Versatility of Titanium Mesh in Comminuted Maxillofacial Fractures. A Retrospective Study.

Background: Titanium mesh provides three-dimensional stability, it is easier and quick in placement, highly malleable and adaptable hence, proved to be worth in restoring the function and form in cases of comminuted maxillofacial fractures. Materials and Methods: A total of 12 patients were included in this retrospective study at Department of Oral and maxillofacial surgery, Sri Rajiv Gandhi College of Dental Science and Hospital, from December 2015 to June 2020. Out of 12 patients, 7 reported with frontal bone fracture and 5 reported with mandibular fracture. Patients were followed up for upto 18 months to evaluate efficacy of titanium mesh on postoperative long-term healing, aesthetic outcomes and return to normal function were evaluated. Results: The results have shown that titanium mesh has low complication rates and the ability to maintain occlusion and chewing postoperatively. Union occurred without complication in 90% of fractures, and patients treated for frontal bone fracture had excellent cosmetic results. Conclusion: The semi rigid nature of the titanium mesh fixation allows micro movement at the healing bone ends, reduces stress shielding effect which may improve functional bone healing. Bony continuity of the mandible can be restored providing three-dimensional morphology and stability. The versatile placement of screws is the principal advantage.

Cost effectiveness of hepatitis C direct acting agents.

INTRODUCTION: Introduction of direct acting antivirals (DAA) has transformed treatment of chronic hepatitis C (HCV) and made the elimination of HCV an achievable goal set forward by World Health Organization by 2030. Multiple barriers need to be overcome for successful eradication of HCV. Availability of pan-genotypic HCV regimens has decreased the need for genotype testing but maintained high efficacy associated with DAAs. AREAS COVERED: In this review, we will assess the cost-effectiveness of DAA treatment in patients with chronic HCV disease, with emphasis on general, cirrhosis, and vulnerable populations. EXPERT OPINION: Multiple barriers exist limiting eradication of HCV, including cost to treatment, access, simplified testing, and implementing policy to foster treatment for all groups of HCV patients. Clinically, DAAs have drastically changed the landscape of HCV, but focused targeting of vulnerable groups is needed. Public policy will continue to play a strong role in eliminating HCV. While we will focus on the cost-effectiveness of DAA, several other factors regarding HCV require on going attention, such as increasing public awareness and decreasing social stigma associated with HCV, offering universal screening followed by linkage to treatment and improving preventive interventions to decrease spread of HCV.

Social Impact of Hepatic Encephalopathy.

Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.

Evaluation and Comparison of Impact Strength and Transverse Strength of Heat Polymerized Polymethylmethacrylate (PMMA) Denture Base Resin Repaired Using Heat Polymerizied PMMA Denture Base Resin, Auto-Polymerized PMMA Resin and A New Light Polymerizied Denture Resin: An In Vitro Study.

Context: Repaired denture prosthesisdemands adequate transverse and impact strength. A new repairdenture base resin- "Lukafix" require to fulfil these criteria. Aims: This study evaluates and compares the transverse and impact strength of heat polymerizing, auto polymerizing and LUKAfix denture resin. Methods and Material: 20 specimens were control(without repair), and other were test specimens which were fractured and repaired with heat polymerized PMMA resin, chemically polymerized PMMA resin and LUKAfix light polymerizing denture resin. Each group wasdivided in two subgroups. Subgroup A was subjected to transverse strength test and subgroup B to impact strength test. Statistical Analysis Used: One way ANOVA was used to identify the mean difference among the four groups. Post-Hoc-Bonferroni was done to observe the difference between the groups. Results: Maximum transverse strength was observed in specimens repaired with heat polymerized (48.33 ± 9.19) and least in LUKAfix denture resin (6.56 ± 1.15). Also, impact strength was maximum for heat polymerized (3.64 ± 0.41) followed by LUKAfix denture resin (2.34 ± 0.44). Conclusions: Repair with LUKAfix denture resin resulted inferior transverse and impact strength as compared to heat polymerized PMMA resin.

Management of Patients After Treatment of Severe Alcohol-associated Hepatitis.

