Objective analysis of microtia reconstruction in Indian patients and modifications in management protocol.

INTRODUCTION: An ideal ear, with representation of all anatomic landmarks, is the aim of any reconstructive surgeon embarking on reconstructing the ear in a microtia patient. The literature is abundant with the description of techniques, but these have been reported mainly in Caucasian and Oriental population. There have been very few publications on results in the population belonging to the Indian subcontinent. In spite of strictly adhering to the recommended techniques of reconstruction, the results obtained in these patients have often been marred by problems that are not reported with the Oriental or Caucasian populations. This may necessitate a relook into the management strategy of these cases. Hindering the assessment of the results, their reporting and auditing the improvement obtained by such change in the management strategy, is the lack of a standardized method for assessment of the outcome. Hence, an attempt was made in a series of patients who underwent microtia reconstruction to assess the outcome using a new tool based on the attained definition of anatomical components of the reconstructed pinna. Further effort was made to document the modifications in the technical execution of the reconstruction during the period of the study. MATERIALS AND METHODS: A retrospective review of 44 patients and a prospective analysis of 11 patients, who underwent ear reconstruction for microtia from December 2003 to September 2014 at a tertiary care teaching hospital, was undertaken. Taking a cue from Nagata's description of an 'ideal reconstructed ear' which should show all the anatomical components, we developed an objective grading system to assess our results. The technique had undergone several changes during these years combining the principles of three universally accepted methods, that is, those described by Nagata, Brent, and Firmin. These changes, as well as the reasons behind them, were documented. RESULTS: On objectively measuring and analysing the replication of normal morphologic characteristics of the reconstructed ears, we documented progressive improvement of our results. Good or excellent results could be achieved in 70% of cases in the second group compared to a poor outcome in more than 2/3(rd) of the cases carried out during the initial period. Based on these results and the changes adopted in our practice we propose suggestions for management of microtia cases in the Indian population. CONCLUSIONS: An objective, weighted grading system has further enabled us to critically evaluate the outcomes and to further improve upon the existing results. Our amalgamation of the salient features of the established techniques as well as changes made based on our experience has enabled us to get good results more consistently in our attempts at microtia reconstruction. We believe that the adoption of such amalgamated methods will be more suitable in Indian patients.

Simplified Virtual Surgical Planning Method for Reconstruction of Secondary Maxilla and Mandibular Defects Using Free Bone Flap.

Objective: Free fibula flap is the commonly used microvascular free tissue transfer for maxillary and mandibular reconstruction to restore form and function after ablative procedures. Bony reconstruction is an important aspect of reconstruction. This paper describes our technique in using virtual surgical planning for secondary reconstruction of the maxilla and mandible using only stereolithographic models. Discussion: In the recent past, virtual surgical planning has become a game changer in planning complex reconstruction of maxilla and mandible. This becomes even more important in the cases of secondary reconstruction. Virtual surgical planning requires close interaction between the surgeon and the design and manufacturing team. The latter is often done remotely making the process cumbersome and less user friendly. We have been using a simplified version of the virtual surgical planning at a low cost set up with effective outcomes. This report consists of 22 cases in which secondary reconstruction using osteo-cutaneous free fibula flap was carried out using virtual surgical planning. Mock surgery was performed on stereolithographic (STL) models (face and fibula), pre-bending of plates and fabrication of occlusal splints helped in precise translation of the treatment plan to the operating room which in turn helped in reducing the surgical time and attaining more predictable results. Conclusion: Secondary reconstruction of maxilla and mandible is complex and requires meticulous planning to achieve optimal and predictable results which directly improves the quality of life of the patients.

Paradigm shift in efforts to end TB by 2025.

