Treatment outcomes in maxillofacial rehabilitation: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to assess the treatment outcomes following maxillofacial rehabilitation and to identify the tools used to evaluate those outcomes. INTRODUCTION: Maxillofacial defects caused due to tumor, trauma, or any pathology affects the patient physically, mentally, and psychologically. Various methodologies and strategies are used for jaw reconstruction and oral rehabilitation to help the patient regain the functions and quality of life that were lost due to the defect. The evaluation of these treatment outcomes is imperative to assess the success of rehabilitation. INCLUSION CRITERIA: The review will include patients with any maxillofacial defect caused by a developmental anomaly, trauma, or tumor. The patients must have undergone any type of reconstruction and/or rehabilitation and can be from any age group. All treatment outcomes of maxillofacial rehabilitation will be considered. Information from primary and secondary sources and from diverse geographical settings will be included. METHODS: This review will follow the JBI methodology for scoping reviews. Databases to be searched will include PubMed (Ovid), Scopus, PsycINFO (EBSCOhost), CINAHL(EBSCO), Web of Science, Cochrane CENTRAL, ProQuest Dissertations and Theses, and Google Scholar (first 10 pages of the search). Two independent reviewers will screen the titles and abstracts and extract data from selected studies. Data will be presented in tabular format, accompanied by a narrative summary. DETAILS OF THE REVIEW CAN BE FOUND IN OPEN SCIENCE FRAMEWORK: https://doi.org/10.17605/OSF.IO/DP8WC.

Prevalence of temporomandibular joint dysfunction among the indigenous population of India.

Purpose: Primary dental care facilities and awareness about temporomandibular disorders are lacking among the indigenous population of Kerala. The aim of the study was to determine the prevalence of temporomandibular joint dysfunction (TMD) disorders among the indigenous populations of Kerala. Methodology: This cross-sectional study included adults aged 18 years and above, visiting primary health care centre in the tribal hamlet in the town of Kalpetta, Wayanad District, Kerala, India, for reasons other than dental. Axis I and II of Research Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) was used to screen for TMD. A local language validated screening questionnaire was used. The clinical examination was carried out as per the DC/TMD by a calibrated examiner. The data was processed using SPSS and the frequencies and proportions for signs and symptoms of TMD were estimated. Results: Among 198 adults screened, 23 (11.6 %) had TMD. Among these 60 % of the adults were aged 31-65 years and predominantly females (86.9 %). 39 % of these patients were dentulous. All affected adults experienced TMD related pain for more than 3 months with 90 % of them experiencing moderate-to-severe pain. Myofascial pain was the most prevalent type. Other findings included moderate anxiety levels in 34.8 % and abnormal oral behaviour and high physical symptoms in 40 % TMD patients. Conclusion: TMD disorders were prevalent among the indigenous population and remained undiagnosed. The study highlights the need for screening and the availability of basic dental care for the indigenous populations.

An Innovative Technique of Microsurgical Training on Fresh "Chicken Quarter" Model: Our Experience.

Purpose Regular practice, quality clinical exposure, and academic discussion are essential in any surgical specialty training. This study discusses and validates the option of using a fresh "chicken quarter" model with a measurable scoring system, as a standard training regimen in microvascular surgery. This can be a very effective, economical, and easily accessible model for residents. Materials and Methods This study was conducted in the Department of Plastic surgery, from October 2020 to May 2021. Twenty-four fresh "chicken quarter" specimens were dissected and the ischial arteries and femoral veins' external diameter (ED) were measured. The microsurgical skills of the trainee were assessed in 6 months intervals using the Objective Structured Assessment of Technical Skills Scale (OSATS) as well as the time taken for anastomosis. All the data were analyzed using SPSS (statistical package for social sciences) version 21. Results A task-specific score value of 50% on October 2020 improved to 85.7% by May 2021. This was found to be statistically significant ( p = 0.043). The mean ED of the ischial artery and femoral vein was 2.07 and 2.26 mm, respectively. The mean width of the vein measured at the lower one-third of the tibia was 2.08 mm. A greater than 50% reduction in anastomosis time was observed after a period of 6 months. Conclusion In our minimal experience, the "chicken quarter model" with OSATS scoring system seems to be effective, economical, very affordable, and easily accessible microsurgery training model for the residents. Our study is done only as a pilot project due to limited resources and we have the plan to introduce it as a proper training method in the near future with more residents.

