The Oral Health Condition of Patients on Hemodialysis at a Tertiary Healthcare Facility in Eastern Nepal.

Objectives: This study was done to compare the oral health of chronic kidney disease (CKD) patients on hemodialysis to healthy individuals and to assess the effect of the duration of dialysis on oral health. Materials and Methods: A comparative cross-sectional study was conducted among purposively selected 54 cases undergoing dialysis and 54 apparently healthy controls. Caries experience and periodontal status were recorded under similar examination conditions and compared between cases and controls. The correlation between oral health and the duration of dialysis was assessed. A p value of <0.05 was considered significant. Results: The mean age of the participants was 47.09 ± 12.23 years. Median caries experience among cases and controls was two (0-26) and three (0-15), respectively (p=0.013). Periodontitis among the two groups was found to be significantly different with a greater number of cases showing increased severity (p < 0.001). The severe form of periodontitis was associated with a greater mean duration of dialysis. Conclusion: Significant differences exist between the periodontal health of patients undergoing dialysis compared to healthy controls. Longitudinal studies are required to check the causal effect of CKD on periodontitis.

Banana fibre-chitosan-guar gum composite as an alternative wound healing material.

Bio-composites, which can be obtained from the renewable natural resources, are fascinating material for use as sustainable biomaterials with essential properties like biodegradable, bio-compatibility as well cyto-compatibility etc. These properties are useful for bio-medical including wound healing applications. In this study, fibre obtained banana pseudo stem of banana plant, which is otherwise wasted, was used as a material along with chitosan and guar gum to fabricate a banana fibre-biopolymer composite patch. The physiochemical properties of the patches were examined using Fourier Transformed Infra-red spectrophotometer (FT-IR), tensile tester, Scanning Electron Microscope (SEM), contact angle tester, swelling and degradation studies. We further demonstrated that a herbal drug, Nirgundi could be loaded to the patch showed controlled its release at different pHs. The patch had good antibacterial property and supported proliferation of mouse fibroblast cells. The study thus indicates that banana fibre-chitosan-guar gum composite can be developed into an alternative wound healing material.

Lower Eyelid Blepharoplasty: Minimizing Complications and Correction of Lower Eyelid Malposition.

Lid retraction is a feared complication of lower blepharoplasty. Anatomical variations like negative orbital vector, horizontal lid laxity, and preexisting lid retraction are more prone to lid malpositions. Meticulous and precise execution of a series of surgical steps is key to preventing complications. This includes minimizing surgical trauma, meticulous hemostasis, preserving innervation to the medial lid and pretarsal orbicularis, safe method of fat excision, septal tightening while maintaining lid traction, and conservative and titrated skin excision. Canthal fixation addresses lid laxity and maintains the lid stretched vertically while postoperative healing and fibrosis are taking place. Post-blepharoplasty lid retraction may occur due to failure to address lid laxity and the occurrence of middle lamellar fibrosis. Excessive skin excision may also result in anterior lamellar deficiency. The "sag and drag" concept is useful to evaluate the post-blepharoplasty retracted lid. The treatment of the retracted lid includes lid massage, replacing the anterior lamella, or releasing the middle lamellar fibrosis or a combination of techniques. In conclusion, understanding the mechanisms of lid retraction, careful preoperative assessment, and surgical precision will help surgeons to prevent and manage this complication.

A Novel Approach to Promote Evidence-Based Development of District Maternal and Newborn Health Plans in Two States in India.

Background: Maternal and child health implementation plan development in districts of India lacks systematic process and capacity resulting in suboptimal health improvements. There is ineffective and limited participation and lack of autonomy to effect changes in district priorities. Objectives: Primary objective was to demonstrate a systematic planning approach to develop evidence-based district implementation plans for mothers and children. Methods: A planning tool named RAASTA (RMNCH + A Action Agenda using Strategic Approach for evidence-based district work plans) adapted from WHO (World Health Organization) program review tools was used in the states of Uttarakhand and Jharkhand. The tool was implemented in the two states for the development of implementation plans in a 6-step process by prioritizing district health goals; reviewing maternal, neonatal, child, and family planning intervention coverage; and linking them with activity implementation status; assessing strengths, and weaknesses of previous implementation plans and developing solutions based on current gaps in intervention coverage's. Results: Tool was used for capacity building of 59 participants and also identification of prioritized activities based on their available data. Several newer activities were identified. The districts mainstreamed them as action plans, many of which were incorporated in the state Program Implementation Plan for budgetary provisions under state NHM (National Health Mission) funds. Conclusion: The use of a tool facilitated the systematic development of evidence-based district implementation plans.

