for Medical Anthropology (CEMA) model coupled with the intersectionality approach. It was found that within various areas in the CEMA model, enabling as well as constraining factors have been encountered in MDA in the study settings. The interplay of income class, geographical location, gender norms and faith-based beliefs may have led to key populations being missed during the conduct of MDA in the study sites. The constraints faced by the target beneficiaries of MDA, as well as programme implementers, must be addressed to enhance service delivery and to control morbidity due to schistosomiasis. Improving compliance with MDA also requires a holistic, integrated approach to addressing barriers to participation, which are shaped by wider socio-political and power structures.

A Comparative Study of Bacteriological Culture Results Using Swab and Tissue in Open Fractures: A Pilot Study.

INTRODUCTION: The role of perioperative cultures to identify infection in open fractures has been doubtful. The method of sampling for cultures in open fractures includes swab or tissue collection. However, the efficacy of either of these two techniques has not been compared in the setting of an acute open fracture. We conducted a study to compare the bacteriological culture results between the two techniques. METHODOLOGY: A pilot study was done at our institution, where all type 2, 3A, and 3B open fractures admitted in the emergency and operated for debridement and stabilization were included in the study. Intraoperatively, after debridement of the wound, swab and tissue specimens were collected and sent to the same laboratory. The results of the cultures were then collected for comparison after the necessary incubation period. Follow-up of outpatient records was also done to see its clinical significance. RESULTS: A total of 30 samples of swab and tissue cultures collected post-debridement of acute open fractures in the operation theater were studied. Only 13 samples grew an organism either in swab/tissue culture or both. Nine tissue samples and eight swab samples showed growth. In four cases, both swab and tissue showed growth, but the same organism grew in only one instance. The other three cases showing growth in both tissue and swab had different organisms. Statistically, the kappa coefficient was found to be 0.26 and the agreement between swab and tissue culture was found fair. However, the kappa did not account for the species of the organisms. Tissue samples showed more number of specific organism growing in them, compared to swab culture samples. CONCLUSION: The ideal technique of taking samples for culture in acute open fractures is uncertain. Tissue culture may be better in isolating specific organisms in an acute open fracture wound. However, it is uncertain if the same organism may cause infection.

Molecular Pathogenesis and Diagnostic Imaging of Metastatic Jaw Tumors.

Metastasis is the spread of malignant cells from a primary tumor to distant sites through lymphatics or blood vessels. Malignant lesions metastasizing to the oral and perioral region are a rarity indeed. Malignant lesions could metastasize to both soft tissue of oral cavity and the hard tissues of the jaws and recent meta-analysis showed that metastasis is more common in the jaws than oral soft tissues because of rich vascular supply. The incidence is very low when compared to the incidence of primary oral cancers; nevertheless, one has to include in the diagnostic workup, metastatic malignant lesions, when an irregular ill-defined radiolucency or radiodensity with ragged edges in noted. It could be a challenging task for a diagnostician, in cases with the presence and location of the primary tumor is unknown. Advanced oral imaging technologies and biochemical markers play a vital role in diagnosing such lesions.

Case of Acute Concomitant Rupture of Anterior Cruciate Ligament and Patellar Tendon of Knee: Surgical Decision Making and Outcome.

INTRODUCTION: Acute concomitant rupture of both anterior cruciate ligament (ACL) and patellar tendon is a rare injury. The diagnosis of either of the injuries may be missed on clinical examination in the emergency room. A high index of suspicion is necessary when active extension is absent, and necessary investigations like ultrasound or magnetic resonance imaging (MRI) should be done to confirm the diagnosis. There are no fixed treatment protocols in these injuries. The options include immediate repair of patellar tendon with either simultaneous or delayed reconstruction of ACL. CASE REPORT: We present a case of 30-year-old man with simultaneous ACL and patellar tendon injury sustained in a RTA, riding pillion on a bike. The mechanism of injury was a direct blow on his flexed right knee followed by landing on the ground, on his foot with a twisting valgus thrust. Following clinical examination and radiographs, MRI was done which showed complete patellar tendon mid substance rupture and ACL tear. A staged procedure was planned, and the patient was taken up for immediate patellar tendon repair. This was followed by 5 weeks of cast immobilization. After 6 weeks, the knee was mobilized and ACL reconstruction was done using hamstring graft. At last, follow-up, the patient regained full knee extension and flexion up to 120° with normal gait. CONCLUSION: High-velocity knee injuries have to be carefully evaluated for such concomitant tears, as they may be missed. If suspected, an immediate ultrasound scan or MRI should be done to confirm the injuries, especially that of the patellar tendon. As of now, a staged procedure comprising immediate patellar tendon repair followed by ACL reconstruction at a later date seems to be the better option of treatment.