Patient Reported Outcomes of Scalp and Forehead Reconstruction for Defects Following Oncological Resections (North-East Indian Tertiary Cancer Centre Study).

Background Approximately 1-2% of all scalp tumours are malignant, but they comprise up to 13% of all malignant cutaneous neoplasms. The current study presents our experience of reconstruction of scalp and forehead for malignant tumours treated at our centre. Methods This is a single institutional observational study conducted at a tertiary cancer centre in North East India. Post-operative outcomes related to quality of life of patients were measured with help of FACE-Q scales. Face-Q -Satisfaction with outcome and FACE-Q- appearance related psychosocial distress scores were analysed. Histograms were used for descriptive statistics. Data were checked for normality using Kolmogorov-Smirnova and Shapiro-Wilk test. For non-normal data Wilcoxon test was used. A p value less than 0.05 was considered as statistically significant at 5% level of significance. Results Mean age of patients was 57.6 ± 14.2 years. The mean defect size was 89.036 ± 81.77 cm2. The mean satisfaction with outcome scores and distress scores at 3-months was 54.9 ± 8.6 and 34.8 ± 8.5 respectively with a statistically significant p value of 0.001.Mean satisfaction scores and psychological distress scores were better at the end of three months when compared to at the time of discharge with a statistical significant p value of < 0.0001. Conclusion Scalp and forehead reconstructions for defects following oncological resections are technically challenging and if chosen carefully with meticulous planning, both local and free tissue transfers give satisfactory outcome in long term follow up. There are lots of reconstruction options for scalp and forehead defects and knowledge of the basic bio-geometry of the each flap is must.

Effectiveness of 38% Silver Diamine Fluoride Application along with Atraumatic Restorative Treatment for Arresting Caries in Permanent Teeth When Compared to Atraumatic Restorative Treatment in Adults-Study Protocol for a Randomized Controlled Trial.

INTRODUCTION: Dental caries in the adult population that require preventive and therapeutic treatment are generally neglected in rural communities. The determination of the effectiveness of the application of 38% silver diamine fluoride (SDF) in arresting caries lesions when combined with atraumatic restorative treatment (ART) is very important, as it serves as a preventive and restorative procedure to regain the function of the permanent dentition. The assessment of optimal SDF application with ART, in comparison with ART alone, in managing cavitated carious lesions in a pragmatic setting, is the need of the hour to recommend optimal dental care, especially in rural settings which have minimal access to comprehensive dental care. METHODS AND ANALYSIS: The clinical trial will enrol 220 adults (18-65 years) with cavitated carious lesions attending the Amrita School of Dentistry in the Ernakulam district, India. This study is a randomized, controlled trial with a 1:1 allocation ratio in two parallel groups. Study arm 1 will receive 38% SDF application and ART, and study arm 2 will receive ART only. A digital radiograph will be taken immediately after restoration (baseline) as well as at the end of the 6th month for evaluation of caries arrest. The assessment of the survival of the restoration will be done on the 7th day, 30th day, and at the end of the 6th month. The final analysis would include both the tooth and person levels. ETHICS AND DISSEMINATION: This trial adheres to the principles of the Declaration of Helsinki and the guidelines of the Indian Council of Medical Research (ICMR). This study protocol has been approved by the Institutional Review Board. This trial has been registered prospectively with the Clinical Trial Registry of India (Registration No: CTRI/2021/12/038816).

Comparative evaluation of implant stability using bone expanders and conventional osteotomy.

