Sex Difference and Rupture Rate of Intracranial Aneurysms: An Individual Patient Data Meta-Analysis

Background and Purpose: In previous studies, women had a higher risk of rupture of intracranial aneurysms than men, but female sex was not an independent risk factor. This may be explained by a higher prevalence of patient- or aneurysm-related risk factors for rupture in women than in men or by insufficient power of previous studies. We assessed sex differences in rupture rate taking into account other patient- and aneurysm-related risk factors for aneurysmal rupture. Methods: We searched Embase and Pubmed for articles published until December 1, 2020. Cohorts with available individual patient data were included in our meta-analysis. We compared rupture rates of women versus men using a Cox proportional hazard regression model adjusted for the PHASES score (Population, Hypertension, Age, Size of Aneurysm, Earlier Subarachnoid Hemorrhage From Another Aneurysm, Site of Aneurysm), smoking, and a positive family history of aneurysmal subarachnoid hemorrhage. Results: We pooled individual patient data from 9 cohorts totaling 9940 patients (6555 women, 66%) with 12 193 unruptured intracranial aneurysms, and 24 357 person-years follow-up. Rupture occurred in 163 women (rupture rate 1.04%/person-years [95% CI, 0.89–1.21]) and 63 men (rupture rate 0.74%/person-years [95% CI, 0.58–0.94]). Women were older (61.9 versus 59.5 years), were less often smokers (20% versus 44%), more often had internal carotid artery aneurysms (24% versus 17%), and larger sized aneurysms (≥7 mm, 24% versus 23%) than men. The unadjusted women-to-men hazard ratio was 1.43 (95% CI, 1.07–1.93) and the adjusted women/men ratio was 1.39 (95% CI, 1.02–1.90). Conclusions: Women have a higher risk of aneurysmal rupture than men and this sex difference is not explained by differences in patient- and aneurysm-related risk factors for aneurysmal rupture. Future studies should focus on the factors explaining the higher risk of aneurysmal rupture in women.

To fight or to flee? -- a systematic review of ectopic pregnancy management during Covid-19.

Background: Concerns about virus spread during surgery contributed to changes in the clinical management of ectopic pregnancies (EP) during the COVID19 pandemic. Objective: To compare published data on EP management prior versus during the COVID-19 pandemic and evaluate any difference in the management, rupture rate and complications where Early Pregnancy Unit (EPU) structures exist. Search strategy: We performed a systematic review of the literature using a keyword strategy based on our PICO criteria. Selection criteria: We included studies which recruited women diagnosed with ectopic pregnancy and compared the management during and prior the COVID-19 pandemic peak. Data collection and Analysis: Three independent reviewers screened the literature and extracted the data. Meta-analysis of the data was performed on Revman. Main Results: Our search yielded 34 studies; 12 were included in our meta-analysis (3122 women). We found no difference in the type of management of EP between the pre-Covid and Covid cohorts [2714 women, OR 0.99(0.63-1.55), p=0.96, I2=77%]. We observed a non-statistically significant reduction of surgical management within the EPU branch ([OR 0.47(0.19-1.13), p=0.09, I2=81%]). There was no difference in the ectopic rupture rate in units with EPU [OR= 0.66 (0.33-1.31), p=0.24, I2=37%]. In contrast, in non-EPU (NPEU) the risk of ruptured EP [OR=2.86(1.84-4.46), p<0.01 I2=13%] and complications [OR=1.69(1.23-2.31), p=0.001, I2=45%] were increased. Conclusions: The worldwide trend was not reflected in the UK suggesting that EPU may have contributed to prompt diagnosis and safe management of EP. Funding: No funding was received. Keywords: ectopic pregnancy, COVID 19, meta-analysis, early pregnancy unit

Rupture Rate, Functional Outcome and Patient Satisfaction after Primary Flexor Tendon Repair with the Modified 4-Strand Core Suture Technique by Tsuge and Using the Arthrex FiberLoop® with Early Motion Rehabilitation

Purpose:Our hypothesis was that the rupture rate after primary flexor tendon repair in the modified 4-strand core suture technique using the FiberLoop® (Arthrex, Munich, Germany) is lower than in other suture materials and functional outcome and patient satisfaction are superior compared to the current literature. Patients and methods: A 2-stage retrospective, randomized follow-up study of 143 patients treated with the Arthrex FiberLoop® after flexor tendon injury in zones 2 or 3 from May 2013 to May 2017 was performed. In the 1st stage, the rupture rate of all patients was assessed after a follow-up of at least one year by interview to exclude revision surgery. In the 2nd stage, 20% of the patients could be randomly clinically examined. Functional parameters, such as finger and wrist range of motion measured by goniometer, grip strength measured by Jamar dynamometer (Saehan, South Korea), patient satisfaction measured by school grades (1–6), pain levels measured by visual rating scales (0–10) and functional outcome according to the DASH-score were assessed. The Buck-Gramcko and Strickland scores were calculated. The length of sick leave was recorded. Results: A rupture rate of 2.1% was recorded. 29 patients (20%) were followed up at a mean of 34 ± 7.5 months postoperatively. 10.3% of these patients had an incomplete fingertip palm distance. The mean postoperative grip strength was 24 ± 3.1 kg. 93% of the patients were very satisfied with the treatment. No patient complained of pain postoperatively. The mean postoperative DASH score was 6.7 ± 2.8 points. The mean Buck-Gramcko score was 14 ± 0.2 points. 93% of the patients had excellent and 7% good results according to the Strickland score. 67% of patients had a work accident and returned to work at a mean of 4 ± 0.2 months postoperatively. 31% of patients suffered a non-occupational injury and returned to work at a mean of 3 ± 0.4 months postoperatively. Conclusions: Primary flexor tendon repair in the modified 4-strand core suture technique using the Arthrex FiberLoop® has proven to be a viable treatment option in our series. The rupture rate was lower than in other suture materials. It leads to acceptable pain relief, grip strength and functional outcome. Level of Evidence: IV; therapeutic.

