Endoscopic push through tragal cartilage tympanoplasty: A 10-year retrospective review of our technique and outcomes

BACKGROUND Endoscopic ear surgery(EES)provides a magnified,high-definition view of the otological surgical field.EES allows otologists to avoid surgical incisions and associated postoperative complications.It is an ideal technique for the perfor-mance and teaching of tympanoplasty.AIM To examine the efficacy of total Endoscopic Push Through Tragal Cartilage Tympanoplasty(EPTTCT),at our institution over a 10-year period.METHODS A retrospective analysis of 168 cases of EPTTCT for closure of small to medium tympanic membrane perforations from 2013-2023 was conducted.Patient sex,age range(pediatric vs adult),etiology of injury,success rate,complications,and postoperative hearing status were collected.RESULTS Graft uptake results indicated success in 94%of patients,with less than a 2%complication rate.Postoperative pure tone audiometry demonstrated hearing status improvement in 69%of patients.CONCLUSION EPTTCT has been shown to be effective in tympanic membrane perforation closures with minimal complications.This study further demonstrates the efficacy and safety of these procedures in a single-center review.

Gastrointestinal radiation injury:Symptoms,risk factors and mechanisms

Ionising radiation therapy is a common treatment modality for different types of cancer and its use is expected to increase with advances in screening and early detection of cancer.Radiation injury to the gastrointestinal tract is important factor working against better utility of this important therapeutic modality.Cancer survivors can suffer a wide variety of acute and chronic symptoms following radiotherapy,which significantly reduces their quality of life as well as adding an extra burden to the cost of health care.The accurate diagnosis and treatment of intestinal radiation injury often represents a clinical challenge to practicing physicians in both gastroenterology and oncology.Despite the growing recognition of the problem and some advances in understanding the cellular and molecular mechanisms of radiation injury,relatively little is known about the pathophysiology of gastrointestinal radiation injury or any possible susceptibility factors that could aggravate its severity.The aims of this review are to examine the various clinical manifestations of post-radiation gastrointestinal symptoms,to discuss possible patient and treatment factors implicated in normal gastrointestinal tissue radiosensitivity and to outline different mechanisms of intestinal tissue injury.

Neoadjuvant radiotherapy for rectal cancer management

Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions.Most patients with early rectal cancer can be adequately managed by surgery alone.However,a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery.Neoadjuvant therapy involves a variety of options including radiotherapy,chemotherapy used alone or in combination.Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery.The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes,within an intact mesorectal package,in order to minimise local recurrence.It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties.Pre-operative staging including CT thorax,abdomen,pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential.Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy.While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure,which includes patients with nodal involvement,extramural venous invasion and threatened circumferential margin.The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.

Gastrointestinal radiation injury:Prevention and treatment

With the recent advances in detection and treatment of cancer,there is an increasing emphasis on the efficacy and safety aspects of cancer therapy.Radiation therapy is a common treatment for a wide variety of cancers,either alone or in combination with other treatments.Ionising radiation injury to the gastrointestinal tract is a frequent side effect of radiation therapy and a considerable proportion of patients suffer acute or chronic gastrointestinal symptoms as a result.These side effects often cause morbidity and may in some cases lower the efficacy of radiotherapy treatment.Radiation injury to the gastrointestinal tract can be minimised by either of two strategies:technical strategies which aim to physically shift radiation dose away from the normal intestinal tissues,and biological strategies which aim to modulate the normal tissue response to ionising radiation or to increase its resistance to it.Although considerable improvement in the safety of radiotherapy treatment has been achieved through the use of modern optimised planning and delivery techniques,biological techniques may offer additional further promise.Different agents have been used to prevent or minimize the severity of gastrointestinal injury induced by ionising radiation exposure,including biological,chemical and pharmacological agents.In this review we aim to discuss various technical strategies to prevent gastrointestinal injury during cancer radiotherapy,examine the different therapeutic options for acute and chronic gastrointestinal radiation injury and outline some examples of research directions and considerations for prevention at a pre-clinical level.

