Dr. Ashish Anand
Department of Orthopaedic Surgery, GV Montgomery Veteran Affairs Medical Center, Jackson, MS, USA.

ISBN 978-93-90888-07-8 (Print)
ISBN 978-93-90888-08-5 (eBook)
DOI: 10.9734/bpi/hmmr/v5

This book covers key areas of medicine and medical research. The contributions by the authors include mental representation, orthodontic smile, aesthetic smile, drawing content analysis, Acute kidney injury, COVID-19, endotoxicosis, hemofiltation, therapeutic apheresis, plasma exchange, hemosorbtion, mitochondrial NADH, microcirculation, NADH redox state, microcirculatory haemoglobin oxygenation, multiparametric monitoring, hemorrhagic shock, blood flow redistribution, pandemic influenza, live attenuated influenza vaccine, pandemic vaccine, classical reassortment, preclinical and clinical trials, safety, vaccine virus shedding, Vascular anomaly, hemangioma, venous malformation, lymphatic malformation, arteriovenous malformation, left ventricular diastolic dysfunction, echocardiography, skeletal hot spot characterization, Rong's Retention Index, Dr. V. Siva's modification, rheumatoid arthritis, polyamines putrescine, spermidine, spermine, interconversion, human sperm, human reproduction, hyperglycaemia, diabetes mellitus, cardiovascular risk markers, isolated pulmonic stenosis, severe pre-eclampsia, caesarean section, colorectal carcinoma, familial adenomatous polyposis, appendicectomy, cholecystectomy. This book contains various materials suitable for students, researchers and academicians in the field of medicine and medical sciences.


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The Mental Representation of the Smile Before and After Orthodontic Treatment

Maria do Rosário Dias, Ana Ferreira, Valter Pedroso Alves, Ana Delgado

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 1-9

Background: Understanding the importance, value, and self-image that the smile represents in the daily life of the individual remains a subject of high scientific interest.

Aim: The present qualitative and exploratory study aims at understanding the importance of the self-perception of the mouth and smile on the mental representation of self-image and the well-being of the individual.

Materials and Methods: The convenience sample consisted of 151 children and youngsters of both genders, ages 8 - 24 years, who used an orthodontic appliance and were invited to draw two portraits of their mouth/smile.

Results: The results suggest differences in the mental representation of the mouth and the smile, namely in the investment of the drawings before and after the use of the orthodontic appliance, as well as in the expressiveness and manifestation of emotions.

Discussion and Conclusions: The results suggest that the main reason that leads participants to the treatment is related to aesthetic and functional issues in which the maximizing of the mental representation of the Orthodontic Smile emerges as a new categorization of the perfect smile.

Perspectives of Therapeutic Apheresis in Acute Kidney Injury

V. A. Voinov, M. G. Kovalev, K. S. Karchevsky, O. V. Isaulov, Y. V. Voinova

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 10-17

Acute kidney injury is a serious complication of various inflammatory diseases of the abdominal and thoracic cavities, severe injuries and burns, eclampsia and sepsis, and a number of infectious diseases. Considering such a variety of etiologies there is a main pathogenesis feature, which is based on endoxemia with accumulation of a number of toxic products that cause disturbances in the vessels endothelium permeability with perivascular edema associated with decrease in the renal blood flow, glomerular filtration, tubular necrosis and oligoanuria. The most common tactics of treatment is to perform kidney replacement therapy, mainly different methods of hemofiltration. However, not all toxic products are removed and the mortality rate remains quite high. The inclusion of hemosorption and plasmapheresis in the complex of therapeutic measures gives more favorable and stable results, showing a significant reduction of the mortality rate.