Episiotomy and Its Complications

Objectives: This study aimed to evaluate the frequency of episiotomy and its early complications in natural vaginal delivery in the maternity ward of Ali Ibn Abitaleb (AS) Hospital in Zahedan from 2014 - 2016. Methods: In this cross-sectional study, which was conducted in 2017, the archives of women who gave birth between 2014 - 2016 were reviewed. Data were collected using information forms and analyzed by SPSS software. Results: Of 418 women were reviewed, the episiotomy rate was 54.5%; there was a significant association between parity and mother age with episiotomy rate. Moreover, 24-hour pain frequency, perineal rupture rate, hematoma rate was significantly higher in the episiotomy group. First- and fifth-minute Apgar of the neonates in the episiotomy group was significantly lower. Conclusions: In overall, the episiotomy rate was 54.5%, and there was a significant association between parity and mother age with episiotomy rate.

Preservation of the Tibial Stump During Anterior Cruciate Ligament Reconstruction Surgery Did Not Increase the Rate of Surgery for Symptomatic Cyclops Lesions

Background: Preservation of the tibial stump during anterior cruciate ligament reconstruction (ACLR) is controversial. While proposed benefits include enhanced graft revascularization, improved proprioception, and decreased graft rupture rates, a potential complication is the development of a symptomatic cyclops lesion. It is therefore important to determine whether any benefits outweigh potential complications. Purpose: To determine whether greater preservation of the tibial stump remnant would be associated with a decreased graft rupture rate without a concomitant increase in the rate of surgery for symptomatic cyclops lesions at 2 years after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of 658 patients in whom the amount of tibial stump preserved was classified as no stump (n = 228), <50% (n = 342), or >50% (n = 88) was followed up for 2 years, with graft ruptures and surgical treatment for cyclops lesions recorded. Contingency and Kaplan-Meier survival analyses were used to determine trends among the 3 remnant preservation groups in terms of graft rupture rates and surgery for cyclops lesions. Subgroup analysis was also conducted to examine sex-based differences. Results: There was no significant association between graft rupture rates and remnant preservation. There was a significant trend for fewer operations for symptomatic cyclops lesions with greater remnant preservation when the entire cohort was analyzed ( P = .04) and also when only female patients were analyzed ( P = .04). Conclusion: Although preservation of the tibial stump remnant was not associated with a reduced graft rupture rate, it was also not associated with increased rates of surgery for symptomatic cyclops lesions.

Comparing Surgical and Conservative Treatment on Achilles Tendon Rupture: A Comprehensive Meta-Analysis of RCTs

Background: The Achilles tendon is the strongest tendon in human and is frequently injured, mainly in the young to middle age active population. Increasing incidence of Achilles tendon rupture (ATR) is still reported in several studies. Surgical repair and conservative treatment are two major management strategies widely adopted in ATR patients, but the consensus of the optimal treatment strategy is still debated. We aimed at thoroughly reviewing the ATR topic with additional assessments and performed a most comprehensive meta-analysis of randomized controlled trials (RCTs).Method: We comprehensively searched PubMed, Embase, Cochrane, and ClinicalTrial.gov and retrieved all RCTs comparing surgical and conservative treatment on ATR for further analysis. Two independent reviewers performed data extraction and random effect model was adopted when I2 &gt; 50%, with data presentation of risk ratio, risk difference, or mean difference and 95% confidence interval.Results: A total of 13 RCTs were included in this meta-analysis. A significant difference was observed in re-rupture, complication rate, adhesion to the underlying tendon, sural nerve injury, and superficial infection. A substantial reduction in re-rupture rate could be observed for surgical treatment while the complication rate was higher compared with conservative treatment.Conclusion: Surgical treatment revealed significance in reducing the re-rupture rate but was associated with a higher complication rate, while conservative treatment showed similar outcomes with a lower complication rate. Collectively, we recommend conservative treatment if patients' status and expectations are suitable, but surgeon and physician discretion is also crucial in decision making.