Subtotal colectomy in ulcerative colitis—long term considerations for the rectal stump

BACKGROUND The initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy.A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis.AIM To review the existing literature in relation to the significant long-term complications associated with the rectal stump,to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort.METHODS A systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis.A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum.RESULTS For rectal stump surveillance guidelines,20%recommended an interval of 6 mo to a year,50%recommended yearly surveillance 10%recommended 2 yearly surveillance and the remaining 30%recommended risk stratification of patients and different screening intervals based on this.All studies agreed surveillance should be carried out via endoscopy and biopsy.Increased vigilance is needed in endoscopy in these patients.Literature review revealed a number of options for surgical management of the remnant rectum.CONCLUSION The retained rectal stump needs to be surveyed endoscopically according to risk stratification.Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy.If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique.

Oral alkali therapy and the management of metabolic acidosis of chronic kidney disease:A narrative literature review

Chronic metabolic acidosis is a common complication seen in advanced chronic kidney disease(CKD). There is currently no consensus on its management in the Republic of Ireland. Recent trials have suggested that appropriate active management of metabolic acidosis through oral alkali therapy and modified diet can have a deterring impact on CKD progression. The potential benefits of treatment include preservation of bone health and improvement in muscle function; however,present data is limited. This review highlights the current evidence,available primarily from randomised control trials(RCTs) over the last decade,in managing the metabolic acidosis of CKD and outlines ongoing RCTs that are promising. An economic perspective is also briefly discussed to support decision-making.

The Ugly Side of Statins. Systemic Appraisal of the Contemporary Un-Known Unknowns

Cardio-vascular specialists have witnessed and actively participated in the revolutionary developments that have occurred in their field of specialization over the last few years. Cutting-edge technologies have led to dramatic improvements in life-expectancy and quality of life. An open-mind and pioneering attitude are necessary when exploring new frontiers to improve our patients’ health. However, naive indiscriminate acceptance of novel mainstream therapies is not always advisable and prudence is required in unearthing harmful, covert side effects. An objective review of contemporary vascular research was performed and industrial bias was sifted out for a fresh prospective on how to promote primary cardiovascular prevention with attainable lifestyle adjustments [1]. A comprehensive review of Pubmed, EM-BASE and Cochrane review databases was undertaken for articles relating to cardiovascular primary prevention and statin side effects with the aim of harmonising their roles within contemporary clinic practice. Particular attention was paid to large-scale randomised controlled trials on contemporary cardiovascular pharmacotherapies and their specific adverse effects on metabolic pathways which feature prominently in cardiovascular primary prevention and regenerative programmes. There is a categorical lack of clinical evidence to support the use of statin therapy in primary prevention. Not only is there a dearth of evidence for primary cardiovascular protection, there is ample evidence to show that statins actually augment cardiovascular risk in women, patients with Diabetes Mellitus and in the young. Furthermore statins are associated with triple the risk of coronary artery and aortic artery calcification. Cardiovascular primary prevention and regeneration programmes, through life style changes and abstaining from tobacco use have enhanced clinical efficacy and quality of life over any pharmaceutical or other conventional intervention.

Sustained virologic response following HCV eradication in two brothers with X-linked agammaglobulinaemia