Tissue Oxygen Homeostasis and LifenLight Score (LLS) of Patients in Critical Care Medicine

Avraham Mayevsky, Michael Tolmasov, Hofit Kutai-Asis, Mira Mandelbaum-Livnat

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 18-56

Patients admitted to the emergency room or intensive care units (ICUs) need real time monitoring of body oxygen balance. As of today the availability of monitoring devices that provide real time data on tissue level of oxygen homeostasis is very limited. The involvement of mitochondrial dysfunction in many pathological states such as stroke, sepsis or heart failure is calling for real time evaluation of this intracellular organelle. In order to avoid the deterioration of the most vital organs in the body (brain and heart) we are proposing to monitor a less vital organ, such as the urethral wall, that serves as an early warning signal for the deterioration of body oxygen balance. This review describes the use of a multiparametric monitoring device (CritiView) connected to the patient’s urethral wall via a 3-way Foley catheter that measures in real time 4 parameters representing tissue oxygen balance. Mitochondrial NADH is measured by surface fluorometry/reflectometry. In addition, tissue microcirculatory blood flow, tissue reflectance and hemoglobin oxygenation are measured as well. The measured 4 parameters could be integrated together with systemic hemodynamic parameters to provide in real time a new Tissue Metabolic Score (TMS). The device was tested both in vitro and in vivo in a small animal models (rats and gerbils) exposed to changes in local or systemic oxygen balance. Also preliminary clinical trials in patients undergoing vascular or open heart surgery were performed. In patients, the monitoring started immediately after the insertion of a 3-way Foley catheter (urine collection) to the patient and was stopped when the patient was discharged from the operation room. The results show that monitoring the Urethral wall oxygen balance provides real time information correlated to the state of the surgical procedure performed. We found that the TMS of the urethral wall could serve as an early warning signal for the possible damage that may develop in the most vital organs in the body.

Approaches in the Development of the Potentially Pandemic LAIV Candidates

Irina Kiseleva, Natalie Larionova

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 57-70

Each year, influenza causes a significant acute respiratory disease burden. In addition, influenza pandemics periodically occur. Vaccination is the best tool for the prevention of both seasonal and pandemic influenza. Currently, three different types of influenza vaccines are available on the market – killed (inactivated), live attenuated (LAIV) and recombinant. As of today, the interest in LAIV has increased, largely because WHO has recognized its advantages in the case of a pandemic situation. Two alternative approaches to generate LAIV candidates are currently existing – classical reassortment of wild type influenza virus with cold–adapted master donor virus (MDV) in embryonated chicken eggs (UltravacÒ, Russia) and reverse–genetics technique (FluMistÒ, the USA). Avian influenza viruses remain a major pandemic threat. In response to this threat, a number of killed and live pandemic vaccines have been developed worldwide. The objective of this chapter is to summarize data from the development and preclinical and clinical evaluations of potentially pandemic LAIVs on the cold–adapted A/Leningrad/134/17/57 master donor virus backbone obtained by routine reassortment procedure. The described in this chapter LAIV candidates are reassortants of wild–type (WT) virus with MDV of 6:2 and 7:1 genomic composition (6 MDV genes: 2 WT genes or 7 MDV genes : 1 WT gene, respectively). Despite the differences in this genome formula, LAIV candidates of H5, H7, and H2 subtypes acquired temperature sensitivity, cold–adaptation, and attenuation for different animal models. In clinical trials, they were safe and immunogenic for healthy adult volunteers. The collected data indicate that 7:1 reassortants carrying the only HA gene of potentially pandemic virus and the seven remaining genes from the MDV might be prospective candidates for the pandemic LAIV.

Paediatric Vascular Anomalies

Hamzaini Abdul Hamid, Riza Sulaiman, Fathinul Fikri Ahmad Saad

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 71-78

Vascular anomalies is very wide and challenging topic. It can be devided into 2 main classification 1) vascular tumour and 2) vascular malformation. Imaging play an important role in the diagnosis of vascular anomalies which include ultrasound including Doppler study and cross sectional imaging either CT scan or Magnetic Resonance Imaging. Rarely these lesions require tissue biopsy. A knowledge on vascular anomalies classification is important so that everyone is talking with similar language that easy to understand and the imaging features of these lesions are also important in order to deliver appropriate treatment to the patient.