Aim: The purpose of this study was to compare the implant stability and bone implant contact obtained using bone expanders to conventional osteotomy. Materials and methods: In this multiphasic study, the first phase was conducted on ex vivo porcine models to standardize the procedure and to check its feasibility. The second phase was conducted as human clinical trial. Phase I: A total of 10 implants were placed in the premolar region on five exvivo porcine models in randomized sequence using conventional osteotomy drills and bone expanders/screw spreaders. Implant stability was measured using resonance frequency analyser on the day of implant placement. Radiological analysis was done using micro-CT in two sectional block specimens randomly selected from each study groups. Phase II: Implants were placed on ten patients fulfilling the inclusion criteria. Implants were placed after randomizing the osteotomy sites. Bone expanders were used in 5 sites and conventional osteotomy technique was used in 5 other sites. Implant stability was measured on the day of implant placement and after three months in pre-loaded state using resonance frequency analyser. Results: Phase I: Average implant stability quotient for bone expanders were 71.2% ± 3.8% and 66.4% ± 1.3% for conventional osteotomy respectively. Bone to implant contact ratio values for bone expanders were 84.7% ± 7.9% and conventional osteotomy drills were 66.3% ± 13.6%. Phase II: Average primary stability at the day of surgery was 71.4 ± 1.3 for bone expanders and 65.6 ± 2.4 for conventional osteotomy drills. After three months (per-loaded state), average primary stability of bone expanders were 74.8 ± 1.1 and conventional osteotomy drills were 71.8 ± 2.5. Conclusion: The bone expanders used when indicated can enhance implant stability and bone to implant contact. Thus osteotomy by bone expanders may be suggested as a promising method especially in compromised bone.

Estimation of cytokine levels in gingival crevicular fluid following the use of different gingival retraction systems in patients requiring fixed partial dentures - An original research.

Gingival retraction is essential to get a dry and debris free field, which enables the impression material to flow into the gingival sulcus and record the area apical to the finish line. Effective gingival retraction without damaging periodontal tissue is extremely important. Objective: To comparatively evaluate the amount of inflammation, as assessed by TNF-α in GCF induced by three different gingival retraction techniques. Methods: Ten patients with a minimum of three teeth that required biomechanical preparation for fixed prostheses and acceptable oral hygiene with no periodontal pathology were included. The patients each received an oral prophylaxis. After a washout period of 10 days patients with gingival index scores of 0 or 1 were included. Measurements of TNF-α was done at baseline, after 30 min, after 7 days and after 28 days using ELISA test kit specific to TNF-α. Results: The sample population for whom Magic Foam cord was used showed a massive reduction in the amount of TNF -α, from 78% at 7 days to 18.6% at 28 days. There was a reduction in the percentage of TNF -α produced in the samples where normal knitted cord was used and for those where Expasyl was used from 95% to 64.2% and from 70% to 48.3% respectively. Conclusion: Maximum amount of inflammatory response was seen with plain knitted gingival retraction cord. This was followed by Expasyl gingival retraction system and the least amount of inflammatory cytokine was recorded with Magic Foam retraction cord.

An Early Experience of Microvascular Surgery in a Tertiary Cancer Centre in North East India.

BACKGROUND: Microvascular surgery is a highly technique sensitive and evolving speciality in reconstructive oncosurgery. There is a definite learning curve associated with it. In this case series, we describe our initial experience in microvascular surgery at a tertiary cancer centre in North East India. METHODS: It is a retrospective observational case series done at a tertiary cancer centre in North East India from May 2018 to Jul 2018. The first ten cases of our free flap journey till now were included in the study. Data were collected from patient records and the hospital online reporting system. All data were analysed using SPSS. RESULTS: In our series, 8 patients were male and 2 patients were female. The mean age in the series was 37 years. Squamous cell carcinoma accounts for 4 the patients, osteosarcoma for 2 of patients and adenoid cystic carcinoma, Ewing sarcoma, rhabdomyosarcoma and low-grade soft tissue sarcoma 1 case each. Out of the ten free tissue transfers, one free ALT flap for total maxillary defect failed during the 4th postoperative day and the patient was managed with a prosthesis. The average hospital stay during the case series was 10.6 days. CONCLUSION: Microvascular surgeries are very complex surgeries. The presence of a good, well-trained plastic surgery team working in conjunction with other specialities is paramount for a good outcome. A dedicated team, cooperative administration, fine and good infrastructure with high-quality equipment are the basic necessities for creating a good microsurgery unit.

Effectiveness of digital data acquisition technologies in the fabrication of maxillofacial prostheses - A systematic review.

