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.

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.

Long-acting microspheres of Human Chorionic Gonadotropin hormone: In-vitro and in-vivo evaluation.

Human Chorionic Gonadotropin (hCG) hormone is used to cause ovulation, treat infertility in women, and increase sperm count in men. Conventional hCG solution formulations require multiple administration of hCG per week and cause patient noncompliance. The long-acting PLGA depot microspheres (MS) approach with hCG can improve patient compliance, increase the efficacy of hCG with a lower total dose and improve quality of life. Therefore, hCG was encapsulated by a modified double emulsion solvent evaporation technique within PLGA MS by high-speed homogenizer and industrially scalable in-line homogenizer, respectively. MS was characterized for particle size, encapsulation efficiency (EE), surface morphology, and in-vitro release. The spherical, dense, non-porous microspheres were obtained with a size of 58.88 ± 0.18 µm. Microspheres showed high EE (77.4% ± 5.9%) with low initial burst release (12.82% ± 2.07%). Circular Dichroism and SDS-PAGE analysis indicated good stability and structural integrity of hCG in the microspheres. Its bioactivity was proven further by a bioassay study in immature Wistar rats. Pharmacokinetic analysis showed that the hCG PLGA MS maintained serum hCG concentration up to 13 days compared to multiple injections of a marketed conventional parenteral injectable formulation of hCG. Thus, it can be ascertained that the hCG PLGA MS may have great potential for clinical use in long-term therapy.

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.

Systemic steroids and risk of fecal-oral shedding and increased transmission of SARS-CoV-2 in pemphigus cases.

Pemphigus and its variants, viz., vulgaris, foliaceous, vegetans, Ig A pemphigus, paraneoplastic pemphigus and Senear-Usher syndrome are rare autoimmune blistering diseases of the skin and/or mucous membranes. The autoantibodies involved in the pathogenesis of pemphigus against desmoglein result in the breach of the skin and mucosal barrier, which acts as the first line of defence against pathogens. In this paper we underscore the importance of the integumentary system as a shield against the acquisition as well as transmission of SARS-CoV-2 virion. We have also made an attempt to delineate the various treatment modalities available and the viral-drug dynamics involved in choosing the optimum therapeutic modality.