Translation and validation of Hindi version of patient scar assessment scale in patients with postburn facial scar.

Background: Patient scar assessment scale (PSAS) is a reliable and standard tool for assessment of scars by the observer and the patient. Till now the scale has not been translated to Hindi. The objective of the study was to translate and validate the PSAS to Hindi. Materials and Methods: We did forward and backward translation of the English PSAS together with its validation. In total, 64 patients with postburn facial scars were included. The validation committee consisted of 6 bilingual members. Results: The PSAS-Hindi showed good internal consistency with Cronbach's α of 0.86. Test-retest reliability showed good correlation with intra class coefficient being 0.94 (95% confidence interval: 0.83-0.97). Conclusion: The PSAS was successfully translated to Hindi, and cross-cultural adaptation was made.

Clinical validation and accuracy assessment of the Capsule Endoscopy-Crohn's Disease index (CE-CD).

OBJECTIVES: To compare the recently proposed Capsule Endoscopy-Crohn's Disease index (CE-CD) to pre-existing capsule endoscopy (CE) scores, to measure its precision and accuracy to predict adverse clinical outcomes in children with Crohn's disease (CD). METHODS: Children with CD who underwent CE at diagnosis and had, at least, 1-year follow-up postprocedure were selected. Capsule study was viewed and the different indices were independently scored by two trained paediatric gastroenterologists. The relationship between pre-existing scores and CE-CD was assessed by linear regression analysis. Clinical outcomes prediction assessment was based on receiver operating characteristics curves, survival analysis and Cox regression. Finally, interobserver agreement was measured. RESULTS: Fifty-nine patients were finally included. CE-CD showed a strong positive correlation with the Lewis score (ρ = 0.947) and the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI) (ρ = 0.982). Both CE-CD and CECDAI were significant predictors of treatment escalation (hazard ratio 1.07 and 1.09, respectively, with both p-values < 0.01). However, no score predicted risk of hospital admission, surgery or clinical/endoscopic relapse. The presence of moderate-to-severe small bowel (SB) inflammation, defined as a score of ≥9 on CE-CD, provided a hazard ratio of treatment escalation of 2.6 (95% confidence interval: 1.3-5.3). This cut-off provided the optimal sensitivity/specificity pair: 48.4%/89.3%. No interobserver misclassification among inflammation categories given by CE-CD were observed (kappa 100%). CONCLUSION: CE-CD is a useful tool to document SB inflammation in children with CD. It correlates strongly with classical scores, can better predict need for treatment escalation and shows good interobserver agreement.

A Randomised Control Trial Comparing the Outcomes of Anterior with Posterior Approach for Transfer of Spinal Accessory Nerve to Suprascapular Nerve in Brachial Plexus Injuries.

Background: In brachial plexus surgery, a key focus is restoring shoulder abduction through spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer using either the anterior or posterior approach. However, no published randomised control trials have directly compared their outcomes to date. Therefore, our study aims to assess motor outcomes for both approaches. Methods: This study comprises two groups of patients. Group A: anterior approach (29 patients), Group B: Posterior approach (29 patients). Patients were allocated to both groups using selective randomisation with the sealed envelope technique. Functional outcome was assessed by grading the muscle power of shoulder abductors using the British Medical Research Council (MRC) scale. Results: Five patients who were operated on by posterior approach had ossified superior transverse suprascapular ligament. In these cases, the approach was changed from posterior to anterior to avoid injury to SSN. Due to this reason, the treatment analysis was done considering the distribution as: Group A: 34, Group B: 24. The mean duration of appearance of first clinical sign of shoulder abduction was 8.16 months in Group A, whereas in Group B, it was 6.85 months, which was significantly earlier (p < 0.05). At the 18-month follow-up, both intention-to-treat analysis and as-treated analysis were performed, and there was no statistical difference in the outcome of shoulder abduction between the approaches for SAN to SSN nerve transfer. Conclusions: Our study found no significant difference in the restoration of shoulder abduction power between both approaches; therefore, either approach can be used for patients presenting early for surgery. Since the appearance of first clinical sign of recovery is earlier in posterior approach, therefore, it can be preferred for cases presenting at a later stage. Also, the choice of approach is guided on a case to case basis depending on clavicular fractures and surgeon preference to the approach. Level of Evidence: Level II (Therapeutic).