OBJECTIVE: The systematic review was designed to review and analyze the outcomes of various digital data acquisition technologies used for treatment planning in the prosthetic rehabilitation of maxillofacial defects. METHODS: The review protocol was registered in PROSPERO data with registration number: CRD42020188415. The PICOS inclusion criteria was employed in the systematic review. An electronic search (PubMed, databases) yielded twenty-eight eligible case reports. The qualitative methodological assessment was done according to an article that provided criteria for special considerations in evaluating case reports. It consisted of four questions, each carrying grading of 0, 1, and 2. During the full-text screening, the reviewers shortlisted six outcomes (time, aesthetics, cost, dimensional accuracy, patient satisfaction, and fabrication process) and graded (0, 1, 3) according to the outcomes they met. RESULTS: The majority of the included case reports used LASER scanners. Auricular and orbital defects were the highest reported cases. In nasal and orbital defects, the mean outcome of the shorter time required for the fabrication was the highest. In auricular prostheses, the mean outcome of dimensional accuracy was highest. In facial prostheses, aesthetics, dimensional accuracy, and patient satisfaction had the highest mean outcome whereas, in obturators, the shorter time required, dimensional accuracy, and patient satisfaction had the highest mean outcome. A total of 18 studies were graded as highly significant studies according to the methodological qualitative assessment. CONCLUSION: LASER scanning systems in nasal prostheses, LASER scanners and combination of CT scan and digital photography in auricular prostheses, digital photography and stereophotogrammetry in case of large facial defects and combination of MRI and CT scan for obturators appeared to be a superior method of digital data acquisition.

Superhydrophilic multifunctional nanotextured titanium dental implants: in vivo short and long-term response in a porcine model.

Current clinical demand in dental implantology is for a multifunctional device with optimum mechanical properties, improved biocompatibility and bioactivity, and having differential interactions with cells and pathogenic agents. This would minimise bacterial infection, biofilm formation and modulate inflammation, leading to a fast and durable osseointegration. The present study intends to establish the multifunctional behaviour of surface modified titanium dental implants that are superhydrophilic, with unique micro-nano or nanoscale topographies, developed by a facile hydrothermal technique. Here, the short and long-term performances of these textured implants are tested in a split mouth design using a porcine model, in pre- and post-loaded states. Quantitative and qualitative analyses of the bone implant interphase are performed through µ-CT and histology. Parameters that evaluate bone mineral density, bone contact volume and bone implant contact reveal enhanced bone apposition with better long-term response for the nano and micro-nano textured surfaces, compared to the commercial microtextured implant. Concurrently, the nanoscale surface features on implants reduced bacterial attachment by nearly 90% in vivo, outperforming the commercial variant. This preclinical evaluation data thus reveal the superiority of nano/micro-nano textured designs for clinical application and substantiate their improved osseointegration and reduced bacterial adhesion, thus proposing a novel dental implant with multifunctional characteristics.

PDS Plate Versus Bone Graft in Orbital Floor Reconstruction: A Prospective Study to Identify the Better Alternative.

The objective of this study is to compare the effect and outcome of orbital floor reconstruction with bone graft and PDS plate. A prospective cohort study was conducted at B J Medical College, Civil Hospital, Ahmedabad from 1st September 2013 to 28th February 2016 by the Department of Burns and Plastic Surgery on patients (N = 35) who reported with orbital floor fracture. Diplopia, enophthalmos, infection rate, hospital stay, and donor site complications were considered. The above variables were assessed as predictors of outcome in the management (PDS vs. bone graft). Inferential statistics was done by chi-square test. The significance level was kept at 5%. Follow-up of 35 patients (2 years), 26 male, and 9 females aged 26-65 years were made. Diplopia and enophthalmos were the main criteria's in the study and neither of them showed any statistical significance. Donor site morbidity was noted in 3 patients among the bone graft group which was managed conservatively. Both the bone graft and PDS plate in orbital floor reconstruction is comparable in almost all aspects of our study. No statistically significant differences were found between the two groups. Pain and wound site infection are possible complications when a bone graft is used as the reconstructive option.

Loupe Assisted Thyroidectomy: A Tool for Reducing Complications.

The objective of this study is to assess if the use of magnification can reduce the incidence of hypocalcemia and vocal cord palsy in thyroid surgery. Data of patients who underwent total thyroidectomy (N = 50) for thyroid malignancy were analyzed retrospectively for 1 year. The patients were divided into two groups based on surgery with and without loupes. Hypocalcemia and Vocal cord palsy was assessed pre as well as post-operatively and the observations were noted. Descriptive statistics were performed to assess the proportion of the respective groups. Inferential statistics to find out the difference between the groups was done using the chi-square test. Significance level was kept at 5%. The incidence of hypocalcemia was 36.9% in the group done without loupes compared to 7.6% with loupes. The event of vocal cord injury though transient was 33% when done without loupes (p < 0.05). Magnification is crucial for the visualization of the neurovascular anatomy which is depicted in our study. Although the study includes less number of cases, it is evident that the use of loupe magnification can reduce the morbidity associated with thyroid surgery to a great extent. We recommend the use of loupe magnification during surgery whenever possible.

