The Normal Active Range of Motion of the Index, Middle, Ring, and Little Fingers in a Sample of Indian Population.

Background The normative data for finger range of motion (ROM) are not available for the Indian population. The aim of our study was to measure the active ROM of finger joints in normal healthy volunteers in a sample of Indian population. Materials and Methods This is a prospective observational study conducted as a part of the Indian normative data project of the Indian Society for Surgery of the Hand (ISSH). The study included one participating center from four geographical regions of the country. Certified goniometers were used to measure the ROM of fingers in all centers. A standardized methodology was devised. A pilot study was done to assess the interobserver and intraobserver reliability, following which data were collected by one measurement. Results This pilot study was performed in 20 hands that showed good interobserver and intraobserver reliability correlation. A total of 390 hands were measured in four participating centers. Active flexion of metacarpophalangeal (MCP) joint was the highest in the middle finger (86.6 ± 10.4 degrees) followed by the index finger (86.0 ± 9.2 degrees), little finger (85.0 ± 8.4 degrees), and ring finger (84.2 ± 8.6 degrees). The index finger (97.2 ± 16.9 degrees) showed maximum proximal interphalangeal (PIP) joint flexion followed by the middle finger (96.2 ± 15.8 degrees), ring finger (96.0 ± 15.9 degrees), and little finger (91.8 ± 12.7 degrees). Distal interphalangeal (DIP) joint flexion increased from the index finger (81.6 ± 13.9 degrees) to the little finger (84.6 ± 12.9 degrees). The little finger MCP joint (26.3 ± 6.2 degrees) showed maximum extension followed by the index finger (25.7 ± 6.8 degrees), middle finger (24.7 ± 6.7 degrees) and ring finger (22.3 ± 7.1 degrees). The middle finger (15.6 ± 8.1 degrees) and ring finger (16.2 ± 8 degrees) had more PIP joint extension when compared to the index (13.7 ± 7.8 degrees) and little finger (13.2 ± 8.4 degrees). The ring finger (8.1 ± 6.8 degrees) and the middle finger (8.4 ± 6.9 degrees) had more DIP joint extension when compared with the index finger (6.0 ± 6.0 degrees) and the little finger (6.8 ± 6.7 degrees). Total active motion (TAM) of the middle finger (315.9 ± 31.0 degrees) was the maximum followed by the index finger (310.2 ± 27.3 degrees), ring finger (308.8 ± 29.1 degrees), and little finger (307.8 ± 25.2 degrees). Gender, body mass index (BMI), mother tongue, geographical location, and occupation were factors that had significant correlation, while no significant differences based on side, hand dominance, and age were noted. Conclusion We have reported normative data of finger ROM and TAM for the index, middle, ring, and little fingers in the Indian population. Finger ROM in the Indian population is highly variable. The observed TAM in the Indian population is higher than what is reported earlier.

Design and Development of Gastro-retentive Drug Delivery System for Trazodone Hydrochloride: a Promising Alternative to Innovator's Controlled-Release Tablet.

Trazodone hydrochloride (TZN) is a serotonin reuptake inhibitor that treats a major depressive disorder. It exhibits a short plasma half-life of 4.1 h and shows pH-dependent solubility. Above its pKa (6.74), solubility of TZN is very low, affecting its dissolution in the lower part of GIT. Hence, the present work aimed to develop gastro-retentive floating tablet of TZN. Central composite design was employed to optimize the formulation. Formulation variables like the concentration of HPMC-K100M, Polyox WSR 303 Leo, and sodium bicarbonate were evaluated for the responses like floating lag time and drug release. X-ray imaging study was performed on rabbits to determine the in vivo gastric retention of the optimized formulation. The accelerated stability study was conducted on optimized tablets as per ICH guidelines. Floating lag time and f2 value of the optimized formulation were found to be 2.51±0.02 min and 62.79, respectively. X-ray imaging studies in rabbits determined the in vivo gastro retention time. After 12 h of administration, tablet remained in the gastric region, indicating better retentive power. Accelerated stability studies showed sufficient formulation stability even after 3 months of storage. All these studies depict that the floating gastro-retentive system could be used as an alternative to the innovator formulation.