X-linked agammaglobulinaemia (XLA) is a humoral immunodeficiency syndrome characterized from childhood by the absence of circulating B lymphocytes, absent or reduced levels of serum immunoglobulin and recurrent bacterial infections. For many affected patients, regular treatment with immunoglobulin is life saving. Hepatitis C viral (HCV) infection acquired through contaminated blood products is widely described in this patient cohort. The natural history of HCV infection in patients with XLA tends to follow a more rapid and aggressive course compared to immunocompetent individuals. Furthermore, standard anti-viral therapy appears to be less efficacious in this patient cohort. Here we report the cases of two brothers with XLA who contracted HCV through contaminated blood products. They were treated with a six month course of Interferon alpha-2b and Ribavirin. We report a sustained virologic response five years after completing treatment.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice.They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes.As the incidence of complicated diverticular disease and colorectal malignancy increases,so too does the extent of fistulous connections between the gastrointestinal and urinary systems.These complex problems will be more common as a factor of an aging population with increased life expectancy.Diverticular disease is the most commonly encountered aetiology,accounting for up to 80%of cases,followed by colorectal malignancy in up to 20%.A high index of suspicion is required in order to make the diagnosis,with ever improving imaging techniques playing an important role in the diagnostic algorithm.Management strategies vary,with most surgeons now advocating for a single-stage approach to enterovesical fistulae,particularly in the elective setting.Concomitant bladder management techniques are also disputed.Traditionally,open techniques were the standard;however,increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management.Unfortunately,due to the relative rarity of these entities,no randomised studies have been performed to ascertain the most appropriate management strategy.Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer.With radiotherapy being a major contributing factor in the development of these complex fistulae,optimum surgical approach and exposure has changed accordingly to optimise their management.Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling,macerated tissues or associated co-morbidities.One may plan for definitive surgical intervention at a later stage.Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available.An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described.In low lying fistulae,a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts.According to recent literature,it offers a high success rate in complex cases.

Using computed tomography scans to develop an ex-vivo gastric model

The objective of this research was to use abdominal computed tomography (CT) scans to non-invasively quantify anthropometrical data of the human stomach and to concomitantly create an anatomically correct and distensible ex-vivo gastric model. Thirty-three abdominal CT scans of human subjects were obtained and were imported into reconstruction software to generate 3D models of the stomachs. Anthropometrical data such as gastric wall thickness, gastric surface area and gastric volume were subsequently quantified. A representative 3D computer model was exported into a selective laser sintering (SLS) rapid prototyping machine to create an anatomically correct solid gastric model. Subsequently, a replica wax template of the SLS model was created. A negative mould was offset around the wax template such that the offset distance was equivalent to that of the gastric wall thickness. A silicone with similar mechanical properties to the human stomach was poured into the offset. The lost wax manufacturing technique was employed to create a hollow distensible stomach model. 3D computer gastric models were generated from the CT scans. A hollow distensible silicone ex-vivo gastric model with similar compliance to that of the human stomach was created. The anthropometrical data indicated that there is no significant relationship between BMI and gastric surface area or gastric volume. There were inter- and intra-group differences between groups with respect to gastric wall thickness. This study demonstrates that abdominal CT scans can be used to both non-invasively determine gastric anthropometrical data as well as create realistic ex-vivo stomach models.

CT Output Dose Performance-Conventional Approach versus the Dose Equilibrium Method

Current output dose measurement in CT is based on (CTDI). The conventional methodology of CT dosimetric performance characterization is not appropriate to modern CT scanners with helical scanning modes, dose modulation, array detectors and multiple slice planes or cone-beam irradiation geometries. AAPM TG 111 report recognizes the shortfall of the CTDI methods and recommends a new technique that more accurately characterizes the dose profile from modern CT scanners, which utilizes a short conventional ion chamber rather than a pencil chamber. We developed and characterize a in-house phantom design using a three separate anatomical regions of clinical scan sequences (Head, chest and abdomen), and determined the equilibrium dose in our dose equilibrium phantom, measured if the attenuation of the beam is the equal to that of CTDI Perspex phantom and compare CTDI dose estimations using a standard pencil chamber to the dose equilibrium phantom measurements. This methodology allows measurements of the accumulated dose for any clinical scan length and allowing measurement of the equilibrium dose. Using the new methodology, we determined that the CTDI approach can underestimate the dose by 25% to 35% and all of our dose values from the water phantom and farmer chamber were independently verified with TLD measurements.

