Three-Dimensional Analysis of Craniofacial Structures of Individuals With Nonsyndromic Unilateral Complete Cleft Lip and Palate.

ABSTRACT: Cleft lip and palate (CLP) is one of the most common congenital deformities. Primary surgeries at an early age result in scar formation, which may impede the growth of craniofacial structures of the maxilla. Orthodontist's role in the management of individuals with CLP is important and starts from the time of birth. The knowledge of craniofacial structures in individuals with a cleft is essential for treatment planning. The purpose of this study was to analyze and compare craniofacial structures of cleft and noncleft side of individuals with non-syndromic unilateral complete cleft lip and palate (NSUCCLP) using cone-beam computed tomography (CBCT). CBCT scans of individuals with NSUCCLP (n = 42) were retrieved from the databases of two cleft centers, which followed the same protocols for timing and type of primary surgeries and secondary alveolar bone grafting (SABG). DICOM files of CBCT scans were integrated into Dolphin 3D software, and analysis was carried out in multiplanar views. The craniofacial structures of individuals with NSUCCLP were analyzed using fourteen parameters. Measurements were also recorded between the cleft and noncleft sides for comparison. The volume of the maxilla was generated by isolating it from adjacent structures on a 3D reconstructed model. MAWC, MAWPM1, MAWPM2, MAWM1, and MV of the cleft side was less than noncleft side (P < 0.05). MHP @ N Aper is less on the noncleft side (P < 0.05). There is an asymmetry of structures around the dentoalveolar and nasal region; however, asymmetries were not affected at deeper structures of the craniofacial region of individuals with NSUCCLP.

Morpho-Functional Septorhinoplasty in Adult Patients With Unilateral Cleft Lip Nasal Deformity: A Comprehensive Approach.

PURPOSE: The aim of this study was to introduce a morpho-functional technique of rhinoplasty for correction of defective nasal morphology of the secondary unilateral cleft lip and improvement of air passage through the nose. MATERIALS AND METHODS: The described comprehensive approach follows the rule of 5 R's: relieve, resect, reposition, restructure, and restrengthen. The extended septal graft serves as a columellar strut on the one hand and as a spreader graft on the other hand. RESULTS: The described morpho-functional septorhinoplasty technique is effective for correction of the unilateral cleft lip nasal deformity because it improves the symmetry of the nose, improves the morphology of the alar cartilage, and increases the nasal tip projection. An improvement in breathing occurs as a result of restored symmetry of the ala and nasal vestibule. CONCLUSIONS: Morpho-functional septorhinoplasty is a practical tool to handle adult patients with secondary cleft nasal deformities.

Correction to: Once-daily sustained-release matrix tablets of nicorandil: Formulation and in vitro evaluation.

When the article was first published, there was an inadvertent typo error in the spelling of "K. Raghuram Reddy". The correct name should be Raghu Rami Reddy Kasu.

Anti-proliferative and anti-malarial activities of spiroisoxazoline analogues of artemisinin.

A series of spiroisoxazoline analogues of artemisinin was synthesized by employing 1,3-dipolar cycloaddition between various in situ generated nitrile oxides and artemisitene. All the synthesized compounds were tested for their anti-proliferative and anti-malarial activities. Among the compounds tested, compound 11a was found to be potent against the HCT-15 cancer cell line with IC50 = 4.04 µM when compared to 5-fluorouracil (IC50 = 35.53 µM). DNA cell cycle analysis shows that 11a was inhibiting cell proliferation at the G2/M phase. Compound 11b was found to be most active against Plasmodium falciparum with IC50 = 0.1 µM and also blocked host hemoglobin hydrolysis by the falcipain-3 receptor. It was demonstrated to have better dynamics of parasite killing efficiency than artemisinin. Molecular docking studies revealed that these compounds interacted with falcipain-3 receptor sites.

Placement of an antibiotic oral pack on the hard palate after primary cleft palatoplasty: a randomized controlled trial into the effect on fistula rates.