Canthoplasty repair for canthal rounding.

BACKGROUND: Canthal rounding can occur following trauma or surgery to the medial or lateral canthus, causing possible aesthetic or functional deficits to patients. Several surgical techniques to repair canthal rounding have been described previously. We report a new technique for canthoplasty repair of canthal rounding with the use of illustrative cases. METHODS: This is a retrospective case series describing the technique using illustrative cases from across three sites (London [UK], Adelaide [Australia], Sydney [Australia]). Twelve patients with post-surgical canthal rounding were included. Information collected for our illustrative cases include patient demographics, diagnosis, complications, outcomes and further treatment. RESULTS: There were no peri- or post-operative complications. All except one patient reported good surgical outcomes after one procedure. In one patient there was rounding recurrence. CONCLUSIONS: Our patients reported excellent outcomes post-operatively without any significant scarring.

Systems E-approach for women at risk (SEWA)-A digital health solution for detection of high-risk pregnancies.

BACKGROUND: High-risk pregnancy (HRP) puts current pregnancy at an increased risk of complications. In the absence of pre-existing HRP implementation model of the country, in collaboration with the Government of Himachal Pradesh, a new digital HRP model called the 'SEWA-A System E-approach for Women at risk' was developed. The current article demonstrates a model for the early identification and line listing of high-risk pregnant women (PW) with appropriate referrals and increased engagement with the healthcare workers using a digital tool in the form of the Android App. METHODS: SEWA was implemented as a pilot intervention in two community development blocks of the Chamba district. The key implementation steps included finalizing protocols for the identification of HRPs, defining processes and roles, mapping health facilities, setting up the communication loop, and developing of digital solutions. The digital app, used by the auxiliary nurse midwife (ANM) and program officers, tracked PW for a year from October 19 to October 20 and recorded the ANC visits, referrals, and birth outcomes. A qualitative assessment was conducted among the health workers to find out their level of acceptance. RESULTS: A total of 1,340 high-risk PW were identified. The intervention year saw a rise in the identification of HRP to 27.9% from 3.5% in the previous year. A total of 2,559 conditions were tagged to the identified 1,340 women categorized into current pregnancy (81%), previous pregnancy (16%), and any existing chronic illness (3%). A majority of the women who required urgent referrals were provided referrals. The application recorded 53% of the delivered HRP with a digital birth preparedness plan, prepared and shared with the PW and Accredited Social Health Activists (ASHA), by text message for compliance. CONCLUSION: The SEWA application is a feasible and sustainable solution to complement the competency of the care providers for early identification of the high-risk conditions and reduce the burden of preventable unprecedented deaths around the time of birth.

Putting the local back into planning-experiences and perceptions of state and district health functionaries of seven aspirational districts in India on an innovative planning capacity building approach.

District functionaries have ostensibly a major responsibility to develop evidence based plans. However, this responsibility is not commensurate with skills and expertise among functionaries in many Indian states. Vriddhi project-technical partner of the government, developed a planning tool for maternal and neonatal health programmes, called RMNCH + A Action Agenda using Strategic Approach (RAASTA), which was introduced in a workshop format in two states and attended by program officers. Qualitative feedback was obtained from selected participants to understand their experience of the workshop and of the planning tool. It emerged that previous planning process had little application of local evidence based solutions. Participants appreciated the alternative approach as RAASTA equipped them to use local evidence. Several action plans derived at the workshop were included in the state plan. At the same time, apprehension was expressed by participants about translating their learnings to practical application as planning was not a central priority in their scheme of duties and tasks. Enhanced support from states in refreshing district planners' skills would be an important step. One state government has scaled up the RAASTA tool while an electronic version is being developed for future use as it demonstrates great potential to equip and aid district officials in developing evidence based plans.

Occurrence of Dirofilaria immitis in Stray Dogs from Nepal.