Gas Embolic Stroke Secondary to Bowel Infarction.

A 69-year-old gentleman with metastatic esophageal adenocarcinoma presented with acute abdominal pain to the emergency medicine department and subsequently developed an acute left hemiplegia while in the resuscitation unit. An unenhanced computed tomography (CT) scan of the head showed right frontal cerebral gas emboli while an unenhanced CT scan of the abdomen and pelvis showed extensive portal venous gas and pneumatosis intestinalis, presumed secondary to bowel infarction.

Corking the WEB and coiling through a jailed microcatheter: WEB assisted coiling, a useful technique avoiding the use of stents in treating wide-necked large intracranial aneurysms.

The WEB is an endovascular flow-disrupting device used in treating wide-necked intracranial aneurysms. Although the device is available in varying sizes, large aneurysms pose a challenge with the need for custom-made devices. We describe the use of coils as an adjunct to the WEB device in successfully treating large aneurysms in two patients, one with an acutely ruptured aneurysm. This novel technique of jailing a microcatheter, deploying the WEB and then coiling the aneurysm saves the need for intracranial stenting, thereby avoiding the need for antiplatelet therapy, which is of benefit in the setting of acute aneurysm rupture.

Corking the WEB and coiling through a jailed microcatheter: WEB assisted coiling, a useful technique avoiding the use of stents in treating wide-necked large intracranial aneurysms.

The WEB is an endovascular flow-disrupting device used in treating wide-necked intracranial aneurysms. Although the device is available in varying sizes, large aneurysms pose a challenge with the need for custom-made devices. We describe the use of coils as an adjunct to the WEB device in successfully treating large aneurysms in two patients, one with an acutely ruptured aneurysm. This novel technique of jailing a microcatheter, deploying the WEB and then coiling the aneurysm saves the need for intracranial stenting, thereby avoiding the need for antiplatelet therapy, which is of benefit in the setting of acute aneurysm rupture.

Pelvic congestion syndrome.

Pelvic congestion syndrome (PCS) is an important cause of chronic pelvic pain in female patients. Chronic pelvic pain, defined as lower abdominal or pelvic pain for a duration of 6 months or more, causes significant morbidity and results in a large number of diagnostic laparoscopies. It is of utmost importance to identify treatable causes of chronic pelvic pain, one of which is PCS. The etiology, clinical features, investigations, and treatment options in PCS have been discussed in this paper.

Clinical and radiological instability following standard fenestration discectomy.

BACKGROUND: Post-surgical lumbar instability is an established complication but there is limited evidence in the literature regarding the incidence of lumbar instability following fenestration and discectomy. We analyzed our results following fenestration discectomy with a special focus on instability. MATERIALS AND METHODS: Eighty-three patients between the age of 17 and 52 years who had undergone fenestration discectomy for a single-level lumbar intervertebral disc prolapse were followed-up for a period of 1-5 years. The criteria for instability included "instability catch,", "painful catch," and "apprehension." The working capacity of the patient and the outcome score of the surgery were assessed by means of the Oswestry disability score and the Prolo economic and functional outcome score. Flexion-extension lateral radiographs were taken and analyzed for abnormal tilt and translation. RESULTS: Of the 83 patients included, 70 were men and 13 were women, with an average age of 37.35 years (17-52 years) at 5 years follow-up. Clinical instability was seen in 10 (12.04%) patients. Radiological instability was noted in 29 (34.9%) patients. Only six (60%) of the 10 patients who demonstrated clinical instability had radiological evidence of instability. Twenty (68.96%) patients with radiological instability were asymptomatic. Three (10.34%) patients with only radiological instability had unsatisfactory outcome. The Oswestry scoring showed an average score of 19.8%. Mild disability was noted in 59 (71.08%) patients and moderate disability was seen in 24 (28.91%) patients. None of the patients had severe disability. These outcomes were compared with the outcomes in other studies in the literature for microdiscectomy and the results were found to be comparable. CONCLUSION: The favorable outcome of this study is in good agreement with other studies on microdiscectomy. Clinical instability in 12.04% of the patients is in agreement with other studies. Radiological signs of instability are seen even in asymptomatic patients and so are not as reliable as clinical signs of instability. Standard fenestration discectomy does not destabilize the spine more than microdiscectomy.