Aim: The Scintimetric characterization principle is applied to the identification and quantification of presence of diastolic dysfunction using the gated thallium SPECT scans. The assessment and differentiation of Left Ventricular Diastolic Dysfunction is critical in the treatment of heart failure patients. Diastolic dysfunction is currently inferred primarily from E and A wave changes in m-mode echocardiographic changes at the mitral orifice. In the gated myocardial perfusion imaging from the time volume curve the Peak Flow Rate and Time to Peak Flow rate are derived and assessed for the presence and extent of diastolic dysfunction. All of these parameters represent changes in the left ventricular muscle mass caused by the underlying diastolic dysfunction.This study aims to highlight the diagnosis of Left Ventricular Diastolic Dysfunction for the first time using visual Phase image analysis in Gated Thallium SPECT Scan. The presence of inhomogeneous, irregular, and insufficient tracer accumulation in diastolic phase images compared to normal and homogeneous tracer distribution in systolic phase images is thought to indicate diastolic dysfunction. It also thrives to quantify the changes observed by calculating the S/D ratio by dividing the Systolic Counts by the diastolic counts obtained from the raw phase images. It is correlated with echocardiographic stages of the Diastolic Dysfunction.

Materials and Methods: This study consists of 75 Males in the age group of 28 to 63 years with mean age of 47.9 +/- 7.8 years and 25 Females in the age range of 32 to 55 years with mean age of 49 +/- 6.8 years. After exercising the patients on a bicycle ergometer using Bruce Protocol 2 mCi of Thallum-201 was injected intravenously Gated SPECT MPI were acquired using Siemens Dual Head E-Cam Gamma Camera. The analysis was done using GATED SPECT PERFUSION ANALYSIS Protocol. The S/D ratio was calculated using the region ratio count protocol in the ICON software.

Results: The discordance between the Diastolic and systolic images were found in 98/100 (98%)- Image1,2. The Echocardiographic evidence of Diastolic dysfunction as classified into Grade II and grade III using E / A ratio analysis was found in 87/100 (87%). The diabetes was seen in 16/100 (16%) and Hypertension was encountered in 63/100 (63%). The S/D ratio was 1.27 +/- 0.32 in Grade IILVDD and 1.68 +/- 0.03 Grade III LVDD.

Conclusion: Finally, the utility of direct visual individual phase image analysis in the detection of Left Ventricular Diastolic Dysfunction is highlighted for the first time. The Scintimetric Characterization of the same with the help of S/D ratio has been shown to be different between stage II and stage III LVDD.

Aim: This study aims to document the utility of Scintimetric Characterization of the Skeletal Hot Spots seen in the Bone Scans done in this referral center during 2016-2017, in differentiating metastatic and non-metastatic lesions.

Materials and Methods: The study group consists of 59 patients referred for metastatic evaluation and non-specific bone complaints to our center. The whole body bone scan was done 3hrs after the intravenous injection of 15 to 25 mCi of Tc99m MDP using GE Millenium Gamma Camera. The 24hr whole body bone scan was repeated in all those who had focal hot spots in their scans and who accepted voluntarily with the consent of the referring physician. The counts in the focal hot spots at 3 and 24 hr bone scan images were calculated using the region ratio count protocol. The Dr. V. Siva’s Retention Ratio was calculated by dividing the3hr counts by the 24 hr counts in the focal hotspots. The values of metastatic and non- metastatic groups were tabulated and analyzed.

Results: In our series 35/59 (59%) scans were negative and did not show any focal changes. 24/59 (41%) scans showed focal changes in the form of hot spots. Out of the total 69 hot spots analyzed 31 (45%) had the value of 13.07 ± 1.02 indicating metastatic nature and 38 (55%) had the value of 6.07 ± 0.62 confirming the benign nature of the lesions. Thus the metastatic group had the mean value which is almost twice that of the benign group. The statistical evaluation confirmed the significant difference between the two groups.

Conclusion: It can be concluded that the Scintimetric characterization of the focal hot spots by Dr. V. Siva’s retention ratio effectively provides useful means to differentiate between the metastatic and non-metastatic lesions in the tertiary referral diagnostic center as well.

Retrospective Analysis of Scintimetric Characterization of Primary Tumors by Dual Phase PETCT Study

V. Sivasubramaniyan, Sai Shiv Narayan, K. Venkataramaniah

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 94-99

Aim: This retrospective analysis of the scintimetric characterization of the primary tumors of various cancers using the dual phase PETCT scans thrives to establish the utility of the Rong's Retention ratio and the Dr. V. Siva's modification of RRI.

