Efficacy and Safety of Teriparatide in Improving Fracture Healing and Callus Formation: A Systematic Review.

Fracture nonunion remains a great challenge for orthopedic surgeons. Some bone fractures don't heal promptly, resulting in delayed unions and nonunions, and there is a need for an additional surgical procedure. Previous research has shown that teriparatide, a type of synthetic parathyroid hormone, can promote the formation of callus and lead to healing in individuals with delayed or non-healing bone fractures. Limited systematic reviews exist that examine the use of teriparatide in cases of delayed healing or non-healing bone fractures, which have their limitations. In this review, we overcome those limitations by including prospective studies, retrospective studies, case reports, and case series together. A systematic search of the literature was conducted in both PubMed and Google Scholar up to September of the year 2022. The studies included in our research included adult patients (over the age of 16) diagnosed with delayed union or nonunion of any bone in the body (flat bone, long bone, short bone, or irregular bone). The studies were limited to those written in English. The outcomes that were tracked and recorded include the healing of the fracture and any negative side effects or adverse events. The initial search yielded 504 abstracts and titles. After reviewing these, 32 articles were selected for further analysis, which included 19 case reports, five case series, two retrospective studies, and six prospective studies. Studies included daily (20 micrograms) or weekly (56.5 micrograms) subcutaneous administration of teriparatide. The duration of follow-up for these studies varied from three to 24 months. Based on the available research, it appears that administering teriparatide subcutaneously is a safe treatment option for delayed healing and non-healing bone fractures, with very few to no reported negative side effects. Using teriparatide for induction of callus formation and treating delayed and nonunions is highly safe and effective.

A Systematic Review of Cystic Fibrosis in Children: Can Non-Medical Therapy Options Lead to a Better Mental Health Outcome?

Cystic fibrosis (CF) is a chronic disorder that begins at an early age, so it is crucial to be aware of the physical and emotional burden placed on individuals suffering from it and their families. It significantly impacts an individual's life; therefore, it is essential to acknowledge the effects of the disease on physical and mental health. Our systematic review aims to highlight the areas of life affected by cystic fibrosis and evaluate various non-medical treatment options that may support the mental health of CF patients. We selected PubMed, Google Scholar, and MEDLINE (Medical Literature Analysis and Retrieval System Online) as our databases. We initially found 146,095 articles and narrowed the number of articles down using filters, exclusion and inclusion criteria, and various combinations of Medical Subheadings (MeSH) and key terms. We decided to use a final count of nine articles for our systematic review. The studies we included highlighted the negative impact of cystic fibrosis on mental health, like depression and anxiety, as well as on sleep, physical health, and overall quality of life. Several non-medical interventions, such as logotherapy, psychological interventions, complementary and alternative medicine, and many more, have been shown to enhance the mental health of many participants. Studies suggested that such therapy options may greatly benefit individuals with cystic fibrosis and their current treatment plan. This review indicates that non-medical therapy options can enhance the mental health of individuals suffering from cystic fibrosis and that it is crucial to bring more attention to preventing and treating mental health issues in cystic fibrosis patients. However, as current data is limited, more research with a larger number of participants over an extended period of time is necessary to better evaluate the efficacy of non-medical interventions on mental health.

A Systematic Review of the Efficacy of Early Initiation of Speech Therapy and Its Positive Impact on Autism Spectrum Disorder.

Autism spectrum disorder (ASD) is a condition that consists predominantly of an apparent early delay in communication and social skills. Among the multiple identified etiologies, genetics play a key role. The implementation of early interventional therapy for children with ASD is starting to show promising results. A few medical databases were used to collect multiple published types of research, which were thoroughly screened. Ultimately, a small amount was selected according to the defined eligibility criteria. The 12 articles that were reviewed involved a more significant number of boys than girls, and most clinical trials displayed the importance of starting early therapy. Astonishingly, the overwhelming effects of the COVID-19 pandemic did not affect the continuation of speech therapy in certain areas. In addition, studies emphasize knowledge scarcity, insufficient resources in certain areas, and the demand to educate the community. Conversely, no difference in the level of severity was noted with the implementation of early therapy. Early therapy, chiefly speech therapy used to treat children with ASD, demonstrated favorable outcomes. Communities require awareness about the condition on a broader scale to educate caregivers on early alarming symptoms. All in all, additional exploration needs to be done.