TB is a deadly infectious disease, in existence since time immemorial. This article traces the journey of TB developments in the last few decades and the path breaking moments that have accelerated the efforts towards Ending TB from National Tuberculosis Control Program (NTCP 1962-1992) to Revised National Tuberculosis Control Program (RNTCP - 1992-2019) and to National Tuberculosis Elimination Program (NTEP) as per the vision of Honorable Prime Minister of India. From increased funding for TB, the discovery of newer drugs and diagnostics, increased access to health facilities, greater investment in research and expanded reach of public health education, seasoned with TB activism and media's proactive role, private sector participation to political advocacy and community engagement, coupled with vaccine trials has renewed the hope of finding the elusive and miraculous breakthrough to END TB and it seems the goal is within the realms of the possibility. The recent paradigm shift in the policy and the drive of several states & UTs to move towards TB free status through rigorous population-based vulnerability mapping and screening coupled with active case finding is expected to act as the driving force to lead the country towards Ending TB by 2025. Continued investments in research, innovations and availability of more effective drugs and the vaccines will add to existing armamentarium towards Ending TB.

Esthesioneuroblastoma with intracranial extension: A non-surgical approach.

Esthesioneuroblastoma is a rare tumor arising from the olfactory mucosa of upper respiratory tract. The primary modality of treatment has been surgery with craniofacial resection followed by post-operative radiotherapy. There are only a few reported cases of non-surgical approaches. We report a case of esthesioneuroblastoma with intracranial extension treated with Vincristine, Adriamycin, Cyclophosphamide, Ifosfamide, Etoposide protocol followed by radiation with 5 years of follow-up. This is the first reported case using this chemotherapy schedule.

Carnitine: a neuromodulator in aged rats.

A wide range of morphological and biochemical changes occur in the central nervous system with increasing age. L-carnitine, a naturally occurring compound, plays a vital role in fatty acid transport across the mitochondrial membrane. L-carnitine (300 mg/kg body wt/day) was administered intraperitoneally to young and old male Wistar rats for 7, 14, and 21 days. Carnitine, dopamine, epinephrine, and serotonin levels were assayed in discrete regions of the brain. Carnitine supplementation increased the levels of dopamine, epinephrine, and serotonin in the experimental animals in our study. Response to carnitine supplementation varied among the brain regions that have been studied. The regions rich in cholinergic neurons such as the cortex, hippocampus, and striatum showed more response after 21 days of carnitine treatment. The results of the present study suggest the role of L-carnitine as a neuromodulator and antiaging medication.

Design and optimization of polyphosphazene functionalized fiber matrices for soft tissue regeneration.

Electrospun polycaprolactone nanofiber matrices surface functionalized with poly[(ethyl alanato), (p-methyl phenoxy),] phosphazene were fabricated for the purpose of soft skeletal tissue regeneration. This preliminary study reports the effect of fiber diameter and polyphosphazene surface functionalization on significant scaffold properties such as morphology, surface hydrophilicity, porosity, tensile properties, human mesenchymal stem cell adhesion and proliferation. Six fiber matrices comprised of average fiber diameters in the range of 400-500, 900-1000, 1400-1500, 1900-2000, 2900-3000 and 3900-4000 nm were considered for primary evaluation. After achieving the greatest proliferation while maintaining moderate tensile modulus, matrices in the diameter range of 2900-3000 nm were selected to examine the effect of coating with 1%, 2% and 3% (weight/volume) polyphosphazene solutions. Polyphosphazene functionalization resulted in rougher surfaces that correlated with coating solution concentration. Analytical techniques such as energy dispersive X-ray analysis, Fourier transform infrared spectroscopy, elemental analysis, differential scanning calorimetry, water contact angle goniometry and confocal microscopy confirmed the presence of polyphosphazene and its distribution on the functionalized fiber matrices. Functionalization achieved through 2% polymer solutions did not affect average pore diameter, tensile modulus, suture retention strength or cell proliferation compared to PCL controls. Surface polyphosphazene functionalization significantly improved the matrix hydrophilicity evidenced through decreased water contact angle of PCL matrices from 130 degrees to 97 degrees. Further, enhanced total protein synthesis by cells during in vitro culture was seen on 2% PPHOS functionalized matrices over controls. Improving PCL matrix hydrophilicity via proposed surface functionalization may be an efficient method to improve cell-PCL matrix interactions.