An Experience of Scalp Island Flap Based on the Posterior Branch of the Superficial Temporal Artery for Patients with Mucormycosis and Cancer.

To find out the utility of the scalp flap based on the posterior branch of the superficial temporal artery in patients with head and neck mucormycosis and malignancy. This was a multi-institutional observational study conducted at a tertiary cancer centre in North East India and a super-speciality hospital in Maharashtra from January 2021 to June 2021. Patients with malignancy and mucormycosis were only considered. In our study, we have seven patients (n = 7), two of them had mucormycosis and 5 had squamous cell carcinoma of the head and neck region. Out of the 5 cases of the head and neck malignancy, two cases were recurrent ones, another two cases where primary flap failed and in the last case, the patient was unfit for free tissue transfer due to cardiac issues. The mean age in the series was 50.42 years and the average duration of raising the flap was 22.86 min. Average hospital stays for head and neck cancer patients are 4.6 days and for mucormycosis patients, it is 22.5 days. No flap related complications were noted during the series. Scalp flap based on the posterior branch of the superficial temporal artery is a useful option in recurrent malignancy cases, in primary cases as a salvage option and in patients where long duration surgery is not possible due to poor general condition like in critical mucormycosis. Post-operative hair growth at the flap site and alopecia at the donor scalp are concerns and therefore, careful patient selection is a must.

Effects of Prosthetic Rehabilitation on Temporomandibular Disorders: Protocol for a Randomized Controlled Trial.

BACKGROUND: Loss of teeth or occlusal imbalance is one of the proposed dental risk factors for temporomandibular disorders (TMDs). Losing some non-free-end teeth cause the original occluding tooth/teeth to supraerupt from the original upright position and causes neighboring tooth/teeth to shift in an angle, causing biomechanical imbalance on the mandible. Based on these sequelae, rehabilitation of missing teeth is the first step in managing TMD in edentulous patients. Even though the prevalence of TMD in association with edentulism and in rehabilitated patients has been increasing, proper guidelines for the management of such cases have not been established. This study describes the protocol to analyze the effect of prosthetic rehabilitation on patients with TMD. OBJECTIVE: This study aims to determine the effectiveness of prosthetic rehabilitation in the reduction of pain in edentulous patients with TMD and to determine the effect of the span of edentulism, the number of quadrants involved, pathological migration, the type of Kennedy classification, and the prosthetic status on temporomandibular joint dysfunction signs and symptoms. METHODS: In this randomized controlled trial, 300 patients diagnosed with TMD will be grouped into one of the three interventional groups based on the type of their edentulous state. The interventional groups are (1) partially edentulous arch: Kennedy Class I and II (prosthetic rehabilitation without splint); (2) partially edentulous arch: Kennedy Class III and IV (prosthetic rehabilitation with a splint); and (3) completely edentulous arches (prosthetic rehabilitation without splint). All three of the mentioned interventional groups have corresponding control groups that will receive symptomatic treatment and comprehensive counseling. The measured primary outcomes are pain and electromyogram, and the secondary outcomes include pain drawing, Graded Chronic Pain Scale, Jaw Functional Limitation Scale, Oral Behaviours Checklist, depression, physical symptoms, and anxiety. The outcome measurements will be recorded at baseline and at the end of 24 hours, 7 days, 28 days, and 3 months. RESULTS: Ethical approval was obtained from the Institutional Review Board of Amrita Institute of Medical Sciences, Kochi, India. Study participants' recruitment began in May 2021 and is expected to conclude in March 2023. This clinical trial protocol was developed based on the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 Statement. CONCLUSIONS: The purpose of this study is to gather data on prosthetic rehabilitation as a treatment for TMD. Obtaining this goal will aid in the development of evidence-based therapy protocols for prosthetic rehabilitation in TMD management. TRIAL REGISTRATION: Clinical Trials Registry - India CTRI/2020/06/026169; http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=42381. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33104.