Methods: In the proven cases of various cancers the SUV max values were obtained in the Early and Delayed PETCT scans using the ROI method over the FDG avid primary sites. The PETCT scans were done using the GE Discovery IQ unit one and 4 hours after the I.V injection of 5 to 10 mCi of F18- FDG after overnight Fasting. The image analysis and the SUV were calculated using the Advantage 4.7 software provided by GE. Total of 19 primary sites at various locations were included and the calculated SUV max were used to arrive at the Rongs Retention Index (RRI) and Dr. V. Siva's modification of RRI. The values were tabulated and analyzed.

Results: The Rong's retention ratio had a very narrow range with wide overlapping. However the Dr. V. Siva's modification of RRI showed much wider values with a definite cut off level. The statistical evaluation of the data confirm that the Dr. V. Siva's modification of RRI significantly correlates well with the Rong's Retention Index (RRI).

Conclusion: It can be concluded that the scintimetric characterization of the primary tumors of various cancers is possible and might be useful in the identification of the primary malignancies.

Aim: This study aims to propose the utility of Scintimetric Characterization of the tracer activity uptake in the joints afflicted by Rheumatoid arthritis in the bone scans.

Materials and Methods: Three out of five patients of confirmed Rheumatoid arthritis who had bone scans for Bone and joint pains showed presence of skeletal hot spots in various joints. They were subjected to the scintimetric evaluation of the skeletal hot spots by Dr. V. Siva’s retention ratio by repeating the 24 hr delayed bone scans. The 58 skeletal hotspots seen in various joint spaces were subjected to the calculation of maximum counts in 3 hr and 24 hr bone scans. They were tabulated and 3/24 hr Dr. V. Siva’s Retention Ratio was calculated and analyzed.

Results: They showed a mean of 5.91 ± 0.35 and standard error of means as 0.3496. The estimated variance was 8.8408 and the estimated standard deviation was 2.9734. For this sample size the estimated variance was 6.6306 and estimated standard deviation was 2.575 by HOJO’s modification. This was unavoidable due to very small size of the Sample population.

Conclusion: Thus this study had shown that the scintimetric evaluation of the skeletal hotspots in the Rheumatoid Arthritis Patients showed a definitive benign value. This could provide a firm base line value to assess the response to treatment and progression as well.

A Short Review on Polyamine Metabolism in Sperm Cell

José D. Méndez

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 105-109

Polyamines putrescine, spermidine and spermine are natural constituents of living organisms. In mammals they are present in tissues and fluids. Since they are basic molecules interact with a variety of polyanions such as nucleic acids. Deoxyribonucleic acid is stabilized by polyamines. Recently, attention has been focused to understand their role in diabetes mellitus and reproductive abnormalities not only in male but also in female reproduction. Several investigations have demonstrated that in un-controlled diabetic men, sperm deoxyribonucleic acid is glycated and fragmented, which has relevance in human reproduction. In our laboratory we show that polyamines prevent both processes. This paper provides information on polyamine synthesis, interconversion and physiological effects in sperm cell with emphasis in human sperm cell.

Polyamines: The Other Legacy of Antonie Van Leeuwenhoek

José D. Méndez

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 110-113

The idea of writing this short chapter is to highlight the enormous contributions that Leeuwenhoek made to science with the development of the microscope, an instrument that allowed him to make countless observations of diverse biological materials, the same were microorganisms, plant tissues, animal tissues, observations in body fluids such as blood, semen and others. He first observed crystals of spermine and other polyamines in human semen. Although he did not know it, we now know that these wonderful molecules regulate multiple functions in organisms and contribute to homeostasis. Polyamines have been studied in humans under conditions of health and disease. Reference is made here to its role related to pancreatic function in hyperglycemic conditions.

Recurrent Diabetic Trigger Finger. Percutaneous or Open Release as Surgical Treatment is More Effective in Long-term Outcomes?

