Anterior Interosseous Nerve to Ulnar Nerve Transfer: A Systematic Review.

Background: Ulnar nerve injuries, especially high (proximal forearm) injuries, result in poor functional recovery. Peripheral nerve transfers have recently become a popular technique to augment nerve repairs and reduce the reinnervation distance before distal motor endplates irreversibly degenerate, leading to incomplete recovery. Objectives: To systematically review and analyse the recent literature regarding anterior interosseous nerve (AIN) to ulnar nerve transfers, including demographics, indications, outcomes, and complications. Methods: A search was performed using PubMed, MEDLINE, EMBASE, CINAHL, Scopus, and Cochrane databases using the keywords ulnar nerve, ulnar nerve injury, ulnar motor nerve, anterior interosseous nerve, anterior interosseous, AIN, nerve transfer, and end-to-side using a 3-component search along with the Boolean operators 'AND' and 'OR'. Results: A total of 341 studies were retrieved using the search criteria. Sixteen studies met the inclusion criteria including 12 retrospective case series, 3 retrospective cohort studies, and a single randomised control trial. Nine studies involved supercharged end-to-side transfer (SETS), 6 involved end-to-end transfer (ETE), and only 1 study compared results between SETS and ETE transfers. A total of 269 patients underwent nerve transfers. In the ETE subgroup, the average time to nerve transfer was 7 months, with a mean follow-up period of 24.5 months. Post-procedure, 100% (37/37) patients recovered intrinsic function of BMRC ≥1, and the average recovery time was 3.6 months. A total of 85% of patients recovered intrinsic function of BMRC ≥3. In the SETS group, the average time to nerve transfer was 2.5 months. The average follow-up in this cohort was 13.2 months. About 93% (145/156) recovered the intrinsic function of BMRC ≥1, and the average time to recovery was 7 months. About 75% of patients recovered the intrinsic function of BMRC ≥3 in their first dorsal interossei. Conclusion: AIN to ulnar nerve transfer carries low morbidity, and there is low quality evidence to suggest recovery of intrinsic muscle function compared with conventional primary repair techniques. The supercharged end-to-side transfer (SETS) seems to be more favourable compared with end-to-side transfer. Outcome measurements are highly variable amongst studies, making standardisation difficult. Results of further trials are highly anticipated in this exciting field of peripheral nerve surgery.

Thromboelastography in Microsurgical Reconstruction: A Systematic Review.

The aim of this review was to identify studies that used thromboelastography (TEG) or rotational thromboelastometry (ROTEM) in microsurgical free flap reconstruction and analyse whether it is a useful adjunct at predicting and identifying thrombotic complications. A search was conducted using the MEDLINE database using the keywords "thromboelastogram", "TEG", "thromboelastography", "free flaps" and "free tissue transfer" using a two-component search with the Boolean operators "OR" and "AND". Eight studies were retrieved using the search criteria. Seven studies met the inclusion criteria, and a further study was found citing several articles from the initial search. Combined, there were 528 patients who underwent 600 free flaps. A total of 10.3% (62) arterial and venous thromboses were reported in the studies, and the combined flap failure rate was 5.2% (26). A total of 67% (4/6) of the studies supported the use of TEG as a predictive tool to detect thromboses, including three retrospective case series and one prospective cohort, which were all statistically significant. There is low-quality evidence (level IV) that a pre-operative TEG and functional fibrinogen to platelet ratio of ≥42 can identify patients at risk of adverse post-operative thrombotic events following free flap surgery; however, further validation is required. Higher quality, standardised prospective or randomised control trials are required to further evaluate the predictive value of TEG. As a pre-operative screening tool, TEG can help to detect pathological changes in coagulation, aid in the transfusion of blood products, target anticoagulation therapy and predict possible adverse events aiding to further reduce patient morbidity.

Pressure related injuries: A burning issue?

INTRODUCTION: To the majority of health care professionals, burns present as a challenging and potentially distracting diagnosis. Because of their perceived complexity, they often eclipse other medical problems which can often be life threatening. Pressure related injuries, in rare instances can mimic and be mistaken for full thickness burns. Long lies may cause pressure necrosis of decubitus areas and compartment syndrome of vulnerable areas. Compartment syndrome, is a surgical emergency requiring prompt diagnosis and intervention. It may be missed in the context of a long lie after a collapse and maybe detrimental to patients' prognosis. METHODS: We reviewed cases referred to our Burns unit in the last four months to find cases of pressure related injuries referred as burn wounds. Furthermore, we also performed a literature search to find any similar cases to ours. RESULTS: Two cases, with acute pressure related injuries from long lies had been mistaken for burn wounds, were referred to our unit in the last four months. In one case a missed compartment syndrome resulted in a below elbow amputation. CONCLUSION: Pattern analysis and recognition are very important diagnostic tools in medicine. Detailed history taking and examination cannot be emphasised enough. Training both emergency departments and plastic surgeons in recognising long lie related injuries will decrease possible associated dangers such as missing a compartment syndrome.