Alcohol-associated liver disease is the leading indication for hospitalization among patients with chronic liver disease. Rates of hospitalization for alcohol-associated hepatitis have been rising over the last 2 decades. Patients with alcohol-associated hepatitis carry significant morbidity and mortality, but there is a lack of standardized postdischarge management strategies to care for this challenging group of patients. Patients warrant management of not only their liver disease but also their alcohol use disorder. In this review, we will discuss outpatient management strategies for patients who were recently hospitalized and discharged for alcohol-associated hepatitis. We will discuss short management of their liver disease, long-term follow-up, and review-available treatment options for alcohol use disorder and challenges associated with pursuing treatment for alcohol use disorder.

The Evolution of Redo Liver Transplantation Over 35 Years: Analysis of 654 Consecutive Adult Liver Retransplants at a Single Center.

OBJECTIVE: To examine liver retransplantation (ReLT) over 35 years at a single center. BACKGROUND: Despite the durability of liver transplantation (LT), graft failure affects up to 40% of LT recipients. METHODS: All adult ReLTs from 1984 to 2021 were analyzed. Comparisons were made between ReLTs in the pre versus post-model for end-stage liver disease (MELD) eras and between ReLTs and primary-LTs in the modern era. Multivariate analysis was used for prognostic modeling. RESULTS: Six hundred fifty-four ReLTs were performed in 590 recipients. There were 372 pre-MELD ReLTs and 282 post-MELD ReLTs. Of the ReLT recipients, 89% had one previous LT, whereas 11% had ≥2. Primary nonfunction was the most common indication in the pre-MELD era (33%) versus recurrent disease (24%) in the post-MELD era. Post-MELD ReLT recipients were older (53 vs 48, P = 0.001), had higher MELD scores (35 vs 31, P = 0.01), and had more comorbidities. However, post-MELD ReLT patients had superior 1, 5, and 10-year survival compared with pre-MELD ReLT (75%, 60%, and 43% vs 53%, 43%, and 35%, respectively, P < 0.001) and lower in-hospital mortality and rejection rates. Notably, in the post-MELD era, the MELD score did not affect survival. We identified the following risk factors for early mortality (≤12 months after ReLT): coronary artery disease, obesity, ventilatory support, older recipient age, and longer pre-ReLT hospital stay. CONCLUSIONS: This represents the largest single-center ReLT report to date. Despite the increased acuity and complexity of ReLT patients, post-MELD era outcomes have improved. With careful patient selection, these results support the efficacy and survival benefit of ReLT in an acuity-based allocation environment.

Complications of Conventional Sinus Augmentation Techniques Versus Modified Osteotome Techniques in Dental Implant Surgery: A 3-Year Retrospective Clinical Study.

Introduction: Sinus Augmentation has proven to be a predictable and popular approach to overcome bone volume deficiency in the posterior maxilla for patients seeking dental implants. The most common surgical methods utilized for maxillary sinus augmentations are the lateral window approach and crestal osteotome technique, which may cause many complications like sinus membrane tear, bleeding, sinusitis, etc. the purpose of this study is to compare complications rates of different sinus lift techniques in dental implant surgery. Aims and Objective: To assess the intraoperative and postoperative complications between the conventional direct or indirect method with alternative sinus lift techniques using Modified Crestal and Lateral (CAS & LAS KIT) ®method (Osstem/Hiossen). Materials and Methods: This is a retrospective study where in all the sinus lift cases done during 3year duration in the center data was collected and analyzed a total of 61 sinus lift procedure was done and all the data is tabulated and analyzed. Results: Results show of the total 61 cases 25 (40%) male patients and 36(59%)female patients traditional techniques like summers osteotome and conventional direct or indirect method had 7 cases (33.3%-37.5%) complication rates compared to Modified Lateral osteotome had 2 complications (14.2%) & Modified Crestal osteotome had only 3 case(3.7%) infections, wound dehiscence, membrane tear etc. Conclusion: Modified Crestal & Lateral Osteotome (CAS KIT & LAS KIT) ® technique does reduce the incidence of complications like sinus membrane tear compared to conventional Direct and Indirect techniques, because of stopper system used in hydraulic lift and the special design of drill head of these instruments.

Comparative Evaluation of Efficacy of EMLA Versus Ice as Topical Anesthetic in Prior to Needle Prick in Palatine Nerve Blocks-A Randomized Split Mouth Study EMLA Versus Ice as Topical Anesthetic in Dental Nerve Blocks.