Drug-Eluting Bead, Irinotecan (DEBIRI) Therapy for Refractory Colorectal Liver Metastasis: A Systematic Review.

Colorectal cancer and related mortality present a profound challenge in its management, even in this modern age. Even today, colorectal cancer-related deaths rank third in the world. Despite having multiple lines of chemotherapy, combined with radiotherapy and chemoembolization techniques, after or before surgical resection, the five-year survival rate is approximately 20%. Drug-eluting bead, irinotecan (DEBIRI) is a new technique that involves embolization of the feeding vessels to the tumour and delivering irinotecan for its chemotherapeutic effects. A significant amount of literature compares DEBIRI as an adjunct to various lines of chemotherapy. However, so far, not much data are available on DEBIRI as a singular treatment for those patients who have had multiple chemotherapies and still progressing and are not fit for liver resection. In this systematic review, we aim to highlight and bring together the results of those studies that focused on this specific patient group. A systematic search of the literature involving three large databases (published between January 2017 and July 2022), excluding languages other than English, was conducted to identify articles documenting patients who had disease progression despite chemotherapy and were not fit for surgical resection. The level of evidence and the quality check were assessed by two independent reviewers, and consensus with the senior author resolved disagreements. Out of seven studies that met the final criteria, we found a pooled cohort of 302 patients. The mean age of the patients was 61.2 years, ranging from 40.7 to 84 years. The most commonly used DEBIRI beads were M1 (70-150 um) and M2 (100-300 um), but two studies reported the use of 40 um as well. The total number of DEBIRI treatments performed in our pooled cohort was 904. The majority of the studies reported only G1/G2 toxicities among the patients, with maximal toxicity of G4 in a few selected patients. The median overall survival in our pooled cohort was 19.52 months. The median progression-free survival in our data was 5.76 months. Our systematic review concludes that DEBIRI is undoubtedly a useful treatment modality with an acceptable toxicity profile. This treatment offers a good overall survival benefit for refractory colorectal liver metastasis.

Effects of Restrictive Bariatric Surgery on Congenital Prader-Willi Syndrome: A Case Report.

Hyperphagia leading to obesity is the most common cause of mortality and morbidity in Prader-Willi syndrome (PWS). It has been classified as the most common genetic cause of the development of life-threatening obesity resulting from a defect in satiety, with an onset during early childhood. Abnormalities in the feedback from gut peptides, including ghrelin, may contribute to the satiety defect; autonomic dysfunction may also play a role in impaired satiety. Usually, pharmacological treatment is ineffective in managing obesity in these patients. A 19-year-old male child with Prader-Willi syndrome presented with morbid obesity, obstructive sleep apnea, and impaired glycemic control. The patient had complained of hyperphagia since early childhood, but food intake increased aggressively in the last few years, which resulted in morbid obesity. The patient was treated with laparoscopic sleeve gastrectomy, and the residual stomach volume was 100 ml. The intervention resulted in a 37.1% weight reduction after one year of surgery with well-controlled blood sugar levels. The patient also reported improved overall quality of life, mood, and functionality. Laparoscopic sleeve gastrectomy can be offered to obese Prader-Willi syndrome patients with heightened mortality, particularly because no other effective alternative therapy is available.

Revascularization Techniques for Limb Salvage in Critical Limb Ischemia: A Single Institutional Study From Pakistan.