Restoring Quality of Life: Assessing the Impact of Free Flap Reconstruction in Coronavirus Disease 2019-Associated Rhino-Orbital Mucormycosis Patients.

Background In India, between May 5 and July 2021, 41,512 cases and 3,554 deaths due to mucormycosis were reported in coronavirus disease 2019 (COVID-19)-infected patients or COVID-19-recovered patients. COVID-19-associated rhino-orbital mucormycosis (CAROM) has been associated with adverse effects that can affect oral health, vision, and physical as well as emotional functioning. After the radical debridement of CAROM and antifungal therapy, reconstructive surgery should be employed to restore function and aesthetics; however, limited clinical data exist on its potential effect on the quality of life (QOL) of these patients. Objective Our objective was to assess the QOL among CAROM patients reconstructed with free flap surgery. Materials and Methods This analysis studied 19 patients of CAROM who had maxillectomy and/or orbital exenteration defects reconstructed with free flaps at a tertiary care center. All these patients were free from any residual disease, as confirmed by tissue biopsy taken from the affected area. The QoL of these patients was assessed 1 week preoperatively and 4 to 6 months postoperatively using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-HN43) questionnaire module. Results There was a statistically significant improvement in 10 out of the total 19 parameters ( p < 0.05) which include pain in the mouth, problems opening mouth, speech, swallowing, weight loss, dry mouth and sticky saliva, body image, fear of progression, social contact, and social eating. Conclusion The EORTC QLQ-HN43 questionnaire module presented a statistically significant improvement in the functional as well as psychological status of the CAROM patients undergoing reconstruction by free flap surgery.

Volumetric assessment of the nose after primary unilateral cleft rhinoplasty using Laberge's technique.

BACKGROUND: There is a lack of standardized surgery for cleft rhinoplasty. We felt that the technique described by Dr Louise Caouette Laberge is an ideal way to approach this problem, thus we tried to quantify the outcome of surgery by volumetric assessment. MATERIAL AND METHOD: We recorded 3D images using an Artec scanner and performed volume calculations of the cleft side and noncleft side of the nose. These readings were taken once in the preoperative and then 2 weeks postoperative. Another scan of the face was performed 2 years after the surgery to compare the volumes of the cleft and noncleft side nostril. RESULTS: Of the 31 patients with unilateral cleft lip operated on (mean age 3-8 months), we found a significant increase in the cleft side volume at 3 weeks postoperative from 3.95 mm3 to 5.65 mm3 (p < 0.001 on paired t-test). A repeat scan done on the study population at 2 years postoperative found that the mean volume of the cleft side was 30.43 mm3 (standard deviation [SD], 2.49) and that of the normal side was 30.82 mm3 (SD, 2.51). An independent t-test found that there was no significant difference between the two volumes (p > 0.05) CONCLUSION: The use of volumetric data in the evaluation of postoperative outcomes provides an objective criterion for assessing the aesthetics as well as the growth. Our study concludes that the Laberge technique provides a good aesthetic outcome with minimal scarring for the management of cleft nose and lip with the anterior palate.

Introduction of Spring-Assisted Cranioplasty for Bicoronal Synotosis in India: Description of First Case and Our Learning Experience.

Background: Various surgical techniques for cranial reconstruction of patients with bicoronal synostosis have been suggested. The outcome is, however, still often suboptimal. Methods: In a 5-month-old child with apert syndrome, following a craniotomy incision, lambdoid suturotomy was done bilaterally. Two springs were implanted bilaterally over the lambdoid sutures. Cephalic index was obtained from three-dimensional computed tomography scans, and photographs were analyzed for aesthetic evaluation. Result: The preoperative calvarial shape was hyperbrachycephalic. The CI improved from 92 to 83 units. Duration of surgery was 1 h 45 min, blood loss was 30 mL, and total hospital stay was 3 days. No major complications were observed. Spring removal was done at 6 months postoperatively and frontoorbital advancement performed. Conclusion: Spring-assisted cranioplasty for bicoronal synostosis is a safe and elegant technique, is less invasive than many other cranioplasties, and results in marked improvement in the calvarial shape.