OBJECTIVE: The objective of this study is to determine whether placement of an antibiotic oral pack on the hard palate reduces fistula rates after primary cleft palatoplasty. SUBJECTS AND METHODS: This study was a parallel blocked randomized controlled trial. The study consisted of two groups of 100 patients each with non-syndromic unilateral complete cleft lip, alveolus, and hard and soft palate that underwent primary palatoplasty. Group A had an oral pack placed on the hard palate for 5 days postoperatively while group B did not. Occurrence of fistulae between both groups was tested using odds ratios (OR). RESULTS: In 2% of the patients in group A, a fistula was found 6 months after palatal surgery. In contrast, in 21% of the patients in group B, a palatal fistula could be confirmed. The fistula occurrence in group A was statistically significantly lower than that in group B (OR = 0.0768, CI = [0.02 … 0.34], p < 0.001). CONCLUSION: The findings of this study provide evidence that the rate of fistula formation after primary palatoplasty is significantly reduced if a pack soaked with antibiotic cream is placed on the palate postoperatively for 5 days. CLINICAL RELEVANCE: The use of an antibiotic pack after cleft palate repair can be recommended to prevent occurrence of oronasal fistulae.

A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction.

PURPOSE OF REVIEW: This study aimed to systematically review small bowel obstruction (SBO), focusing on recent changes in diagnosis/therapy. RECENT FINDINGS: SBO incidence is about 350,000/annum in the USA. Etiologies include adhesions (65%), hernias (10%), neoplasms (5%), Crohn's disease (5%), and other (15%). Bowel dilatation occurs proximal to obstruction primarily from swallowed air and secondarily from intraluminal fluid accumulation. Dilatation increases mural tension, decreases mucosal perfusion, causes bacterial proliferation, and decreases mural tensile strength that increases bowel perforation risks. Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation. Physical exam may reveal restlessness, acute illness, and signs of dehydration and sepsis, including tachycardia, pyrexia, dry mucous membranes, hypotension/orthostasis, abdominal distention, and hypoactive bowel sounds. Severe direct tenderness, involuntary guarding, abdominal rigidity, and rebound tenderness suggest advanced SBO, as do marked leukocytosis, neutrophilia, bandemia, and lactic acidosis. Differential diagnosis includes postoperative ileus, narcotic bowel, colonic pseudo-obstruction, mesenteric ischemia, and large bowel obstruction. Medical resuscitation includes intravenous hydration, correcting electrolyte abnormalities, intravenous antibiotics, nil per os, and nasoenteral suction. Abdominal CT with oral and intravenous gastrografin contrast is highly sensitive and specific in detecting/characterizing SBO. SBO usually resolves with medical therapy but requires surgery, preferentially by laparoscopy, for unremitting total obstruction, bowel perforation, severe ischemia, or clinical deterioration with medical therapy. Overall mortality is 10% but increases to 30% with bowel necrosis/perforation. Key point in SBO is early diagnosis, emphasizing abdominal CT; aggressive medical therapy including rehydration, antibiotics, and nil per os; and surgery for failed medical therapy.

Pelvic Fracture Urethral Injuries in Children: A Case Report and Appraisal of Their Emergency Management.

Pelvic fracture urethral injuries are uncommon injuries that are frequently overlooked in the emergency department. We present a case of a 2-year-old girl whose urethral trauma was initially missed and potentially worsened by the placement of a urinary catheter. The clinical and diagnostic features of these rare injuries are discussed along with the controversies surrounding urinary catheter placement and retrograde urethrography.

Clinical guidelines for imaging and reporting ingested foreign bodies.

OBJECTIVE: The purpose of this article is to familiarize radiologists with the specific characteristics of foreign bodies, obtained from image interpretation, to guide further management. Details of object morphologic characteristics and location in the body gained through imaging form the backbone of the classification used in the treatment of ingested foreign bodies. CONCLUSION: The characteristics of foreign bodies and predisposing bowel abnormalities affect the decision to follow ingested objects radiographically, perform additional imaging, or proceed with endoscopic or surgical removal.