G. Kastanis, A. Pantouvaki, P. Kapsetakis, C. Christoforidis, C. Chaniotakis, G. Magarakis

Highlights on Medicine and Medical Research Vol. 5, 23 April 2021, Page 114-122

Stenosing Tenosynovitis is a common complication in diabetic patients. The release of the A1 pulley is the final treatment (open or percutaneous). The functional outcomes and complication rates of two methods (open versus percutaneous release) for recurrent trigger finger in diabetic patients are compared in this study.

Materials and Methods: 114 patients with diabetes mellitus and an average age of 48 years (range 28-64 yrs old) were treated for recurrent trigger finger. The modified Quinnell grading system was used as a selection criterion for the classification of trigger digit. The patients were divided in two groups randomly. Group A, included 52 patients who were treated with open release of A1 pulley and group B included 62 patients who were treated with percutaneous release using the tip of an 18-gauge or knife (Ophtalmic Corneal/ Scleral knife 19 Gauge).

Results: The median follow-up was 12 months (range from 10-14 months). The results were based on the Visual Analogue Scale (VAS), Quick Dash, and Gilberts & Wereldasma Questionnaire. At 3 months, the results seemed to be better in group B, while there was no statistical difference at six months and at one year postoperatively.

Conclusions: In long-term postoperative follow-up, both surgical approaches (open and percutaneous release) produced comparable therapeutic efficacy. The advantages though of the percutaneous release over the classic open method in short-term outcomes are: 1) low cost, 2) less complication rates and 3) immediate functional recovery.

Background: We recently documented better efficacy of glimepiride in non obese subjects for delaying progression from Pre diabetes to type 2 diabetes as compared to metformin in obese subjects over duration of 5-9 years (mean, 7.2±0.2). Metformin was the first-line therapeutic agent among newly diagnosed overweight patients with diabetes. Moreover, no deaths or adverse cardiovascular events occurred in either group and this finding may be attributed to beneficial changes in lipids and cardiovascular surrogate markers. However, the effects of interventions on lipids and cardiovascular surrogate markers were not reported.

Objective: Therefore, Cardiovascular risk factors including Lipid fractions, e.g. serum Total cholesterol (TC), Triglyceride (TG), Low density Lipoprotein cholesterol (LDLC), High Density Lipoprotein Cholesterol (HDLC) and other markers, e.g. Homocysteine (HomC), highly sensitive C-Reactive Protein (CRP), Fibrinogen (FIBR) and Plasminogen Activator Inhibitor1 (PAI1) were assessed prior to intervention and at interval of 6 months’ in subjects with Pre diabetes; lean treated with glimepiride and obese administered metformin.

Subjects and Methods: 18 non obese subjects, 10 men and 8 women ages 27-78 years and 20 obese subjects, 10 men and 10 women with ages 32-81 years with Pre diabetes (fasting plasma glucose, 100 – 125 mg/dl and/or HbA1c, 5.7-6.4%) participated in the study. The study period was 5-9 years (mean, 7.2 ± 0.2). Non obese subjects received glimepiride and obese subjects were administered metformin. Subjects were counseled with lifestyle intervention (appropriate diet and exercise) at each visit during the study. Comparisons were conducted between lipids and CV markers at entry, at six months and at the last visit of the study for individual group as well as between groups for levels at baseline and at the end of the study period.

Results: In glimepiride group, marked improvements occurred in all parameters following treatment (Post Rx) at 6 months and were sustained till the end of the study HbA1C (%): 6.2 ± 0.2, 5.5± 0.1*, 5.7 ± 0.1*; TC (mg/dl): 212± 15, 174 ± 13*,178 ± 14*; TG (mg/dl): 202± 32, 162± 28*, 178± 14*; LDLC: 130± 12, 105± 10*, 109± 9*; Non HDLC(mg/dl): 181 ± 24, 130 ± 14*,109± 9*; HomC (? Mol/l): 18± 3, 11± 2*, 12 ± 2*; CRP(Units): 13 ± 3, 6 ± 2*,5 ± 2*; FIBR (mg/dl): 403 ± 41, 296 ± 32*, 289± 28*; PAI1 (ng/ml): 18 ± 4, 13 ± 3*, 12 ± 4*; Post Rx vs. Pre Rx, p<0.05 for all values]. HDLC was not significantly altered. Similar changes were also noted in obese subjects treated with metformin. No significant differences were also noted between 2 groups at the entry, 6 months or the end of study.