Background and Objectives: The study aims to evaluate the pain efficacy of EMLA versus ice in palatine nerve blocks undergoing extraction. Materials and Methods: A prospective randomized study, single-blind, split-mouth study carried out on a total of 20 healthy individuals needing extraction of bilateral maxillary teeth under local anesthesia referred to our department in the university from March 2021 to April 2022. Patients were randomly categorized into two groups: Group E (5% EMLA) and Group I (ice application), with 20 operative sites, respectively. In the study, the VAS-pain and satisfaction score and SEM score were analyzed. Statistical analysis was done using SPSS version 20.0 software using the Mann-Whitney U test. Results: Study results showed that 13 patients were men and 7 were women whose ages ranged from 46 ± 18 years. Statistical analysis of pain on the VAS scale showed that the mean score for Group E and Group I were 2.3 ± 0.47 and 3.2 ± 0.41(mean ± SD), respectively, which was statistically significant (P < 0.001). On the statistical analysis of the SEM scale for Group E and Group I, the mean score was 1.00 ± 0.00 and 1.25 ± 0.44426 (mean ± SD), respectively, which was statistically significant (P < 0.018). Conclusion: EMLA and ice were both good topical anesthetics each with advantages and disadvantages in clinical use. Each clinician needs to weigh the pros and cons of the different available methods and expenses to determine what type of anesthetic to use for each particular case during treatment.

Role of Biomarkers to Assess the Use of Alcohol.

Alcohol-associated liver disease has seen a significant rise in the last 2 decades, with an associated rise in the need for accurate alcohol use assessment. Alcohol use has been associated with poor outcomes in both the pre-liver transplant and post-liver transplant patients. Patients with alcohol use disorder often under-report their alcohol consumption because of varying factors, highlighting the need for objective assessment of alcohol use. Aside from the available self-report questionnaires, multiple serologic biomarkers are currently available to assist clinicians to assess recent alcohol consumption among patients with chronic liver disease, liver transplant candidates, and recipients. In this review, we will assess some of these alcohol biomarkers, discuss their strengths and weakness, and review-available data to discuss their role in pre-liver transplant and post-liver transplant population.

Cone-beam computed tomography (CBCT) analysis of maxillary sinus septa in Indians.

It is of interest to assess the presence of maxillary sinus septae in patients undergoing implant treatment using Cone Beam Computed Tomography (CBCT).This retrospective study evaluated CBCT scans of 99 patients who opted for implant placement. A total of 198 sinuses were analyzed. The cases were divided into two group's namely edentulous group and non-edentulous groups. The location of septa was divided for analysis into 3 regions namely, the anterior (1st and 2nd premolar), middle (1st and 2nd molar) and posterior (behind 2nd molar) regions. Out of 198 sinuses assessed 15 sinuses had septa. It was more common in males. Mean height of septa was 7.7mm. It was more commonly seen in the middle region (1st and 2nd molar). All of the septa were partial in nature. Septa were common on the right side. It was absent in the edentulous group. To conclude this study showed low prevalence of septa in patients who were assessed as a part of pre-operative planning for implant placement. Modified sinus lift procedures were completed for placement of bone grafts in patients with septa,. This reduced the chances of membrane perforation and increases the chances of better outcomes. CBCT with its low cost and high resolution is useful for assessing the sinus.

Evaluation of effects of platelet-rich fibrin on treatment outcomes after impacted mandibular third molar surgery: A randomized controlled clinical study.

Background and Objective: Impaction of the third molar teeth is a common disorder which often necessitates their removal. After third molar surgery, the common postoperative sequelae are pain, trismus, and buccal swelling. Our study sought to evaluate the effect of platelet-rich fibrin (PRF) on postoperative pain, swelling, trismus after surgical extraction of impacted mandibular 3rd molars. Materials and Methods: Over a period of 22 months (December 1, 2016-September 30, 2018), 44 patients in the age group of 18-40 years, who required surgical extraction of impacted third molar and met the inclusion criteria were recruited. After surgical extraction of the third molar, only primary closure was performed in the control group (22 Group), whereas PRF was placed in the socket followed by primary closure in the study group (22 patients). The outcome variables were pain, swelling, and maximum mouth opening were measured with a follow-up period of 1 week. Results: The application of PRF in the study group lessens the severity of immediate postoperative sequelae such as pain, swelling, and trismus compared to the control group. Conclusion: The treatment outcomes and postoperative sequel were better in the PRF group as compared to other control group on days 1, 3, and 7 postoperatively.

Early Liver Transplantation for Severe Alcohol-Associated Hepatitis and a History of Prior Liver Decompensation.