Severe Acute Hepatitis: An Emerging Grave Illness in Children.

Acute hepatitis of unknown origin in children has been recently described in the literature, and a case definition has also been proposed for this condition. The exact etiology is unknown and exclusion of infectious, metabolic, autoimmune and toxin mediated injuries is essential. Management for this condition is supportive, but some may require liver transplantation. Infection prevention and control practices are important as the etiology remains unidentified.

Is "Initial Size of the Graft the Real Culprit behind Primary Contraction of Full-Thickness Skin Graft"? - A Cross-Sectional Study.

Background Primary contraction of full-thickness graft has been traditionally quoted to be 40%. There are lacunae in literature to elaborate on the factors influencing it ever since. Methods About 75 subjects who underwent full-thickness grafting procedures to resurface small defects were included in the study. The initial and final graft dimensions after primary contraction were traced on X-ray templates and the percentage of contraction was evaluated using the graphical method. This was further correlated with age, collagen, elastic matrix metalloproteinases-1 (MMP-1) and -2 content along with dermal thickness of the skin specimen sent from the graft. Results The primary contraction of the graft had a very significant correlation only with the initial size of graft harvested with a linear regression of 33.3% and a Spearman's correlation of 0.587 significant at a p -value of 0.001. Conclusion This study though preliminary tries to highlight an important factor that primary contraction of grafts is a physical phenomenon independent of its contents like collagen, elastin, or MMP-1 and -2 or age and dependent on its initial size of harvest instead.

Adipose Tissue in Peripheral Obesity as an Assessment Factor for Pressure Ulcers.

Scope and Significance: Pressure ulcers are very difficult to treat and pose an economic burden, just below cancer and cardiovascular illness, at 4.82 billion U.S. dollars. It is important to understand the pathophysiology of the condition, risk stratification, and ways of preventing it. Prevention forms the most important aspect of their management. The authors systematically evaluated the existing risk prediction scales and explored the evidence from literature regarding the role of additional factors including body mass index, obesity, subcutaneous tissue thickness, and skin integrity in pressure ulcers. With this review it is hoped that the future management of pressure ulcers will concentrate on the preventable and alterable factors in its pathophysiology. Translational Relevance: The review focuses on how adipose tissue thickness can predict the occurrence of pressure ulcer. If adequately proved that a definite thickness of peripheral adipose tissue is efficient in prevention of pressure ulcers, then methods of maintaining the thickness of this tissue will be the next effective strategy in the management of this chronic issue. Clinical Relevance: The review addresses the management of pressure ulcers to wound care providers and emphasize on confounding parameters of obesity, subcutaneous tissue thickness, and skin integrity during the treatment regimen of pressure ulcers. Objectives: The main objective of this review is to draw a consensus concerning the role of adipose tissue in pressure ulcers, based on the published research. A review of the various preexisting predictive scales for pressure ulcers is a secondary objective to highlight the shortcomings in ulcer management. This review finally aims in the future at paving a way to refine our prognosticating scales for pressure sores based on these results. Accurate preventative injury risk scales are needed so that preventative resources can be directed to the patients for whom they are the most appropriate.

Humero-Pectoral Band in Poland Syndrome.

The humero-pectoral band in Poland syndrome is a rare presentation and needs urgent surgery because it restricts the shoulder abduction of the patient. In our case, instead of excising the band, we have made use of the tissue by including it in the Z-plasty flaps which make the flaps reliable even though they were supplied by a narrow base.

Early One Stage Functional Reconstruction of a Mangled Upper Extremity.