OBJECTIVES: The study aimed to determine the frequency of successful limb salvage in patients presenting with critical limb ischemia utilizing the available revascularization modalities. This descriptive cross-sectional study was conducted in the Department of General Surgery, Shifa International Hospital, Islamabad, from April 2017 to August 2017. METHODOLOGY: A total of 96 patients with critical limb ischemia requiring urgent surgery for limb salvage were included in our study. Patients who had undergone previous surgeries for limb ischemia involving the same limb, had concurrent venous disease, or suffered from acute limb ischemia were excluded. All patients underwent either endoscopic angioplasty or bypass surgery. All patients were followed up for six months for the success of limb salvage and the requirement for amputation. Data were analyzed by SPSS version 26.0 (Armonk, NY: IBM Corp.). RESULTS: Our patients had a mean age of 62.03±8.46 years, of whom 63 (65.6%) were men. A total of 47 (49.0%) patients required surgery for a non-healing ulcer, while 49 (51.0%) had resting leg pain. In 55 (57.3%) patients, bypass surgery was performed, while 35 (36.5%) underwent endoscopic angioplasty. The remaining six (6.2%) patients received a combination of both procedures. Limb salvage was successful in 78 (81.3%) patients. There was no difference between outcomes across gender (p=0.122), nor was there any difference in outcome between bypass surgery and endoscopic angioplasty (p=0.665). CONCLUSION: Encouraging results can be obtained in treatment of critical limb ischemia if revascularization techniques are utilized prudently in a time-effective manner and individualized to each patient's requirements.

An Analysis of the Risk Factors for the Development of Parastomal Hernia: A Single Institutional Experience.

OBJECTIVES:  To study the frequency of risk factors affecting the development of parastomal hernias in patients undergoing stoma formation. STUDY DESIGN: A retrospective descriptive cross-sectional study. Duration of Study: This study was conducted at the Department of General Surgery between January 2017 to December 2020. METHODOLOGY:  A total of 163 patients aged between 20 and 100 years and who required a stoma formation were included in the study. The patients with incomplete data and those lacking post-operative imaging were excluded. According to this selection criteria, 80 patients were excluded. The data was collected for all patients from the hospital database. This included patient's demographic information, co-morbidities, pre-surgery patient characteristics, an indication of stoma formation, the location of stoma exit, type of surgery, associated comorbidities, subcutaneous fat thickness, and type of stoma formed. Data were analyzed using IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. RESULTS:  The mean age was 68.46 ± 16.50 years, with males in the majority: 48 (57.8%). Most of the patients, 53 (63.8%), had malignant disease. Post-stoma formation, a total of 38 (45.9%) patients developed parastomal hernias, mostly involving the sigmoid colon (n=62, 74.7%). However, there was a statistically significant relationship between paroxysmal sympathetic hyperactivity (PSH) incidence with non-trans-rectus stomas (trans-oblique n=07, junctional n=28) (OR 3.04, CI 1.23-7.5, p=0.014). Furthermore, malignancy was also not an independent predictor of PSH (OR 0.408, CI 0.15-1.2, p=0.056). All other risk factors included in this study were nonsignificant. CONCLUSION:  Our study shows that the incidence of parastomal hernias is rising with a high rate demonstrated in our patients. There was no statistically significant association between patient-related preoperative and operative factors with increased risk of parastomal hernias in our population except for a non-trans-rectus stoma, which was identified as an independent risk factor for parastomal hernias. Based on our findings, we would recommend a trans-rectus stoma over all other stoma sites. However, a much larger study is needed to validate this finding further.

Intra-thoracic Symptomatic Gallstones in a Right-Sided Post-traumatic Diaphragmatic Hernia: A Case Report.