Options for the nasal repair of non-syndromic unilateral Tessier no. 2 and 3 facial clefts.

BACKGROUND: Non-syndromic Tessier no. 2 and 3 facial clefts primarily affect the nasal complex. The anatomy of such clefts is such that the ala of the nose has a cleft. Repairing the ala presents some challenges to the surgeon, especially to correct the shape and missing tissue. Various techniques have been considered to repair these cleft defects. AIM: We present two surgical options to repair such facial clefts. MATERIALS AND METHODS: A nasal dorsum rotational flap was used to treat patients with Tessier no. 2 clefts. This is a local flap that uses tissue from the dorsal surface of the nose. The advantage of this flap design is that it helps move the displaced ala of a Tessier no. 2 cleft into its normal position. A forehead-eyelid-nasal transposition flap design was used to treat patients with Tessier no. 3 clefts. This flap design includes three prongs that are rotated downward. A forehead flap is rotated into the area above the eyelid, the flap from above the eyelid is rotated to infra-orbital area and the flap from the infraorbital area that includes the free nasal ala of the cleft is rotated into place. RESULTS AND CONCLUSIONS: These two flap designs show good results and can be used to augment the treatment options for repairing Tessier no. 2 and 3 facial clefts.

Perceptions of family members of children with cleft lip and palate in hyderabad, India, and its rural outskirts regarding craniofacial anomalies: a pilot study.

Objective : This pilot study aimed to understand cultural perspectives on cleft anomalies in the community of Hyderabad, India, and its rural outskirts. Design : Interviews focusing on perceptions of cleft lip and palate were conducted using a 21-item interview guide approved by the director of the Gosla Srinivas Reddy Institute of Craniofacial Surgery (GSR). Settings : Interviews were conducted at GSR, a specialty surgical center located in Hyderabad, India. Patients and Participants : All patients who presented to GSR with either cleft lip, cleft palate, or cleft lip and palate at the time of this study were included. Results : Of the 23 families interviewed, 12 mothers believed the cleft was caused by an eclipse, and two believed the scientific explanation their physician offered. Fourteen families were offered no explanation for the cleft lip and/or palate at the time of their first physician visit. No families practiced non-Western methods for treatment of the cleft. One family identified beliefs held in the community that their child with a cleft lip was bad luck. Conclusion : A commonly held belief in this community in India is that cleft lip, cleft palate, or cleft lip and palate are caused by an eclipse. Physicians appear to be providing families with insufficient education on cleft impairments. Data generated from studies similar to this can be used to design educational protocols that address this gap in community understanding of orofacial clefting.

Emergency ABO-incompatible living donor liver transplantation in Wilson disease-induced acute liver failure.

We report the clinical outcome of an emergency ABO incompatible-liver transplantation (LT) for an 8-year-old child with Wilson's disease-induced acute liver failure. The pretransplant anti-A antibody titer was 1:64, and hence he underwent three cycles of conventional plasma exchange as pretransplant liver supportive treatment for deranged coagulopathy and liver function followed by one cycle of immunoadsorption (IA) prior to LT. The posttransplant immunosuppression consisted of rituximab, tacrolimus, mycophenolate mofetil, and corticosteroid. The patient had anti-A isoagglutinin rebound with elevated aminotransferases levels from postoperative day 7 for which he was restarted on IA plasmapheresis, but antibody titers did not decrease. Hence, he was switched to conventional plasmapheresis (CP) with which anti-A antibody titers decreased. The total dose of rituximab (150 milligrams/square meter of body surface area) was given in two divided doses of 75 mg at D-1 and D + 8 which was much less than the dose conventionally advocated (375 milligrams/square meter of body surface area). He is clinically well with good graft function without rejection after 1 year of follow-up. This case illustrates that IA and CP in conjunction with adequate immunosuppression is a viable approach in emergency ABO-incompatible-LT in Wilson disease-induced acute liver failure.

Improving Adolescent Violent Trauma Outcomes With a Hospital-Based Violence Prevention Initiative.