Background: A crush injury to the upper extremity with a MESS (Mangled Extremity Severity Score) more than or equal to 10 carries a poor salvage prognosis and functional outcome. Usually performing multiple staged surgeries in these patients make the follow up and rehabilitation regimen long and complicated. This means either the patient doesent return or fails to gain any function. In order to overcome this problem we have done a single stage functional reconstruction in a mangled upper extremity. Case: A young female presented with a crush injuiry of the upper limb where a functional reconstruction with an LD (Latissimus Dorsi) flap was done 48 hrs after limb salvage surgery. The flap provided cover to the shoulder and elbow joint and also acted as a motor for elbow flexion. Result: After 6 months following surgery, the patient had regained active motion in her elbow and shoulder joint, and at 1 year she was able to carry out activities of daily living without any external help. Conclusion: Our case demonstrates that the mangled upper extremity can have varied presentations but the surgeon should use every knowledge and technique at their disposal to achieve the maximum chance of autologous functional reconstruction. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00700-w.

The prospective study of change of perception of postgraduate students on objective structured clinical examination in burns and plastic surgery.

BACKGROUND: In this study, we attempted to assess the change of perception of postgraduate students on objective structured clinical examination (OSCE) in burns and plastic surgery after first five OSCE. METHODS: A prevalidated feedback questionnaire was used to assess and score the perception of postgraduate students on OSCE in burns and plastic surgery. The opinion of postgraduate students on the feedback questionnaire after first and fifth assessment tests based on OSCE was analyzed. The results were compiled on a data sheet and analyzed using Microsoft Excel and plotted as graphical interpretation. The statistical analysis was done using MedCalc software. RESULTS: The results of the study showed that there is a positive change in perception of students in favor of monthly assessment based on OSCE in burns and plastic surgery after fifth assessment. The mean students' favorable perception score after the first assessment with was 30.2 ± 2.828 (mean ± standard deviation [SD]) and after fifth assessment, 43 ± 2.828 (mean SD) with Student's test t = 10.119 and P < 0.0001 which is highly significant statistically in favor of OSCE after fifth assessment. CONCLUSIONS: We observed in our study that the monthly assessment based on OSCE is well accepted by the students of our subspecialty after few assessments; however, further studies are required to augment the evidence.

The COVID-19 pandemic impact on clinical load of plastic and reconstructive surgery in a tertiary care hospital of north India: A retrospective comparative analysis.

BACKGROUND: The objective of the study was to analyze and determine statistically significant impact of the COVID-19 on clinical load of plastic and reconstructive surgery practices. MATERIALS AND METHODS: The retrospective analysis and comparison of the number of patients visiting to outpatient clinic, number of patients admitted, number of patients operated in the plastic and reconstructive surgery department during the COVID-19 pandemic months of January 2020-June 2020 with the same months of preceding non-COVID-19 year was done. The data obtained were tabulated in Microsoft Excel spread sheet and the statistical analysis done using MedCalc statistical software. RESULTS: The mean ± standard deviation of patients attended in outpatient department (OPD), admitted in inpatient department (IPD), emergency surgeries performed, and elective surgeries performed during -COVID-19 versus COVID-19 pandemic period is (651.167 ± 310.42 vs. 212.5 ± 307.591), (83.5 ± 16.263 vs. 34.333 ± 53.74), (5.167 ± 4.243 vs. 3.333 ± 4.95), and (74.333 ± 28.284 vs. 40.833 ± 60.811), respectively. The difference in means is highly significant statistically in the number of patients attended in OPD, admitted in IPD, and elective surgeries performed during pre-COVID versus COVID period; however, the difference in the means is not statistically significant in the number of emergency surgeries performed during pre-COVID versus COVID period. CONCLUSION: The COVID-19 pandemic has significantly reduced the number of patients attended in OPD, admitted in IPD, and elective surgeries performed in the department of plastic surgery. However, there is a reduction in number of emergency surgeries but statistically insignificant. The strategy is to use telemedicine portal e-Sanjeevani services for OPD, encourage admission of patients with reverse transcription polymerase chain reaction negative for COVID-19, and perform reconstructive and esthetic plastic surgery operative procedures using COVID-19 appropriate precautions.

The Passot Technique Revisited: No Vertical Scar Reduction Mammoplasty in Unmarried Females: A Case Series.