Cervical Disc Replacement: A Systematic Review of Medline Indexed Literature

Anterior Cervical Discectomy and Fusion (ACDF) currently remains as the gold standard treatment for cervical disc herniation and Degenerative Disc Disease (DDD) refractory to conservative management. Even though anterior cervical fusion provides excellent clinical results, it has been implicated in abnormal kinematic strain on adjacent disc level resulting in symptomatic adjacent segment disease. Anterior cervical disc replacement (ACDR) is an alternative procedure to anterior cervical discectomy and fusion. The aims of cervical disc replacement were to preserve the motion at the index level and to protect the adjacent levels from accelerated symptomatic degeneration. The aim of this systematic review was to evaluate the outcomes of cervical disc replacement published in MEDLINE indexed literature. A literature search was carried out in medical electronic database MEDLINE. Keywords used for the search were Cervical vertebrae, Cervical spine, Neck, Intervertebral disc, Total disc replacement, Arthroplasty, Replacement, Treatment outcome. Two authors reviewed titles and abstracts of all two hundred and thirty six hits. The articles that satisfied the inclusion criteria were critically appraised while remaining articles were discarded. Anterior cervical disc replacement is a relatively new technology in spinal surgery. There are several short and intermediate term follow-up studies to prove the safety and efficacy of ACDR with satisfactory clinical and radiological outcomes. More intermediate to long-term follow-up studies are needed to prove the safety and efficacy of ACDR.

Critical appraisal of stem cell therapy in peripheral arterial disease: Do current scientific breakthroughs offer true promise or false hope?

Over the last forty years in the field of peripheral arterial disease, there has been a plethora of research into cell-based therapies for tissue repair, regeneration and angiogenesis, progressing from protein-based therapies to gene therapies to stem cell research. Initial pre-clinical research successes have given birth to a whole industry, aimed at translating these laboratory hopes into clinical successes. However, heretofore these expected clinical results have failed to materialize, in part due to the lack of attention to the ischaemic desert like tissue and systemically diseased patient into which the stem cells are being implanted. Unsatisfactory clinical outcomes on the treatment of Critical Limb Ischaemia (CLI) have forced researchers to direct their efforts to the less intimidating challenge of claudication and to lower their clinical outcome thresholds from superior to “non-inferior”. Major questions on safety and durability have also arisen. What needs to be objectively established is the impact on the net health outcome of these therapies. Infusion or injection for stem cell therapy is still considered experimental and investigational. In this review we examine the clinical evidence for angiogenic therapies, focusing specifically on stem cell trials, in an attempt to answer the question “Is stem cell therapy a failed experiment or will there be light at the end of the tunnel?”

Incidence of Oxa23 and Oxa51 Genes Associated with Bacterial Isolated from Patients with Urosepsis: Single Centre Prespective

Background: Urosepsis is one of the most common infections that require empirical broad spectrum antibiotics immediately after diagnosis. This has led to development of bacterial resistance by acquiring the capability to destroy the β-lactam ring. Methodology: This is a cross-sectional hospital-based study. The study was conducted from 2019 to 2020 at Gezira Hospital for Renal diseases and surgery (GHRDS). A hundred patients were diagnosed clinically with urosepsis and the isolated organisms were Escherichia coli, Staphylococcus aureus, Proteus mirabilis, Klebsiella pneumonia and Pseudomonas aeruginosa. The susceptibility test was conducted by Kirby Bauer disc diffusion technique according to clinical laboratory standard institute (CLSI) guidelines. Seventy eight samples of bacterial genomic DNA were confirmed by 16srRNA and multiplex PCR, were performed for genotypic blaOXA-51 and blaOXA-23 gene characterization of isolated bacteria. Then gel electrophoresis was used to identify the presence or absence of (blaOXA-51 and blaOXA-23) genes. Results: 88.5% (69/78) in 16srRNA detected. Using multiplex PCR, the frequencies of blaOXA-51 and blaOXA-23 genes were 13% and 10.1%, respectively. The percentages of isolates which yielded both blaOXA-51 and blaOXA-23 among P. aeruginosa was 25% (1/4), among K. pneumonia was 17% (1/6), and among E. coli was 8% (3/37). Only blaOXA-51 was detected in P. mirabilis 10% (1/10) and only blaOXA-23 was detected in S. aureus 5% (1/18). Conclusion: In this study, the presence of blaOXA-51 and blaOXA-23 genes was increased in the isolated bacteria.