Herniation of abdominal contents through the diaphragm into the thoracic cavity can occur after blunt abdominal injury, resulting in a permanently acquired diaphragmatic hernia. Their clinical presentation is varied and non-specific, which can go unnoticed for a long duration. A 27-year-old male presented with right upper quadrant pain and right-sided pleuritic chest pain for the past 20 days. His past medical history included high-impact blunt trauma a few years back. His workup revealed a right-sided diaphragmatic hernia through which the gallbladder had herniated into the thoracic cavity, along with liver and hepatic flexure of the colon. The gallbladder contained gallstones which were the cause of his symptoms. The patient was managed successfully with a laparotomy and repair of the diaphragmatic hernia and cholecystectomy. After blunt abdominal trauma, right-sided diaphragmatic injury is less common because most of the trauma is absorbed by the liver, providing a protective effect. The sign and symptoms of acquired diaphragmatic hernia lack sensitivity and specificity, due to which many cases remain undiagnosed and are incidentally picked up on chest auscultation where bowel sounds are audible in the chest, and breath sounds on the affected side are absent, whereas patients have complaints of respiratory difficulty and recurrent pneumonia. Chest and abdominal imagining in the form of chest X-rays and abdominal ultrasound can help diagnose. The case we present was a unique presentation of acquired right-sided diaphragmatic hernia resulting in herniation of the gallbladder in the right-sided chest and leading to acute cholecystitis. The treatment modality is surgical repair of the diaphragm. Any patient presenting with unusual symptoms of pneumonia or abdominal pain should be investigated, especially patients with a history of blunt abdominal trauma.

Decrease in Sperm Count After Bariatric Surgery: Case Reports.

Morbid obesity is associated with a large number of complications, including infertility; weight loss can help to improve fertility and increase the number of sperm in males. However, two of our patients developed azoospermia after bariatric surgery for weight reduction. A 30-year-old male presented to the outpatient department (OPD) with a BMI of 81.2 kg/m2 (258 kg) with no known co-morbidities. The patient had a normal sex life and one child. After bariatric surgery, he noticed a change in the consistency of his semen and azoospermia. In the second case, a 48-year-old man presented to the OPD with a BMI of 52 kg/m2 (189 kg) with no known co-morbidities. He had three children. He underwent bariatric surgery for weight loss and, after one year, he developed azoospermia. Bariatric surgery is a lifesaving procedure for morbidly obese patients and helps in restoring normal daily activities. This weight reduction surgery helps in decreasing blood pressure, increasing glycemic control and improving sexual activity. However, bariatric surgery may be followed by a further decline in semen parameters, resulting in azoospermia and severe oligoasthenoteratozoospermia. This is caused by the combined effects of two different processes: 1) the subduing of the negative effects of obesity, and 2) a deficiency of nutrients along with the release of some harmful substances. Bariatric surgery patients should be informed about the risk of complications and about the possibility for cryopreservation of sperm. In rare cases, bariatric surgery can result in a decrease in sperm count and infertility in males.

Enhanced Recovery After Surgery: Are Benefits Demonstrated in International Studies Replicable in Pakistan?

Objectives To determine the efficacy of enhanced recovery after surgery (ERAS) protocols in terms of frequency of surgical site infection (SSI) and length of hospital stay in patients undergoing colorectal surgeries for colorectal carcinoma. Study design Quasi-experimental study. Setting/Duration of study Department of Surgery, Shifa International Hospital, Islamabad, from May 7, 2019 to November 6, 2019. Methodology A total of 120 patients with colorectal carcinomas who fulfilled that sample selection criteria were studied. After randomization, patients were divided into two equal groups; one group received management under ERAS while the second group received conventional management. All patients were recorded for length of hospital stay and the development of SSIs. Data were analyzed using SPSS 26.0. Results The mean age was 42.34 ± 14.45 years, with a male majority, i.e., 72 (60%). The mean duration of in-patient stay was 3.45 ± 1.73 days with ERAS and 8.25 ± 1.58 days with conventional management (p < 0.001). A total of 28 (23.3%) SSIs developed, of which nine (7.5%) SSIs occurred with ERAS, while 19 (15.8%) occurred with traditional management (p = 0.031). Conclusion ERAS protocols have been demonstrated to be effective, cheap, and safe. There is a tangible reduction in length of hospital stay and incidence of SSIs which translates into reduced utilization of resources and financial costs. However, strict adherence to the protocol may be necessary to obtain the aforementioned benefits, which may be difficult to do in the face of professional, institutional, and personal inertia. Intensive efforts are required to make these protocols more convenient and attractive to implement, so as to facilitate conversion to this management approach.