Prevalence and correlates of anemia among women in the reproductive age (15-49 years) in a rural area of Tamil Nadu: An exploratory study.

BACKGROUND: Anemia is a major public health problem among reproductive-aged women in India. Despite many programs implemented for decades to fight anemia, still the prevalence of anemia is high because its associated factors vary among different regions. This exploratory study was carried out to find the prevalence of anemia and factors influencing it among nonpregnant reproductive-aged women (15-49 years) in a rural area of Coimbatore. MATERIALS AND METHODS: The study was conducted in the field practice area of Rural Health Training Centre, PSG IMSR, Coimbatore, during March 2016 to August 2016. Participants were recruited by two-staged random sampling method and 426 participants were enrolled. A predesigned semi-structured questionnaire was used to collect the data pertaining to the factors influencing the prevalence of anemia, and their hemoglobin level was measured using a hemoglobin photometer. The data were analyzed using SPSS-24. (IBM Corporation, SPSS Inc., Chicago, IL, USA) Univariate analysis was done using Chi-square test and the strength of association was estimated by odds ratio. Those factors which were found to be significant by univariate analysis were further subjected to multivariate logistic regression analysis. P < 0.05 was considered statistically significant. RESULTS: The prevalence of anemia was estimated as 64.8% (95% confidence interval: 60%-69%). Significant predictors for anemia among the study participants were less frequent intake of green leafy vegetables (adjusted odds ratio [AOR] = 3.65, confidence interval [CI]: 2.17-6.12), low socioeconomic status (AOR = 3.36, CI: 1.93-5.84), illiteracy (AOR = 3.09, CI: 1.09-5.24), birth spacing <2 years (AOR = 2.49, CI: 1.19-5.25), excessive menstrual bleeding (AOR = 2.27, CI: 1.09-4.76), and inadequate knowledge regarding anemia (AOR = 2.03, CI: 1.19-3.44). CONCLUSION: Anemia is still prevalent in high magnitude in reproductive-aged women, and measures to prevent and control it are not optimum. Hence, its multifactorial determinants have to be addressed to alleviate its burden.

Applications of proportional odds ordinal logistic regression models and continuation ratio models in examining the association of physical inactivity with erectile dysfunction among type 2 diabetic patients.

PURPOSE: Many studies have observed a high prevalence of erectile dysfunction among individuals performing physical activity in less leisure-time. However, this relationship in patients with type 2 diabetic patients is not well studied. In exposure outcome studies with ordinal outcome variables, investigators often try to make the outcome variable dichotomous and lose information by collapsing categories. Several statistical models have been developed to make full use of all information in ordinal response data, but they have not been widely used in public health research. In this paper, we discuss the application of two statistical models to determine the association of physical inactivity with erectile dysfunction among patients with type 2 diabetes. METHODS: A total of 204 married men aged 20-60 years with a diagnosis of type 2 diabetes at the outpatient unit of the Department of Endocrinology at PSG hospitals during the months of May and June 2019 were studied. We examined the association between physical inactivity and erectile dysfunction using proportional odds ordinal logistic regression models and continuation ratio models. RESULTS: The proportional odds model revealed that patients with diabetes who perform leisure time physical activity for over 40 minutes per day have reduced odds of erectile dysfunction (odds ratio=0.38) across the severity categories of erectile dysfunction after adjusting for age and duration of diabetes. CONCLUSION: The present study suggests that physical inactivity has a negative impact on erectile function. We observed that the simple logistic regression model had only 75% efficiency compared to the proportional odds model used here; hence, more valid estimates were obtained here.

Restoration of elbow flexion in adult traumatic brachial plexus injury - a quantitative analysis of results of single versus double nerve transfer.