Pellet Embolization after Subclavian Artery Injury:A Case Report

Acute upper limb ischemia caused by a gunshot penetrating vascular injury and subsequent arterial embolization by foreign body is uncommon in everyday practice and is associated with high morbidity/mortality rates, especially with emergency surgery. We present the case of a 72-year old male who attempted suicide using a gun. A gunshot entry wound was evident in the right upper chest region with no pellet exit wound. Radial pulses were palpable bilaterally. Angiography revealed right subclavian artery direct injury and pellet embolization to the brachial artery. The patient underwent open surgery, with reversed saphenous vein interposition graft to replace subclavian artery defect. A pellet was removed by a separate arteriotomy in the brachial artery. Associated injuries were clavicle-comminuted fracture and subclavian vein injury. The patient remained well 5 months later with no reported complications. In conclusions, the presence of radial pulses alone on clinical exam cannot rule out the presence of a significant vascular injury.

Utility of CT and MRI in assessment of mandibular involvement in oral cavity cancer

Objective:Oral cavity squamous cell carcinoma (SCC) may present with early invasion of mandibular bone.Preoperative planning of surgery is essential considering patient's postoperative quality of life.Our purpose was to evaluate the efficacy of computer tomography scan (CT) and magnetic resonance imaging (MRI) in detecting mandibular bone involvement in oral SCC.Methods:A retrospective study was conducted on 98 patients with SCC of floor of mouth,lower alveolus and retromolar trigone operated on with curative intent.Preoperative CT and MRI scans were re-reviewed by a consultant radiologist and original histology slides were rereviewed by 3 pathologists.Results:Forty-five patients were included in the final study.Combined CT and MRI had a sensitivity of 100% and a specificity of 72%.Conclusion:The results suggest that combined CT and MRI have diagnostic utility in detecting mandibular invasion by oral cancer,but with a significant false positive rate.

Laparoendoscopic single-site radical prostatectomy： technique and initial outcomes

Background Laparoendoscopic single-site surgery radical prostatectomy （LESS-RP） is a challenging urological procedure and needs to be further evaluated. This study was undertaken to illustrate the safety and initial results of pure LESS-RP with conventional available instruments.

年轻人和老年人热相关性慢性肾病的死亡:不同的发病机制,可能类似的解决方案?

根据世界卫生组织(WHO)的报告,全球变暖是对地球未来最大的威胁。气候变化导致过去10年间气候相关性灾害的较高发生率,其中包括热暴露。在无通常危险因素的年轻人中,因慢性肾病(CKD)患病率上升相关的病死率增加引起了人们的关注。这个问题尤其集中于中美洲、印度、斯里兰卡和埃及等地区,这些地方的年轻人长期暴露于过热的环境中。这种疾病有时被称为中美洲肾病或不明原因慢性肾病(CKDu)。在室内工作也会被累及,其中影响更多的是女性,包括在有烤箱的厨房、冶炼厂和钢铁锻造厂工作的人们。全球约有40%的人口居住于全年受到过热气候影响的地区。世界各地早发型CKD的发病率都在增长,其中萨尔瓦多的病死率最高。

A fifteen-year review of skin allergy testing in Irish patients with symptomatic rhinitis

Objective:Our objective was to review skin prick allergy testing(SPAT)results in patients with symptomatic rhinitis in an Irish population.Methods:A fifteen-year retrospective review of our database of symptomatic patients with rhinitis was performed.All patients who had SPAT performed during this interval were included.Data was analysed in terms of demographics and dominant allergens.Results:1158 patients were included.617 Females vs 541 Males.Age range five to eighty-five years old.Mean age thirty-four years.49%of our patients tested positive to at least one aeroallergen.The most common allergens were dust mites(23%)and timothy grass(22%).Patients born during the Irish pollen season(April-July)were between 5 and 7 times more likely to be sensitive to timothy and ryegrass pollens compared to others tested.241 patients had both SPAT and serum allergen specific IgE testing(SASIgET)performed;positive results were consistent between both groups.Conclusion:Results demonstrated that half of our patients with symptomatic rhinitis had allergen sensitisation.Dust mites and grass were the main allergens in our area.Our nurse led clinic has allowed efficient patient education and the development of a unique Irish SPAT database.Retesting a patient with a known allergy test result it is not indicated.