BACKGROUND: Violent trauma results in significant morbidity/mortality in Black/Hispanic males aged 15 to 24 years. Hospital- and community-level interventions may improve patient and community outcomes. OBJECTIVE: To determine if a hospital-based violence prevention intervention using community outreach workers was associated with improved violent trauma patient postdischarge follow-up and reinjury rates. METHODS: This is a retrospective, single-center, cohort study of admitted violent trauma patients to a public hospital in the Bronx, NY. Data were collected from a convenience sample of patients aged 15 to 24 years admitted with International Classification of Diseases, 10th Revision, codes for gunshot wound, stab wound, or physical assault from August 2014 to April 2018. The exposure variable was documentation of intervention team evaluation during admission. The outcome variables included attending >50% scheduled postdischarge follow-up visits, and subsequent violent reinjury (gunshot wound, stab wound, blunt assault) during the study time period. Multivariable regression models were used to determine the association between the exposure and outcome variables. RESULTS: A total of 535 patients were evaluated and were primarily male (92.5%), Black (54%)/Latino (36.4%), with mean age of 19.1 years. Patients in the exposure group had increased odds of attending >50% of scheduled clinic postdischarge follow-up visits (odds ratio, 2.29; 95% confidence interval 1.59-3.29) and decreased odds of subsequent violent reinjury presentation (odds ratio, 0.41; 95% confidence interval 0.22-0.75) 3 months after hospital discharge. CONCLUSION: A hospital-based violence prevention intervention may be associated with decreased odds of violent reinjury and increased odds of postdischarge scheduled appointment adherence in admitted pediatric violent trauma patients.

Ocular Hypertelorism: Principles and Management.

Background: Ocular hypertelorism (OH) was initially considered as un-differentiated congenital cranio-facial deformity, however, I.T Jackson mentioned it as teleorbitism, considering it as increase in the inter-canthal width, inter-pupillary as well as inter-orbital distance as a result of lateralization of the orbital complex in total. Furthermore, Sailer further refined it and included the distance from the lateral orbital wall, i.e. he denoted increased inter-orbital distance along with the distance between lateral orbital walls as true hypertelorism. This condition is rare and is seen in association with midline congenital defects affecting the cranio-facial region. Classification and review of cases: The ideal time for the OH correction is usually between 5 and 8 years of age. However, the management of OH is complex, and several techniques have been described in literature for the same. Here, we describe our classification of OH, along with the evolution of the surgical aspects, the key treatment principles we follow, together with the types of the osteotomies and their indications. Furthermore, we delineate the four main principles that we have set for OH management. Results: Though the improvement in appearance is seen immediately post-surgery, however, this challenging surgery faces a multitude and common postoperative complications which have been represented in this article. The surgeon needs both the technical expertise and an inclination towards aesthetics for the execution of such procedures. Conclusion: It is preferred that the management of OH should be individualized as per the stage of the craniofacial growth and the psychosocial needs of the patient and the parents.

Comprehensive Morpho-Functional and Dental Rehabilitation of a Complete Unilateral Cleft Lip and Palate Patient.

Congenital clefts cause compromised function and esthetics, inadvertently affecting a patient's social and mental health. These defects can be successfully managed by a multidisciplinary team that can provide holistic care from birth till adulthood and beyond. A 17-year-old girl with left side congenital cleft, who had undergone cleft surgeries at our center, reported with a chief complaint of a missing front tooth in the upper region. Clinical and radiographic investigations showed a need for tertiary grafting, which was done using an autologous iliac graft. After six months, a dental implant was placed and immediately loaded after implant stability quotient assessment. Treatment of cleft patients is arduous and technique sensitive and should be done following pre-defined protocols. Each case should be handled by a multidisciplinary team giving attention to each aspect of the treatment requirement. It is an added advantage if the treatment is holistically catered at a single center as it provides patient comfort and avoids patient dependence on past records.

Is There an Age Cutoff for Intracranial Pressure Monitoring?: A Propensity Score Matched Analysis of the National Trauma Data Bank.