INTRODUCTION: In the published studies of early liver transplantation (LT) for alcohol-associated hepatitis (AH), patients with a prior liver decompensation are excluded. The appropriateness of this criteria is unknown. METHODS: Among 6 American Consortium of Early Liver Transplantation for Alcohol-Associated Hepatitis sites, we included consecutive early LT for clinically diagnosed AH between 2007 and 2020. Patients were stratified as first vs prior history of liver decompensation, with the latter defined as a diagnosis of ascites, hepatic encephalopathy, variceal bleeding, or jaundice, and evidence of alcohol use after this event. Adjusted Cox regression assessed the association of first (vs prior) decompensation with post-LT mortality and harmful (i.e., any binge and/or frequent) alcohol use. RESULTS: A total of 241 LT recipients (210 first vs 31 prior decompensation) were included: median age 43 vs 38 years ( P = 0.23), Model for End-Stage Liver Disease Sodium score of 39 vs 39 ( P = 0.98), and follow-up after LT 2.3 vs 1.7 years ( P = 0.08). Unadjusted 1- and 3-year survival among first vs prior decompensation was 93% (95% confidence interval [CI] 89%-96%) vs 86% (95% CI 66%-94%) and 85% (95% CI 79%-90%) vs 78% (95% CI 57%-89%). Prior (vs first) decompensation was associated with higher adjusted post-LT mortality (adjusted hazard ratio 2.72, 95% CI 1.61-4.59) and harmful alcohol use (adjusted hazard ratio 1.77, 95% CI 1.07-2.94). DISCUSSION: Prior liver decompensation was associated with higher risk of post-LT mortality and harmful alcohol use. These results are a preliminary safety signal and validate first decompensation as a criterion for consideration in early LT for AH patients. However, the high 3-year survival suggests a survival benefit for early LT and the need for larger studies to refine this criterion. These results suggest that prior liver decompensation is a risk factor, but not an absolute contraindication to early LT.

Hepatocellular Carcinoma Due to Nonalcoholic Fatty Liver Disease: Current Concepts and Future Challenges.

Obesity has been labeled as the global pandemic of the 21st century, resulting from a sedentary lifestyle and caloric excess. Nonalcoholic fatty liver disease (NAFLD), characterized by excessive hepatic steatosis, is strongly associated with obesity and metabolic syndrome and is estimated to be present in one-quarter of the world population, making it the most common cause of the chronic liver disease (CLD). NAFLD spectrum varies from simple steatosis to nonalcoholic steatohepatitis (NASH) and cirrhosis. The burden of NAFLD has been predicted to increase in the coming decades resulting in increased rates of decompensated cirrhosis, hepatocellular carcinoma (HCC), and liver-related deaths. In the current review, we describe the pathophysiology of NAFLD and NASH, risk factors associated with disease progression, related complications, and mortality. Later, we have discussed the changing epidemiology of HCC, with NAFLD emerging as the most common cause of CLD and HCC. We have also addressed the risk factors of HCC development in the NAFLD population (including demographic, metabolic, genetic, dietary, and lifestyle factors), presentation of NAFLD-associated HCC, its prognosis, and the issue of HCC development in non-cirrhotic NAFLD. Lastly, the problems related to HCC screening in the NAFLD population, the remaining challenges, and future directions, especially the need to identify the high-risk individuals, will be discussed. We will conclude the review by summarizing the clinical evidence for treating fibrosis and preventing HCC in those at risk with NAFLD-associated HCC.

Primary Hepatic Neuroendocrine Tumor With Ectopic Adrenocorticotropic Hormone Production.

This report describes the case of a 63-year-old female with a metastatic neuroendocrine tumor (NET). Imaging studies revealed a primary hepatic NET (PHNET) originating in the porta hepatis and associated with extensive hepatic metastasis. This represents an extremely rare presentation of PHNET associated with ectopic adrenocorticotropic hormone (ACTH) production and hypercortisolism. As such, it is a unique presentation of an otherwise rare pathology and hence we believe it contributes to the literature on PHNETs by supplementing it with information on an uncommon variation of an infrequent pathology.

Long-Term Management of the Successful Adult Liver Transplant: A Patient-Friendly Summary of the 2012 AASLD and AST Practice Guideline.

Content available: Author Audio Recording.

