Pregnancy and Vaginal Childbirth Followed by Reconstructive Vulval Surgery in a Woman with Giant and Isolated Vulval Elephantiasis.

Isolated elephantiasis of the vulva refers to a gigantic swelling of the vulva without concomitant swelling of the lower limbs. It is a rarely reported entity and its occurrence during pregnancy has been reported only once. We report a case of an isolated vulval elephantiasis during pregnancy and we discuss the possible etiologies and management issues. Our patient had a successful vaginal delivery followed by a satisfactory genital reconstruction at eight months postpartum and no recurrence thereafter.

Angioinvasive mucormycosis in burn intensive care units: A case report and review of literature.

BACKGROUND: Mucormycosis is a rare, rapidly progressive and often fatal fungal infection. The rarity of the condition lends itself to unfamiliarity, delayed treatment, and poor outcomes. Diagnosis of fungal infections early enough to enable appropriate treatment occurs in less than half of affected patients. CASE SUMMARY: An 11-year-old girl with a history of 15% total body surface area scald burns involving both lower limbs progressed to develop angioinvasive mucormycosis. This further led to a thrombosis of the right external iliac artery and vein and rapidly progressive necrosis of surrounding soft tissues. She also had dextrocardia and patent foramen ovale. A right hip disarticulation and serial aggressive debridements were performed but she went on to develop systemic sepsis with multisystem involvement and succumbed to the infection. Pathology revealed mucor species with extensive vascular invasion. CONCLUSION: This case highlights the importance of maintaining vigilance for mycotic infections and acting appropriately when there are signs of fulminant wound infection.

Evaluation of skull bone viability and effect of early surgical intervention in electrical contact burns using 18 F-Sodium Fluoride PET-CT imaging.

OBJECTIVE: Electrical contact burns of the scalp cause serious morbidity and mortality. Early necrotic bone debridement and flap cover are crucial for successful wound closure. 18 F Sodium Fluoride (NaF), with high bone-to-soft tissue activity ratio, is useful for bone viability assessment. This study evaluated the role of 18 F NaF PET-computed tomography (CT) in objectively defining the extent and depth of nonviable calvarial bone, to guide adequate bone debridement. METHOD: Of 20 patients referred to our institute with electrical contact burns of the scalp during a 2-year period, 15 were enrolled in the study. Two weeks after the initial management, tracer uptake pattern was noted on 18 F NaF PET-CT of the head and exposed bone measured. Surgical bone debridement was based on scan findings, followed by wound closure. All patients underwent clinical evaluation and follow-up scan 3 months after surgery. RESULTS: Eight patients showed a central photopenic area in the exposed bone (maximum standardized uptake value [SUVmax] of 0.76 ± 0.14 with mean maximum dimensions 4.10 ± 1.76/2.67 ± 1.54 cm). High tracer uptake (SUVmax, 9.66 ± 6.03) was seen peripheral to the exposed bone (mean maximum dimensions, 8.14 ± 3.03/4.75 ± 1.61 cm). Postoperatively, there was no significant change in tracer uptake in the central debrided region or peri-debridement bone area under the flap. Clinically all patients showed a well-healed flap. CONCLUSION: 18 F NaF PET-CT appears useful for objective evaluation of skull bone viability and planning necrotic bone debridement in patients with electrical contact burns. However, additional studies with longer patient follow-up are required to validate these results.

Traumatic degloving injuries: a prospective study to assess injury patterns, management, and outcomes at a single center in northern India.

Purpose: This study investigated the epidemiology, management, outcomes, and postoperative disabilities of degloving soft tissue injuries (DSTIs) treated at a tertiary care center in northern India. Methods: A prospective study of patients with DSTIs was conducted over 15 months. The type of degloving injury, the mechanism of injury, and any associated injuries were analyzed using the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 along with the management, outcomes, and disabilities at a 3-month follow-up. Results: Among 75 patients with DSTIs, the average age was 27.5 years, 80.0% were male, and 76.0% had been injured in traffic accidents. The majority (93.3%) were open degloving injuries. Lower limbs were affected most often (62.7%), followed by upper limbs (32.0%). Fractures were the most commonly associated injuries (72.0%). Most patients required more than two procedures, including secondary debridement (41.3%), split skin grafting (80.0%), flap coverage (12.0%), or vacuum-assisted closure (24.0%), while five patients underwent conservative management for closed degloving injuries. Postoperative complications included surgical site infections (14.7%) and skin necrosis (10.7%). Two patients died due to septic shock and multiple organ dysfunction syndrome. The mean length of hospital stay was 11.5±8.1 days, with injuries affecting the lower limbs and perineum requiring longer hospital stays. The mean WHODAS 2.0 disability score at 3 months was 19. Most patients had mild disabilities. Time away from work depended largely upon the site and severity of the injury. Approximately 75% of patients resumed their previous job or study, 14% changed their job, and 8% stopped working completely due to residual disability. Conclusions: DSTIs are common injuries in trauma and management is challenging. Although open DSTI are clinically evident at secondary survey, closed degloving injuries may be missed in the primary survey, necessitating a high index of suspicion, thorough clinical examination, and protocol-based management. Primary preventive strategies (e.g., road safety protocols, preplacement training, and proper protective equipment in industries) are also needed to reduce the incidence of these injuries.