Management of Flexor Pollicis Longus Injury - Experience in BSMMU

Anatomic consideration: Flexor pollicis longus (FPL) tendon arises from volar aspect of middle third of radial shaft and from the lateral aspect of interosseous membrane. The anterior interosseous branch of median nerve innervates the muscle in the proximal/mid forearm. Blood supply is predominantly from radial artery. Abstract Purpose: The purpose of this study was to evaluate the results of repair and one stage reconstruction of FPL injury and to find out complications and rupture rate and effectiveness of repair and reconstruction. Method: This retrospective review was carried out in Bangabandhu Sheikh Mujib Medical University from January 2015 to December 2018. 30 consecutive patients were enrolled in the study. 4 strands core suture with simple circumferential suture were used for repair and reconstruction. Tendon transfer was done in few cases. Power grip, active and passive range of motion, American Society for Surgery of the Hand criteria and Buck-Gramcko criteria were used for outcome assessment. Results: Out of 30 patients, 20 (67%) were male and 10 (33%) were female. Mean age was 30 years. Mean follow up period was 1.5 years. All cases were due to various type of cut injuries. In subjective assessment 40% patients achieved excellent, 50% good, 10% fair results. Our rupture rate was 0%. Mean power grip, pinch grip strength of index and key pinch strength were 87.5%, 68.18% and 86.66% respectively from contralateral normal hand. Active range of motion of IP joint was 64.28% of normal side. Conclusions: Use of 4 strands core sutures and early active motion give good to excellent results in 90% cases of repair, reconstruction and tendon transfer in FPL injuries with 0% rupture rate J Shaheed Suhrawardy Med Coll, December 2020, Vol.12(1); 20-26

Retrospective Analysis of Follow-up and Treatment of Patients With Ectopic Pregnancy and Our 6 Years of Clinical Experience

Objective: In this study, we aimed to make a retrospective analysis of the follow-up and the treatment of the patients who were admitted to our clinic, which is a tertiary center, with the preliminary diagnosis of ectopic pregnancy between 2010-2016 in order to contribute to the data related to ectopic pregnancy in our country.Materials and Methods: We retrospectively evaluated the follow-up and the treatment of 452 patients who were admitted to our clinic with a diagnosis of ectopic pregnancy between 2010-2016. We separated these cases into different groups according to their diagnosis, the way of treatment and results.Results: The study was conducted in …….. Hospital, between 2010-2016 with 452 female cases. We did not visualize any ectopic mass in 12,6% of the cases (n = 57); 85% (n = 385) was tubal; 0.2% (n = 1) was cornual; 1.2% (n = 5) was ovarian, 0.2% (n = 1) was heterotropic; 0.4% (n = 2) was molar pregnancy, and 0.2% (n = 1) was scar pregnancy. Methotrexate(MTX) treatment success rate was 72.7% 17% (n = 77) of the cases used MTX; general rupture rate of the cases were 25,7% (n = 116); rupture rate after MTX treatment was 27.2% (n = 21). In the MTX group the rate of detecting an ectopic mass was significantly higher (p = 0.001; p <0.01). 74.1% (149 cases) of the cases we performed laparoscopy and 25.8% (53 patients) of the cases we performed laparatomy. 86% (173 patients) was performed salpingectomy, 10.9% (18 patients) salpingostomy, and 2.9% ovarian resection.Conclusion: Looking at the data in our clinic, we use follow-up, surgical and medical treatment methods. The success rate of medical treatment was 72.7% and laparoscopic surgery was performed in 74.1% of the cases.

Mast Cell Promotes the Development of Intracranial Aneurysm Rupture

Background and Purpose: Inflammation has emerged as a key component of the pathophysiology of intracranial aneurysms. Mast cells have been detected in human intracranial aneurysm tissues, and their presence was associated with intramural microhemorrhage and wall degeneration. We hypothesized that mast cells play a critical role in the development of aneurysmal rupture, and that mast cells can be used as a therapeutic target for the prevention of aneurysm rupture. Methods: Intracranial aneurysms were induced in adult mice using a combination of induced systemic hypertension and a single injection of elastase into the cerebrospinal fluid. Aneurysm formation and rupture were assessed over 3 weeks. Roles of mast cells were assessed using a mast cell stabilizer (cromolyn), a mast cell activator (C48/80), and mice that are genetically lacking mature mast cells (Kit W-sh/W-sh mice). Results: Pharmacological stabilization of mast cells with cromolyn markedly decreased the rupture rate of aneurysms (80% versus 19%, n=10 versus n =16) without affecting the aneurysm formation. The activation of mast cells with C48/80 significantly increased the rupture rate of aneurysms (25% versus 100%, n=4 versus n=5) without affecting the overall rate of aneurysm formation. Furthermore, the genetic deficiency of mast cells significantly prevented aneurysm rupture (80% versus 25%, n=10 versus n=8, wild-type versus Kit W-sh/W-sh mice). Conclusions: These results suggest that mast cells play a key role in promoting aneurysm rupture but not formation. Stabilizers of mast cells may have a potential therapeutic value in preventing intracranial aneurysm rupture in patients.