Anesthetic management of parturients with Arnold Chiari malformation-I: a multicenter retrospective study.

BACKGROUND: Consensus regarding the safest mode of delivery and anesthetic management for parturients with Arnold Chiari malformation-I (ACM-I) remains controversial. This study assessed their anesthetic management and reported anesthetic complications during hospitalization for delivery. METHODS: This was a multicenter, retrospective, cohort study of patients with ACM-I undergoing vaginal or cesarean delivery. Data were obtained from the electronic databases of four United States academic institutions using International Classification of Diseases (ICD) codes from 2007-2017 at three sites and 2004-2017 at one site. The primary outcome was anesthetic complications. RESULTS: Data were analyzed for 185 deliveries in 148 patients. Diagnosis of ACM-I was made prior to delivery in 147 (80%) cases. Pre-delivery neurosurgical consultation for management of ACM-I was performed in 53 (36%) patients. Pre-existing symptoms were recorded for 89 (48%) of the deliveries. Vaginal deliveries occurred in 80 (43%) cases, and 62 women (78%) received neuraxial labor analgesia. Cesarean delivery was performed in 105 (57%) cases, of which 70 women (67%) had neuraxial anesthesia and 34 (32%) received general anesthesia. Post-dural puncture headache was reported in three (2%) patients who had neuraxial anesthesia, and in two (12%) patients with syringomyelia. There was one (3%) reported case of aspiration pneumonia with general anesthesia. CONCLUSIONS: The findings suggest that anesthetic complications occur infrequently in patients with ACM-I regardless of the anesthetic management. Although institutional preference in anesthetic and obstetric care appears to drive patient management, the findings suggest that an individualized approach has favorable outcomes in this population.

Chronic obstructive pulmonary disease: Does gender really matter?

BACKGROUND: Limited data is available on the clinical expression of chronic obstructive pulmonary disease (COPD) from India. The impact of gender on expression of COPD has received even less attention. Apart from tobacco smoke, indoor air pollution, especially from biomass fuel may play an important role in development of COPD in women. MATERIALS AND METHODS: Seven hundred and two patients of COPD were studied regarding the etiological and risk factors leading to COPD, gender-related differences in clinical presentation, radiological expression of COPD and the co-morbidities in COPD. RESULTS: Tobacco smoke in the form of beedi smoking was the predominant smoke exposure in males, whereas smoke from biofuel burning was the predominant exposure in females. As compared to males, females were younger, reported more dyspnea, more severe bronchial obstruction, more exacerbations, and exhibited higher prevalence of systemic features. Also, females smoked less and had lesser incidence of productive cough, lower body mass index, lesser co-morbidities and less number of hospital admissions as compared to males. Males were more likely than females to have an emphysema-predominant phenotype, while airway-predominant disease was more common among females. CONCLUSION: The current study shows that gender-related differences do exist in COPD patients. Understanding these differences in etiological agent and clinical picture will help early diagnosis of COPD in females.

Sleep-wakefulness in alcohol preferring and non-preferring rats following binge alcohol administration.

The alcohol-preferring (P) rat is a valid animal model of alcoholism. However, the effect of alcohol on sleep in P or alcohol non-preferring (NP) rats is unknown. Since alcohol consumption has tremendous impact on sleep, the present study compared the effects of binge alcohol administration on sleep-wakefulness in P and NP rats. Using standard surgical procedures, the P and NP rats were bilaterally implanted with sleep recording electrodes. Following post-operative recovery and habituation, pre-ethanol (baseline) sleep-wakefulness was electrographically recorded for 48 h. Subsequently, ethanol was administered beginning with a priming dose of 5 g/Kg followed by two doses of 2 g/Kg every 8 h on the first day and three doses of 3 g/Kg/8 h on the second day. On the following day (post-ethanol), undisturbed sleep-wakefulness was electrographically recorded for 24 h. Our initial results suggest that, during baseline conditions, the time spent in each of the three behavioral states: wakefulness, non-rapid eye movement (NREM) sleep and REM sleep, was comparable between P and NP rats. However, the P rats were more susceptible to changes in sleep-wakefulness following 2 days of binge ethanol treatment. As compared to NP rats, the P rats displayed insomnia like symptoms including a significant reduction in the amount of time spent in NREM sleep coupled with a significant increase in wakefulness on post-ethanol day. Subsequent analysis revealed that binge ethanol induced increased wakefulness and reduced NREM sleep in P rats occurred mainly in the dark period. This is the first study that: (1) demonstrates spontaneous sleep-wake profile in P and NP rats, and (2) compares the effects of binge ethanol treatment on sleep in P and NP rats. Our results suggest that, as compared to NP rats, the P rats were more susceptible to sleep disruptions after binge ethanol treatment. In addition, the P rats exhibited insomnia-like symptoms observed during abstinence from alcohol in human subjects.