Survival following liver transplantation for locally advanced, unresectable intrahepatic cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (iCCA) has previously been considered a contraindication to liver transplantation (LT). However, recent series showed favorable outcomes for LT after neoadjuvant therapy. Our center developed a protocol for neoadjuvant therapy and LT for patients with locally advanced, unresectable iCCA in 2010. Patients undergoing LT were required to demonstrate disease stability for 6 months on neoadjuvant therapy with no extrahepatic disease. During the study period, 32 patients were listed for LT and 18 patients underwent LT. For transplanted patients, the median number of iCCA tumors was 2, and the median cumulative tumor diameter was 10.4 cm. Patients receiving LT had an overall survival at 1-, 3-, and 5-years of 100%, 71%, and 57%. Recurrences occurred in seven patients and were treated with systemic therapy and resection. The study population had a higher than expected proportion of patients with genetic alterations in fibroblast growth factor receptor (FGFR) and DNA damage repair pathways. These data support LT as a treatment for highly selected patients with locally advanced, unresectable iCCA. Further studies to identify criteria for LT in iCCA and factors predicting survival are warranted.

Early versus delayed thromboprophylaxis with LMWH in pelvic-acetabular trauma- a prospective study.

BACKGROUND: Delayed presentation of pelvic-acetabular fractures is a common scenario in developing countries and there is usually a delay of more than 24 h in their presentation. OBJECTIVES: We aim to comparatively analyse early(<24 h) versus delayed (>24 h) thromboprophylaxis with low molecular weight heparin (LMWH) in prevention of deep venous thrombosis (DVT) in Pelvic Acetabular fractures. METHODS: Patients of pelvic-acetabular fractures who presented during 1 year of study period were divided into 2 groups after exclusion of patients with contraindications for thromboprophylaxis. Group A included patients who received LMWH prophylaxis within 24 h of injury. Group B included patients who received LMWH prophylaxis after 24 h of injury. All patients underwent CT venography at day 14 and were followed up with doppler ultrasound on 4th and 8th week. RESULTS: 110 patients with pelvic-acetabular fractures were included after exclusion of 61 patients. 4 out of 29 patients in group A (13.8%) and 12 out of 81 patients (14.8%) in group B developed DVT. There was no significant difference in incidence of DVT between Group A and B (P value-0.893). CONCLUSION: There was no difference between early and delayed thromboprophylaxis with LMWH in pelvic-acetabular trauma.

Evaluation of Sagittal Curving Osteotomy vs Conventional Advancement Genioplasty in Retrogenia Patients: a Randomized Control Trial.

Background and Objectives: With increasing aesthetic awareness, in addition to the forehead, nose, and cheekbone prominence, the chin nowadays is seen as one of the most important parts of the facial skeleton. Position of the chin has a strong influence on the assessment of the facial harmony; its different types and forms dominate the appearance. Furthermore, the expression of the chin is equated with character traits, and thus, it is an important component of the profile forms. Genioplasty is a routine procedure for the correction of aesthetic and functional deformity of the chin region. It is therefore one of the contour-enhancing surgical methods. The purpose of the present study is to study the versatility of sagittal curving osteotomy for advancement genioplasty as an alternative to conventional technique. Materials and Methods: A total of 24 subjects were enrolled for the study who were randomly distributed into two groups: group 1(n-12) comprising of patients in whom sagittal curving osteotomy was done and group 2 (n- 12) comprising of patients in whom conventional osteotomy was done. Neurosensory disturbances and hard and soft tissue relapse were compared between the two groups. Results: On comparison of all the variables, it was found that the conventional osteotomy technique had more hard tissue relapse and more neurosensory disturbance as compared to sagittal curving osteotomy technique. Conclusion: Results of this study suggest that the use of sagittal curving osteotomy may be helpful in reducing postoperative neurosensory disturbances and relapses following genioplasty. Hence, it is recommended that sagittal curving osteotomy can be used as an alternative osteotomy technique for advancement genioplasty.

Klebsiella pneumoniae Infection as a Mimicker of Multiple Metastatic Lesions.

We describe the case of a 42-year-old man with cirrhosis who presented with fever and imaging concerning for metastatic disease from suspected renal cell carcinoma. He had a right renal mass with multiple pulmonary masses and underwent a lung biopsy and oncology consultation. Blood cultures revealed Klebsiella pneumoniae, and all the lesions disappeared after intravenous (IV) antibiotics. Our case attempts to increase awareness of this unique presentation of invasive Klebsiella infections and discusses host factors that can predispose to this condition.