BACKGROUND: Despite mostly favorable past evidence for use of intracranial pressure monitoring (ICPM), more recent data question not only the indications but also the utility of ICPM. The Fourth Edition Brain Trauma Foundation guidelines offer limited indications for ICPM. Evidence supports ICPM for reducing mortality in patients with severe traumatic brain injury (TBI) and cites decreased survival in elderly patients. METHODS: All patients ≥ 18 years of age with isolated TBI, head Abbreviated Injury Scale (AIS) ≥ 3, and a Glasgow Coma Scale (GCS) ≤ 8 between 2008 and 2014 were included from the National Trauma Data Bank. Exclusion criteria were head AIS = 6 and death within 24 hours. Patients with and without ICPM were compared using TBI-specific variables. Patients were then matched via propensity-score matching (PSM), and the odds ratio (OR) of death with ICPM was determined using logistic regression modeling for 8 different age strata. RESULTS: A total of 23,652 patients with a mean age of 56 years, median head AIS of 4, median GCS of 3, and overall mortality of 29.2% were analyzed. After PSM, ICPM was associated with death beginning at the age stratum of 56-65 years. Intracranial pressure monitoring was associated with survival beginning at the age-group 36-45 years. DISCUSSION: Based on a large propensity-matched sample of TBI patients, ICPM was not associated with improved survival for TBI patients above 55 years of age. Until level 1 evidence is available, this age threshold should be considered for further prospective study in determining indications for ICPM.

Apical extrusion of debris with root canal instrumentation in primary teeth: A systematic review.

Aim: This study aimed to systematically review available literature of in vitro studies on apical extrusion of debris through rotary instrumentation in comparison to manual instrumentation in pediatric endodontics, and also to perform a comparison between various rotary instrumentation systems for assessment of debris extrusion. Materials and Methods: A comprehensive search was conducted on PubMed, Medline, Cochrane Library, Embase, Scopus, and Google Scholar without any language restriction and year of publication. A planned search strategy was made for PubMed and applied to other databases. After full-text reading, 7 articles were selected for quantitative synthesis. Modified CONSORT checklist of items for reporting in vitro studies of dental materials was used for quality assessment of included studies. Results: Root canal preparation with rotary instrumentation led to lesser apical debris extrusion than manual instrumentation. Self-adjusting file system was associated with the least debris extrusion among all included studies, followed by ProTaper Next, Kedo-S, ProTaper, K3, Mtwo, Revo-S, and Wave One. Conclusion: More apical debris extrusion was seen with manual instrumentation than rotary instrumentation. Furtrhermore, variance in debris extrusion was seen with different rotary file systems.

Reconstruction options in pediatric population with hemi or total mandibulectomy defects: A systematic review.

Purpose: Mandibular pathologies causing extensive defects in pediatrics is relatively rare, and sparse literature is available for the reconstructive options of the same. The main aim is to provide optimum esthetics and function. Materials and methods: PubMed, Cochrane CENTRAL, Embase, MEDLINE and Scopus databases were searched for articles published only in English language up to May 2021, involving reconstruction of hemi or total mandibulectomy defects in patients with the age of 8 years or less, associated with benign or malignant pathology. Primary outcome variable was the success of reconstruction. Qualitative analysis was performed using a microsoft excel-sheet. Results: Of the 2201 articles reviewed, only fourteen were selected for data extraction. 22 patients were included. Fifteen were benign, six were malignant pathologies, and one was not defined. Hemi-mandibulectomy was performed in twenty-one cases, while one underwent total mandibulectomy. Condyle was preserved in five cases, while was removed in nine. Single-stage reconstruction was done in nineteen cases, while second-stage reconstruction was done in the other three. Reconstruction was done with fibular graft in thirteen cases, while CCG was used in others with variable follow-up time. Though minor complications were observed, success was observed in all cases post reconstruction with either fibula or CCG graft, defined either by function, or growth. Conclusion: Irrespective of the age-group, nature of pathology and size of the defect, reconstruction should be considered with either fibula or CCG in single-stage, as they are equally efficacious, with minor complications. Well-defined reconstructive paradigm should be developed for pediatric mandibular reconstruction.