Assessing the effect of piezoelectric ultrasonic scaler tip wear on root surface roughness under influence of various working parameters: A profilometric and atomic force microscopic study.

Background: Assessing the effect of scaler tip wear on the root surface roughness using piezoelectric ultrasonic scaling device under influence of various working parameters, i.e. power setting, lateral force, and instrumentation time. Materials and Methods: An experimental study was conducted using 160 single-rooted tooth samples divided into two groups of new (n = 80) and worn tips (n = 80). Samples were prepared to examine the root surface roughness after being instrumented by new and worn piezoelectric ultrasonic tips (8 new/8 worn) at different parameters. The erosion ratio (ER) of the new/worn tip was examined under an atomic force microscope and roughness over root surface was measured by a contact surface profilometer. One-way analysis of variance test, post hoc Tukey's test, and independent t-test were used for intragroup, pair-wise multiple comparisons and intergroup comparison of average roughness (Ra) value. Results: A statistically significant difference was found between the ER of new and worn scaler tips (P < 0.001). Intragroup comparison between subgroups 1 and 8 showed a higher Ra value in both the groups (P < 0.005). There was a significantly higher Ra value of worn tips compared to new tips (P < 0.05). Significantly higher mean Ra value was shown when lateral force changed from 50 g to 100 g (P < 0.005). Conclusions: Increasing value of power setting, lateral force, and instrumentation time caused more surface roughness in worn-out scaler tips compared to new scaler tips. Lateral force and instrumentation time proved to be a major factor influencing surface roughness.

Epidemiology of electrical burns and its impact on quality of life - the developing world scenario.

BACKGROUND: Electrical burns are devastating injuries and can cause deep burns with significant morbidity and delayed sequelae. Epidemiological data regarding the etiology, socioeconomic differences and geographic variation are necessary to assess the disease burden and plan an effective preventive strategy. These severe injuries often lead to amputations and thus hamper quality of life in the long term. AIM: To identify the population at maximum risk of sustaining electrical burns. We also studied the impact of electrical burns on these patients in terms of quality of life as well as return to work. METHODS: The study was conducted at a tertiary referral teaching hospital over a period of eighteen months. All patients with a history of sustaining electrical burns and satisfying the inclusion criteria were included in the study. All relevant epidemiological parameters and treatment details were recorded. The patients were subsequently followed up at 3 mo, 6 mo and 9 mo. The standardized Brief Version of the Burn Specific Health Scale (BSHS-B) was adopted to assess quality of life. Statistical analysis was conducted using IBM SPSS statistics (version 22.0). A P value of < 0.05 was considered statistically significant. RESULTS: A total of 103 patients were included in the study. The mean age of the patients was 31.83 years (range 18-75 years). A significant majority (91.3%) of patients were male. The mean total body surface area (TBSA) in these patients was 21.1%. In most of the patients (67%), the injury was occupation-related. High voltage injuries were implicated in 72.8% of patients. Among the 75 high voltage burn patients, 31 (41%) required amputation. The mean number of surgeries the patients underwent in hospital was 2.03 (range 1 to 4). The quality of life parameters amongst the patients sustaining high voltage electrical burns were poorer when compared to low voltage injuries at all follow-up intervals across nine domains. In eight of these domains, the difference was statistically significant. Similarly, the scores among the amputees were poorer when compared to non-amputees. The difference was statistically significant in six domains. CONCLUSION: Electrical burns remain a problem in the developing world. Most injuries are occupation-related. The quality of life in patients with high voltage burns and amputees remains poor. Work resumption was almost impossible for amputees. These patients could not regain pre-injury status. Steps should be taken to create awareness and to implement an effective preventive strategy to safeguard against electrical injuries.