BACKGROUND: Macromastia in adolescent girls is a distressing condition. There is an increase in the number of patients opting for reduction mammoplasty in the late teens. The semicircular horizontal method of breast reduction, first described by Passot in 1925 has the advantage of being able to do larger reduction, particularly suitable for pendulous breasts and having a hidden scar in the inframammary fold. METHODS: Eleven patients of adolescent macromastia were included in this study. It was conducted over a period of 4 years (2013-17) at two teaching institutions in Kolkata and Rishikesh, India. The mean age of the patients was 19.2 years. The Passot technique of reduction mammoplasty was performed in each case and the volume of resected breast tissue recorded by weighing the specimen. The aesthetic outcome was assessed by Lowery scale (volume, contour, placement of the breast mound and inframammary fold). Patient satisfaction was assessed after 6 months of follow up on a scale of 1 to 10, where 1-4 was poor, 5-6 fair, 7-8 good and 9-10 excellent. RESULTS: Mean total reduction per breast was 856 gm. Patients reported a mean decrease of cup size by 1.5. The aesthetic outcome was excellent in 6 patients and good in 5 patients. Patient satisfaction was excellent in 9 patients and good in 2 patients. CONCLUSION: Passot technique is a safe and effective technique of reduction mammoplasty and is especially useful in adolescent macromastia where the absence of visible scar on the breasts is very satisfying for the patients.

Evaluation of pedicled flaps for type IIIB open fractures of the tibia at a tertiary care center.

BACKGROUND: Soft tissue coverage plays a vital role in replacing the vascularity of the underlying bone in Gustilo type IIIB fractures. The aim of this article was to evaluate the feasibility of local pedicled flaps in type IIIB fractures at a tertiary care center. METHODS: We included all cases of open Gustilo-Anderson type IIIB fractures of the tibia treated with local flap coverage from January 2017 to February 2019. We carried out a retrospective analysis to investigate the relationships of complications, hospital stay, and cost-effectiveness with the choice of flap, infective foci, site and size of the defect, and type of fixation. RESULTS: Out of 138 Gustilo type IIIB fractures analyzed in our study, 27 cases had complications, of which 19 (13.76%) involved flap necrosis, four (2.89%) were infections, three (2.17%) involved partial necrosis, and one (0.72%) was related to bone spur development. Flap complications showed a statistically significant association with the perforator flap category (propeller flaps in particular) (P=0.001). Flap necrosis showed a significant positive correlation with cases treated within 3 weeks after trauma (P=0.046). A significant positive correlation was also found between defect size and the duration of hospital stay (P=0.03). CONCLUSIONS: Although local flaps are harvested from the same leg that underwent trauma, their success rate is at least as high as microvascular flaps as reported from other centers. Amidst the local flaps, complications were predominantly associated with perforator flaps.

Advances in Therapeutic Drug Monitoring in Biologic Therapies for Pediatric Inflammatory Bowel Disease.

In the current era of treat-to-target strategies, therapeutic drug monitoring (TDM) has emerged as a potential tool in optimizing the efficacy of biologics for children diagnosed with inflammatory bowel disease (IBD). The incorporation of TDM into treatment algorithms, however, has proven to be complex. "Proactive" TDM is emerging as a therapeutic strategy due to a recently published pediatric RCT showing a clear benefit of "proactive" TDM in anti-TNF therapy. However, target therapeutic values for different biologics for different disease states [ulcerative colitis (UC) vs. Crohn's disease (CD)] and different periods of disease activity (induction vs. remission) require further definition. This is especially true in pediatrics where the therapeutic armamentarium is limited, and fixed weight-based dosing may predispose to increased clearance leading to decreased drug exposure and subsequent loss of response (pharmacokinetic and/or immunogenic). Model-based dosing for biologics offers an exciting insight into dose individualization thereby minimizing the chances of losing response. Similarly, point-of-care testing promises real-time assessment of drug levels and individualized decision-making. In the current clinical realm, TDM is being used to prolong drug durability and efficacy and prevent loss of response. Ongoing innovations may transform it into a personalized tool to achieve optimal therapeutic endpoints.