Nasal symmetry after different techniques of primary lip repair for unilateral complete cleft lip with or without cleft of the alveolus and palate: A systematic review.

The aim of this systematic review was to establish the effect of different surgical repairs for the lip on nasal symmetry. PubMed, Scopus, Embase, Cochrane CENTRAL, and Ovid databases search was performed initially for only English-language articles, in patients with unilateral complete cleft lip with or without cleft alveolus and palate (UCCLAP) who were younger than 1 year of age and undergoing cleft lip repair, and are published from the earliest data available up to December 31, 2020. The primary outcome variable was nasal symmetry, with reported complications being secondary variables. A qualitative synthesis was provided. A total of 19,828 records were obtained, and 17 articles were selected for final review. Assessment of the risk of bias of the included randomized controlled trials (RCTs) (N-1) was done with the Cochrane Risk of Bias 2 (RoB-2) tool, and the ROBINS-I tool was used for non-randomized studies (n = 14). Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to evaluate the quality of the body of evidence. The majority of the included studies compared the triangular repair with the rotation advancement (RA) techniques, and preferred RA or its modifications. In terms of the nasal symmetry, the Fisher repair proved to be superior to the RA technique. Neither RA nor straight line repair was superior to one another. The Delaire technique may be preferred over the modified RA. Also, satisfactory outcomes were observed with simultaneous lip-nose repair. This systematic review examined a plethora of techniques, and the heterogeneity between studies was very high regarding type of surgery, method of nasal symmetry assessment, and length of follow-up, thus producing low-quality evidence; therefore, results should be interpreted with caution. Future research requires RCTs with larger sample sizes and appropriate length of follow-up, and surgeries preferably performed by a single experienced surgeon.

Quantitative analysis of aesthetic outcomes of morphofunctional septorhinoplasty for secondary cleft lip nasal deformity.

The main aim of this study was to assess nasal symmetry after morphofunctional septorhinoplasty, more specifically, symmetry of the alar base and nostrils, and nasal projection, in patients with unilateral and bilateral cleft nasal deformities. Secondary cleft rhinoplasty was performed using morphofunctional septorhinoplasty techniques in 150 patients with unilateral and bilateral cleft lip and nose deformities. Nasal changes were analysed by measuring nasal tip projection, nostril height, nostril width, alar base width, and nasal gap area preoperatively and postoperatively on standard submentovertex view 2-dimensional photographs. In the unilateral cleft group there were statistically significant improvements (p<0.001) in ratios of nasal height and width (p=0.024) and nasal gap area, and in nasal tip projection and alar base width. In the bilateral cleft group there were statistically significant improvements in nasal gap area ratio (p=0.009), nasal tip projection, and alar base width. The morphofunctional septorhinoplasty technique improved aesthetic outcomes.

Effect of antibiotic pack on hard palate after fistula closure on nasal airflow and reoccurrence rate.

This parallel blocked randomized controlled trial was done in two groups of 30 patients each to determine if placement of an antibiotic oral pack on the hard palate after hard palatal fistula repair reduces nasal air emission and fistula re-occurrence. Group A had an oral pack on the hard palate for 5 days post-operatively while group B did not. In group A, percentage of nasal air emission was tested using nasometry with and without pack. Paired t-tests were performed to compare nasal emissions for patients with and without pack. Recurrence of fistulas after 6 months between group A and B was tested using odds ratio. Effect of nasal air emission on fistula rates was tested using paired t-tests. There was a significant increase (p < 0.0001) in nasal emission after removal of the pack in group A. Fistula re-occurrence tended to be higher in group B (no pack) than group A but this was not significant (p = 0.242). There was no correlation between nasal air emission and fistula rates. In patients with recurrent fistulae, placement of an oral pack after fistula repair diminishes nasal air emission. Whether this has an impact on re-occurrence of fistulae needs to be investigated further.