Pluripotent Stem Cells for Livestock Health and Production.

Pluripotent stem cells (PSCs) have unlimited capacity for self-renewal and differentiation so that they can potentially produce any cell or tissue of animal's body. The PSCs derived from livestock represents a more appropriate model than a rodent for investigating human diseases due to their higher anatomical and physiological resemblance with human. Apart from that, livestock PSCs hold immense promises for innovative therapies, transgenic animal production and their biomedical interest. The realization of the full potential of PSCs, however, depends on the elucidation of the molecular mechanisms which play a critical role in the maintenance of pluripotency and reprogramming procedure remains poorly understood in livestock which in turn impedes the generation of true PSCs and their usage for clinical research. An in-depth understanding of pluripotency is extremely essential for improving health and welfare of livestock animals. Therefore, the present review focuses on the milestone achievements of PSCs in livestock animals and their potential application in health and production of livestock.

Non-Invasive in Vivo Quantification of Directional Dependent Variation in Mechanical Properties for Human Skin.

Skin is the body's largest organ, and it shows non-linear and anisotropic behavior under the deformation. This behavior of the skin is due to the waviness and preferred orientation (in a particular direction) of collagen fibers. This preferred orientation of collagen fibers results in natural pre-tension and anisotropy of the skin. The knowledge of natural skin pre-tension and anisotropy is essential during incisions and surgery. The available suction-based devices quantify the anisotropy through the displacement field and cannot measure the stress-strain relation in particular directions. Therefore, in the current study, an in vivo full-field measurement suction apparatus was developed to measure the stress and strain of skin in all planar directions through a single experiment. First, this apparatus was tested on silicone substrates of known properties, and then it was used to test the skin of 12 human forearms. Further, to check the effect of hand stability on the measurements, the obtained results of the skin were compared with the results of a standard test performed in the same skin using a steady setup. The consistency between these two results confirms that the stability of the hand does not influence the measurements of skin properties. Furthermore, using the developed apparatus, the skin's anisotropy and its relation with the Kraissl's lines orientation was quantified by measuring the toe and linear moduli at an interval of one degree. The minimum and maximum values of the toe and linear moduli were 0.52 ± 0.09 and 0.59 ± 0.11 MPa, and 3.09 ± 0.47 and 5.52 ± 1.13 MPa, respectively. Also, the direction of maximum moduli was found almost similar to Kraissl's lines' orientation. These results confirm the contribution of skin pre-tension on the anisotropy of the skin. The present apparatus mimics the tissue expansion procedure, where observation of the test may be helpful in the selection of size and shape of the expander.

Cryobanking of primary somatic cells of elite farm animals - A pilot study in domesticated water buffalo (Bubalus bubalis).

Buffalo is an important farm animal species in South and South-east Asian countries. Cryopreservation allows long-term storage of somatic cells, which can be made available to research communities. This study aimed to 1) establish and cryopreserve somatic cells from elite buffaloes, and 2) share stored somatic cells and their associated data with researchers. To achieve these targets, somatic cells were established successfully from tail-skin biopsies of 17 buffaloes. The informative data such as buffalo details (breed, date of birth, sex, and age at the time of tissue biopsy collection, and production traits), the number of cryovials stored, and freezing dates were recorded in an electronic file and a printed inventory record. The established somatic cells were flat, spindle-shaped morphology, and expressed vimentin (a fibroblast-like cell type marker) and the negative expression of cytokeratin-18 (an epithelial cell type marker). Altogether, we cryopreserved 970 cryovials (0.1 million cells per vial) from two buffalo breeds, namely Murrah and Nili-Ravi (at least 45 cryovials per animal), for cryobanking. Somatic cell nuclear transfer (SCNT) experiments demonstrated the utility of cryopreserved cells to produce cloned buffaloes. Importantly, these cryopreserved somatic cells are made available to scientific communities. This study encourages the cryopreservation of somatic cells of elite farm animals for their utilization in cell-based research.

Major Upper Limb Replantation: An Account of Patient Tenacity.

Supplemental Digital Content is available in the text.

Early debridement and delayed primary vascularized cover in forearm electrical burns: A prospective study.