Pickering Dry Emulsion System for Improved Oral Delivery of Fenofibrate.

The current study reports a Pickering dry emulsion (PDE) system for improved oral delivery of fenofibrate, a poorly water-soluble model drug. The silica nanoparticles were modified by surface modifiers and explored as a stabilizer for emulsion. The wetting property of modified silica nanoparticles was evaluated by contact angle study. Emulsion was spray-dried to obtain PDE. PDE was evaluated for particle size analysis, drug loading, TGA, DSC, XRPD, FEG-SEM, in vitro dissolution study, and in vivo pharmacodynamic study. The particle size of liquid emulsion was found within the range of 0.3-0.6 µm; after spray drying, the particles agglomerated and exhibited an increase in particle size (1.5 µm). The high drug loading (13% w/w) was found in PDE. DSC and XRD study confirmed the amorphous form of fenofibrate. SEM study showed the formation of a spherical porous microcapsule structure. In vitro dissolution exhibited significant enhancement in drug release for the PDE system as compared to plain fenofibrate. The PDE significantly lowered serum lipid level as compared to plain fenofibrate in a Triton-based hypercholesterolemia model in rats, which ultimately confirmed the enhancement in bioavailability. Thus, the PDE system has good potential in the drug delivery area.

Management of Posttraumatic Posterior Elbow Defects by Nonmicrosurgical Reconstruction.

Introduction Reconstruction of posterior defects is challenging due to the quality and uniqueness of the excess skin at the elbow that is durable, thick, pliable, and without much subcutaneous tissue. The goal of reconstruction is to cover the elbow defects with a durable skin cover that will facilitate full passive range of motion. In this era of microsurgery, free tissue transfer is feasible for almost any defect. However, in this article, we discuss various locoregional and pedicled flap options and the protocol followed at our institute to tackle posttraumatic posterior elbow defects. Materials and Methods This is a retrospective analysis of 48 patients with posttraumatic posterior elbow defects admitted from January 2012 to February 2020. Posterior elbow defects were assessed according to the size and location and managed with a nonmicrosurgical reconstruction. Results Of 48 patients, 32 were managed with nonmicrosurgical flaps. Eighteen patients had large defects and 14 had small defects. Reverse lateral forearm flap was the workhorse flap for defect coverage. Of 32 flaps, nine developed complications; however, no patient had total flap necrosis. Conclusion Posterior elbow defects are a difficult problem to tackle. To achieve optimal results, all patients with elbow trauma should be attended and managed by orthopaedic and plastic surgeons in collaboration for optimal results. We believe that most of these defects can be resurfaced by nonmicrosurgical reconstruction with proper planning and execution and their utility cannot be understated.

A novel association of efavirenz induced severe cutaneous adverse reactions with HLA- DRB1*03:01: A case-control study from North-East India.

HIV-infected patients have a higher risk of developing cutaneous reactions to drugs than the general population. Severe cutaneous adverse reactions (SCARs) are not uncommon in patients taking antiretroviral therapy (HAART]. To evaluate HLA class I and II allele frequencies in HIV patients on HAART who develop SCARs due to nevirapine (NVP] or efavirenz (EFZ] containing regime and compare this genotype composition with HAART tolerant patients and healthy organ donors. A case-control study for 4 years was conducted with four subsets of patients hailing from north-east India:Cohort 1- HIV seropositive patients who developed SCARs due to EFZ (n = 8];Cohort 2 - HIV seropositive patients who developed SCARs due to NVP (n = 15]; Cohort 3 -HIV seropositive NVP/EFZ-tolerant patients (n = 18]; Cohort 4 - Healthy HIV seronegative organ donors (n = 169].Cohort 3 & 4 acted as control-group. These patients were genotyped for the HLA-A, HLA-B, HLA-C, HLA-DRB1, HLA-DQB1, and HLA-DPB1 by a sequence-based HLA typing method. HLA-DRB1*03:01 allele revealed a significant association with EFZ regimen-induced SCARs in 62.5% patients compared with only 5.56% observed in HAART-tolerant patients and 4.14% in healthy organ. HLA-B*3505was found to be significantly associated with NVP induced SCARs. We found significant novel association of HLA-DRB1*03:01 with EFZ induced SCARs in North-East Indian HIV patients. Thus, HLA-DRB*03:01 may be useful as a genetic marker to avoid EFZ induced serious cutaneous rashes. The molecular HLA characterization of these alleles may provide a novel insight into the immunological basis of the antiretroviral drug reactions.