Occipitofrontal switch for correction of anterior plagiocephaly planned through virtual mock surgery.

BACKGROUND: Unilateral coronal synostosis causing anterior plagiocephaly can result in restricted brain development and severe facial deformities. Various surgical procedures have been described for the correction of this deformity. Cranial vault remodeling, however, is associated with several complications. Occipitofrontal switching is a novel technique which utilizes a part of the contralateral occipital bone to reconstruct the frontal area. This is the first such case reported from India and first report where virtual mock surgery has been utilized for precision and improving outcome in this elegant procedure. CASE DESCRIPTION: A 5-year-old girl presented with left anterior plagiocephaly. 3D image of her skull was reconstructed using Geomagic Freeform software (3D Systems, Rock Hill, SC). Measurements were accurately drawn and the procedure was practised virtually before performing the occipitofrontal switch on the patient. There were minimal blood loss and postoperative morbidity. One year follow-up of the patient showed optimal correction of the defect in the forehead region, symmetrical shape of the frontal and occipital region and symmetrical brows. CONCLUSION: The technique of occipitofrontal switch for correction of anterior plagiocephaly is an elegant procedure with good functional and aesthetic outcome.

Frequency of anemia and micronutrient deficiency among children with cleft lip and palate: a single-center cross-sectional study from Uttarakhand, India.

BACKGROUND: Children with cleft lip and/or palate can be undernourished due to feeding difficulties after birth. A vicious cycle ensues where malnutrition and low body weight precludes the child from having the corrective surgery, in the absence of which the child fails to gain weight. This study aimed to identify the proportion of malnutrition, including the deficiency of major micronutrients, namely iron, folate and vitamin B12, in children with cleft lip and/or palate and thus help in finding out what nutritional interventions can improve the scenario for these children. METHODS: All children less than 5 years with cleft lip and/or cleft palate attending our institute were included. On their first visit, following were recorded: demographic data, assessment of malnutrition, investigations: complete blood count and peripheral blood film examination; serum albumin, ferritin, iron, folate, and vitamin B12 levels. RESULTS: Eighty-one children with cleft lip and/or palate were included. Mean age was 25.37± 21.49 months (range, 3-60 months). In 53% of children suffered from moderate to severe wasting, according to World Health Organization (WHO) classification. Iron deficiency state was found in 91.6% of children. In 35.80% of children had vitamin B12 deficiency and 23.45% had folate deficiency. No correlation was found between iron deficiency and the type of deformity. CONCLUSION: Iron deficiency state is almost universally present in children with cleft lip and palate. Thus, iron and folic acid supplementation should be given at first contact to improve iron reserve and hematological parameters for optimum and safe surgery.

Outcome analysis of biplanar mandibular distraction in adults.

BACKGROUND: Mandibular deficiency leading to facial asymmetry causes cosmetic deformity as well as psychological stigma for the patient. Correction of these mandibular asymmetries is a major challenge. The study investigates the efficacy of bidirectional mandible distraction for the treatment of mandibular deficiency. METHODS: This prospective study included six individuals aged between 17 and 24.4 years. Five patients had hemifacial microsomia and one had unilateral temporomandibular joint ankyloses. All patients underwent mandibular distraction osteogenesis. Postoperative skeletal changes in affected mandible, and changes in occlusal plane and oral commissure cant were evaluated using three-dimensional reconstruction. Patient satisfaction and understanding of the procedure were assessed through three questionnaires administered during pre-distraction, distraction and postdistraction phases. RESULTS: In pre-distraction phase, aesthetic appearance seemed to be the primary indication for surgery. In distraction phase, pain while chewing was the primary handicap. In post-distraction phase all patients were satisfied with the aesthetic outcome. The facial deformity was improved through mandibular distraction osteogenesis. On the affected side in all the patients, height and length of the mandible increased. Canting of the occlusal plane and oral commissure was corrected. CONCLUSION: Bidirectional mandible distraction is an effective treatment for correction of mandible deformities in adult patients.