AIM: To look into the management options of early debridement of the wound, followed by vascularized cover to bring in fresh blood supply to remaining tissue in electrical burns. METHODS: A total of 16 consecutive patients sustaining full thickness forearm burns over a period of one year were included in the study group. Debridement was undertaken within 48 h in 13 patients. Three patients were taken for debridement after 48 h. Debridement was repeated within 2-4 d after daily wound assessment and need for further debridement. RESULTS: On an average two debridements (range 1-4) was required in our patients for the wound to be ready for definitive cover. Interval between each debridement ranged from 2-18 d. Fourteen patients were provided vascularized cover after final debridement (6 free flaps, 8 pedicled flaps). Functional assessment of gross hand function done at 6 wk, 2 mo, 3 mo and 6 mo follow-up. CONCLUSION: High-tension electrical burns lead to significant morbidity. These injuries are best managed by early decompression followed by multiple serial debridements. The ideal timing of free flap coverage needs further investigation.

Cutaneous mucormycosis of scalp and eyelids in a child with type I diabetes mellitus.

Scalp mucormycosis in children is extremely rare. We present a case of pediatric scalp mucormycosis caused by Rhizopus oryzae in a 9-year-old diabetic girl who was successfully diagnosed and treated with amphotericin B deoxycholate and wound debridement. At 3 months follow up, the patient was stable although she had lost her vision.

Comparison of the nutritional status and outcome in thermal burn patients receiving vegetarian and non-vegetarian diets.

BACKGROUND: The importance of adequate nutritional support in burned patients cannot be overemphasised. For adequate long-term compliance by the patients, diet should be formulated in accordance with their pre-burn dietary habits, religious beliefs, and tastes. PATIENTS AND METHODS: A study was conducted in 42 consecutive patients suffering from 10% to 50% of 2(nd) and 3(rd) degree thermal burns with the aim to compare nutritional status, clinical outcome, and cost-effectiveness of vegetarian and non-vegetarian diets. The patients were divided into two groups depending upon their pre-injury food habits. Total calories were calculated by Curreri formula. Both groups were compared by various biochemical parameters, microbiological investigations, weight, status of wound healing, graft take, and hospital stay and they were followed for at least 60 days postburn. RESULTS: The results were comparable in both groups. Vegetarian diet was found to be more palatable and cost-effective. CONCLUSION: Vegetarian diet is a safe and viable option for the patients suffering from burn injury. The common belief that non-vegetarian diet is superior to vegetarian diet is a myth.

Extensive ulnar nerve necrosis: a complication of tuberculoid leprosy.

Pure neural leprosy without cutaneous manifestations is a relatively rare manifestation of leprosy. It can present as a mono- or poly-neuritis with sensory and/or motor impairment. Neural leprosy may or may not be associated with thickening of the involved nerve. We report the case of a 14 year old boy with extensive ulnar nerve necrosis who was diagnosed to have tuberculoid leprosy. What makes this case unique is that we have here a case of pure neural leprosy with a single nerve turned 'necrotic'.

Unfavourable outcomes in maxillofacial injuries: How to avoid and manage.

Faciomaxillary injuries remain one of the common injuries managed by plastic surgeons. The goal of treatment in these injuries is the three-dimensional restoration of the disturbed anatomy so as to achieve pre-injury form and function. In this article, the authors review the anatomic, diagnostic and management considerations to optimise results and minimise the late post-traumatic deformities. Most of the adverse outcomes are usually a result of poorly addressed underlying structural injury during the primary management. An accurate physical examination combined with detailed computed tomographic scanning of the craniofacial skeleton is required to generate an appropriate treatment plan. This organised approach has proven effective in restoring the injured structures to pre-injury status. Multiple clinical cases are used to illustrate the different fracture patterns along with various surgical techniques to achieve an acceptable outcome. Early diagnosis and timely management of complications in these complex injuries is also discussed.

The management of perineal wounds.

Management of perineal wounds can be very frustrating as these invariably get contaminated from the ano-genital tracts. Moreover, the apparent skin defect may be associated with a significant three dimensional dead space in the pelvic region. Such wounds are likely to become chronic and recalcitrant if appropriate wound management is not instituted in a timely manner. These wounds usually result after tumor excision, following trauma or as a result of infective pathologies like hideradenitis suppurativa or following thermal burns. Many options are available for management of perineal wounds and these have been discussed with illustrative case examples. A review of literature has been done for listing commonly instituted options for management of the wounds in perineum.