BACKGROUND: Restoration of elbow flexion is one of the key components of adult brachial plexus surgery. Nerve transfers are routinely used to attain elbow flexion. PURPOSE: This study aims to quantify the recovery of elbow flexion power and to compare the outcome following single nerve transfer and double nerve transfer to branches of the musculocutaneous nerve in adult traumatic brachial plexus injury. METHOD: We conducted a retrospective cohort study of patients with traumatic upper brachial plexus injury who underwent nerve transfer of the musculocutaneous nerve with either Ulnar nerve fascicles (SN) or both Ulnar and Median nerve fascicles (DN) for restoring elbow flexion. Patients with a minimum follow up of 18 months after surgery were included in this study. Elbow flexion strength was quantified using a force transducer and software module and the results were compared between the two groups. RESULT: The median strength of elbow flexion was 14.3 Newton meter. In the SN group, the mean strength of elbow flexion was 5.4 ± 5 Nm, and for DN group it was 20.4 ± 9.9 Nm. Elbow flexion strength following DN procedure was significantly better when compared with SN. CONCLUSION: The additional nerve transfer of median nerve fascicles with musculocutaneous nerve branch to the brachialis muscle does not add clinically obvious morbidity to the patient but has definite benefit as observed in this study. We advocate double fascicular nerve transfer for elbow flexion in upper brachial plexus injuries if the median and ulnar nerve functions are normal.

Perceptions of a comprehensive dental care teaching clinic among stakeholders in a dental teaching hospital in South India: A baseline assessment.

BACKGROUND: When the dentist starts practicing independently, they need to plan and treat comprehensively and prioritise the procedures accordingly. This contrasts with dental students learning years where they deal with only a clinical subject during a fixed period. To improve this scenario a comprehensive dental care teaching clinic was introduced, and baseline assessment was performed. METHODS: The perceptions of patients, dental undergraduate students, clinical instructors, and clinic co-ordinators regarding Comprehensive Dental Care was evaluated by a cross sectional survey. The questionnaire was developed through a focus group discussion and content validation was performed by experts. Three domains including orientation to the clinics, clinical training of undergraduates and clinic management were assessed. Descriptive statistics were performed using SPSS. RESULTS: The results reveal, 53.5% of undergraduate students and 61.3% of clinic instructors agreeing that students trained under comprehensive system can confidently manage patients independently. Good collaboration (80%) among the dental team and regular monitoring of the clinic management (80%) were reported by clinic co-ordinators. The challenges ahead for this teaching clinic includes instrument and facilities availability, which has found to higher disagreement percentages by undergraduate students (43.7%), clinic instructors (38.7%) as well as clinic co-ordinators (50%). Patient satisfaction for all three domains were noted to be high. CONCLUSION: With the introduction of the comprehensive dental care teaching clinic better patient management and improved clinical training of undergraduate students were reported by the stakeholders. This new system is a major shift in dental service delivery and can be adopted to similar settings to improve patient care and dental education.

Treatment Failures of Direct Oral Anticoagulants.

BACKGROUND: Use of direct oral anticoagulants (DOACs) has increased over the years, because they have become a safe and effective alternative to the Vitamin-K antagonists in various clinical scenarios. With their increased use, reports have emerged describing their failure. STUDY QUESTION: What are the patient characteristics and clinical settings in which DOAC treatment failure manifests? DATA SOURCES: We searched published reports in Google Scholar, PubMed, MEDLINE, and Embase from the introduction of DOACs in any therapy until March 2019. STUDY DESIGN: Information on patient characteristics, comorbidities, primary anticoagulation indications, pharmacologic treatment, and outcomes were collected. Primary endpoints were new thrombus formation, failure of resolution of an existing thrombus, or discovery of subtherapeutic drug level. Other endpoints were time to treatment failure, manifestations of treatment failure, and new treatment after DOAC failure. RESULTS: Our search yielded 51 manuscripts, describing 79 patients who exhibited DOAC failure. The most common treatment failures were in patients with antiphospholipid syndrome (44.3%), atrial fibrillation (30.4%), and deep venous thrombosis (6.3%). There was a trend toward higher failure rate for rivaroxaban (65.8%) followed by dabigatran (27.8%), apixaban (7.6%), and then edoxaban (1.3%). Each agent had different median failure times. Most common manifestations of treatment failure were stroke/transient ischemic attack (20.3%), pulmonary embolism (19.0%), and deep venous thrombosis (19.0%). More than half of patients were transitioned to a Vitamin-K antagonist after DOAC failure (55.7%). CONCLUSIONS: Our analysis illustrates that DOACs may fail in the setting of Food and Drug Administration and non-Food and Drug Administration- approved indications. In clinical practice, it may be best to choose between available anticoagulant drugs on a case-by-case basis.