Cutaneous manifestations of viral outbreaks.

As the world tries to grapple with the COVID-19 pandemic, dermatologists are left in a lurch as there is a lacuna in dermatologic literature as well as training regarding the cutaneous manifestations of varied viral agents capable of causing epidemics/pandemics or the potential to be bio-weaponised. Such outbreaks have the potential to become a pandemic given this age of globalisation. The quote by George Santayana stands true 'Those who cannot remember the past are condemned to repeat it'. Thus, this article lends a perspective to the recent viral outbreaks and is aimed at summarising these agents and their clinical features to serve as a quick reference for dermatologists.

Efficacy of Topical Insulin Therapy for Chronic Trophic Ulcers in Patients with Leprosy: A Randomized Interventional Pilot Study.

BACKGROUND: Chronic trophic ulcers (CTUs), especially those located over the plantar region, are a leading cause of deformity and disability in patients with leprosy. Despite the various treatment modalities available, CTUs can be chronic and refractory to treatment. The successful use of topical insulin in various types of wounds led researchers to evaluate its safety and efficacy in the treatment of plantar CTUs. METHODS: Forty-two patients who had completed a multidrug treatment for leprosy were recruited and randomized into two groups. In the test group, 23 patients received 10 units (0.1 mL) of topical insulin (Actrapid) in 1 mL of normal saline twice daily over treated areas. The placebo group (n = 19) received topical normal saline only. The primary end point was the proportion of patients with complete wound closure by 12 weeks. Secondary end points included time to healing, wound area reduction, Physician Global Assessment of Efficacy scores, and Dermatology Life Quality Index scores at the end of 12 weeks. RESULTS: The majority of CTUs (80%) were situated over the forefoot; the metatarsal head of the hallux was the most common site (86%). Wound healing was faster (0.61 ± 0.31 vs 0.14 ± 0.42 cm per week, P < .0001), and the number of days to complete healing was significantly shorter in the test group compared with the placebo group (31.5 ± 17.6 vs 44.3 ± 16.2 days, P = .02). The only observed adverse effect in the test group was white granular deposits over the CTU (n = 10). CONCLUSIONS: Topical insulin therapy may be a safe, efficacious, cheap, and easily available treatment option in CTUs among patients with leprosy.

Eyelash length for the diagnosis of atopic dermatitis and ichthyosis vulgaris in children-a case control study.

Eyelash trichomegaly (ET) is increased length (≥ 12 mm), curling, pigmentation, or thickness of eyelashes. Among acquired causes, allergic diseases and atopic dermatitis (AD) have been found to be associated with eyelash trichomegaly especially in children; however, to date, this claim has not been studied in detail. To compare the eyelash lengths of AD and ichthyosis vulgaris (IV) patients with those of age- and sex-matched patients with unrelated skin disorders, we measured (with a digital Vernier caliper) and compared the eyelash lengths of AD (n = 58) and IV (n = 31) patients to those of age- and sex-matched patients with unrelated skin disorders (n = 178). The eyelashes of the AD and male IV patients were found to be significantly longer than those of the controls (p < 0.05). The severity of atopic dermatitis, i.e., SCORAD of > 50, hyperlinearity of palms and soles, and high IgE levels significantly correlated with the long eyelashes. The limitations of study are single-center study and filaggrin gene mutation in patients of IV could not be studied. CONCLUSION: Thus, long eyelashes may act as surrogate marker of severe AD and serve as a cutaneous marker of IV patients. What is Known: • Among acquired causes, allergic diseases and atopic dermatitis have been found to be associated with eyelash trichomegaly especially in children. What is New: • The severity of atopic dermatitis, i.e., SCORAD of > 50, hyperlinearity of palms and soles, and high IgE levels significantly correlate with the long eyelashes; thus, long eyelashes may act as surrogate marker of severe atopic dermatitis. • It may also serve as a cutaneous marker of ichthyosis vulgaris especially in male patients and patients with palmoplantar hyperlinearity.