Conclusion: In subjects with Pre diabetes, glimepiride is as effective in improving lipid profiles and cardiovascular surrogate markers in nonobese when compared with metformin in obese subjects thus explaining similar cardiovascular outcomes in both groups.

Isolated Pulmonic Stenosis is a rare cardiac lesion leading to a right ventricular outflow tract obstruction and potentially a fixed right sided cardiac output. It is graded based on severity of stenosis and the peak pressure gradient. A thorough understanding of the dynamics of a cardiac lesion is imperative while administering an anaesthetic to such a patient. To complicate matters, concomitant pregnancy in a patient with Pulmonic Stenosis presents a challenge. Early diagnosis, increased frequency of antenatal visits as pregnancy progresses, and formulation of a plan for labour, delivery and childbirth is imperative. Avoiding cardiac decompensation, maintaining fetomaternal sufficiency and post-operative management in an enhanced maternal care setting are recommended.

Introduction: Familial adenomatous polyposis (FAP) is a rare diagnosis in East Africa. It is less common in females than in males and occurs around the age of puberty. The author reports a case of a 21 year old gentleman presenting with occasional passage of blood stained stool, and found to have familial adenomatous polyposis coli. This is followed by a literature review on the pathogenesis, clinical features and treatment options of FAP in East Africa.

Presentation of Case: This patient presented with a strong family history of familial adenomatous polyposis, blood stained stool and a rectal mass. A total proctocolectomy and ileoanal anastomosis was carried out. The postoperative course of this patient was uneventful.

Discussion: The typical gross pathological and histological features of familial adenomatous polyposis and rectal adenocarcinoma were seen on the resected colorectal specimen. In addition this study reviews the literature regarding the clinical presentation, pathological characteristics and treatment options of familial adenomatous polyposis coli.

Conclusion: FAP should always be considered in a young patient presenting with a strong family history of CRC. Colonoscopy should be performed on these patients with early symptoms and those patients with a strong family history of FAP. In East Africa, the creation of a permanent stoma is unacceptable and therefore a proctocolectomy and Brooke ileostomy will not be a desirable option in a young patient in this part of the world.

Background: In many surgical conditions, laparoscopic surgery has been used for surgical access. In the West, laparoscopic cholecystectomy is the gold standard treatment for cholecystitis. On the other hand controversy has been generated with laparoscopic appendicectomy due to the cost, time consuming nature of the procedure, together with many trocar sites which in all approximate to the length of an open appendicectomy incision. The advantages of laparoscopic surgery include an early return to normal lifestyle, shorter hospital stay and a reduced postoperative analgesia requirement. The purpose of this study is to audit the initial laparoscopic units experience in a developing country in East Africa.

Methods: This was a retrospective study conducted in the Department of Surgery. All patients that consented to laparoscopic cholecystectomy and laparoscopic appendicectomy over the initial period of 13 months were included in this study.

Results: A total of thirty (30) patients consented to having laparoscopic surgery; Ten (10) patients consented to laparoscopic cholecystectomies with a male:female ration of 1:2.33 and twenty (20) patients consented to laparoscopic appendicectomies with a male:female ratio of 1:1.2. The mean operating time was 58.5 minutes for laparoscopic cholecystectomy and 40.45 minutes for laparoscopic appendicectomy. The duration of post-operative admission ranged from 3 days to 5 days with a mean duration of 4.2 days for laparoscopic cholecystectomy and from 2 days to 5 days with a mean of 2.65 days for laparoscopic appendicectomy. No complications were reported apart from spinal headache in 2 patients (2.6%) out of the total laparoscopic procedures. There were no readmissions over the one month of follow up.

Conclusions: Laparoscopic cholecystectomy and laparoscopic appendicectomy allows for early discharge and is safe. In Uganda, the low incidence of cholecystitis compared to the higher incidence of appendicitis, supports the adoption of laparoscopic appendicectomy compared to cholecystectomy for hand and eye coordination training. The surgeons’ initial cases of laparoscopic procedures have demonstrated an adequate level of safety which supports laparoscopic appendicectomy to acquire the basic laparoscopic surgery skills.