BACKGROUND: Nematodes of the genus Dirofilaria are widespread vector-borne helminths (VBH) of veterinary relevance. Dirofilariosis caused by D. immitis is frequently diagnosed in dogs often showing a severe clinical condition known as heartworm disease. Assessing the distribution pattern of canine dirofilariosis is pivotal to undertake appropriate control measures and define the risk of infection in animals and humans. This study provides original data on the occurrence of D. immitis in naive stray dogs from Nepal. METHODS: An epidemiological study was performed on stray dogs from Siddharthanagar, Lumbini region, Nepal. Alive animals were blood sampled and examined for microfilariae using direct microscopy, buffy coat centrifugation and modified Knott's method. In addition, hematobiochemical parameters, including packed cell volume (PCV), alanine aminotransferase (SGPT), aspartate aminotransferase (SGOT), alkaline phosphate (ALP), creatinine, blood urea nitrogen (BUN), urea and total protein were analysed, along with a clinical scoring (body temperature and respiratory rate). During the observation period, data on autopsies performed on stray dogs showing canine heartworm disease were also included. RESULTS: The overall prevalence of D. immitis in both alive and necropsied dogs was 22.49% (38/169). Out of 150 alive dogs, 29 (19.3%) were positive for D. immitis microfilariae. The prevalence of the infection varied according to the technique used, ranging from 16.0 to 19.3% based on direct blood smear microscopy and modified Knott's technique, respectively. The infection rate was significantly higher (p < 0.05) in dogs aging more than 3 years. A positive correlation was observed between SGPT and SGOT and the presence of microfilariae (p < 0.05). Among the 19 dead stray dogs, 9 animals showed adult D. immitis nematodes. CONCLUSION: Results of this survey account for the presence of D. immitis in stray dogs from Nepal, thus supporting the existence of a local transmission cycle of diroflariosis in the region. Further investigations are warranted to accurately define the prevalence of the infection in the canine population and to undertake appropriate control measures to reduce the burden on the infection in dogs and, accordingly, the risk of transmission to humans.

Visual loss from dermal fillers.

BACKGROUND: An increasing number of people are undergoing non-surgical aesthetic procedures, especially injections of botulinum toxin and dermal fillers. While toxin injections have lower rates of complications, profound and serious consequences can arise with the use of dermal fillers. CASE: A 29-year-old woman presented to the eye casualty department with sudden visual loss, ptosis and ophthalmoplegia after having had non-surgical rhinoplasty in a beauty salon in West London. The filler was administered by a healthcare professional not registered with the General Medical Council (GMC) or similar governing body. DISCUSSION: Despite prompt measures on arrival at our service, the symptoms of visual loss, ptosis and ophthalmoplegia persisted. Attempts from the patient and medical services to report the incident (to trading standards and the police) were to no avail. CONCLUSION: This case highlights the poor treatment response to filler-related ophthalmic complications. It is also evident that in the United Kingdom, there appears to be poor regulation in the use of these products, a lack of clear guidelines for the management of their complications and finally no recourse for patients to challenge practitioners who lack medical registration and are not held accountable.

Significance of Early Postoperative Eyelid Position on Late Postoperative Result in Mueller's Muscle Conjunctival Resection and External Levator Advancement Surgery.

PURPOSE: The purpose of this study was to determine whether advancement of the levator aponeurosis in external levator resection surgery or Mueller's muscle and conjunctiva in Mueller's muscle conjunctival resection (MMCR) surgery has a differential effect on variation in eyelid position during the postoperative period. METHODS: In this retrospective observational cohort study, 2 groups of patients were defined. The first underwent MMCR surgery without tarsectomy by surgeon 1. The second underwent external levator resection without dissection posterior to the levator aponeurosis by surgeon 2. Marginal reflex distance (MRD1) was calculated based on digital photographs at baseline, 1 week postoperatively and at 3-month follow up. The primary outcome measure was change in MRD1 over time. The secondary outcome was defined as the proportion of patients with minimal early postoperative change (change of MRD1 less than 0.5 mm at 1 week postoperatively). Repeated measures analysis of variance, t test, and chi-square analyses were performed. RESULTS: Of the 114 eyes in the sample, there were 68 in the MMCR group and 46 in the external levator resection group. A significant interaction between group and time was noted (p < 0.05), indicating change in MRD1 over time was different between the groups. Bonferroni corrected multiple comparisons yielded significant differences between each time point for MMCR surgery (p < 0.01). No difference in MRD1 was noted for the external levator resection group from the early to late postoperative visit. Comparing each time point across groups revealed significantly lower MRD1 for the MMCR group at the early postoperative visit (p < 0.01). Preoperative and late postoperative MRD1 did not significantly differ between the groups. Regarding the secondary outcome, patients undergoing MMCR surgery were 3.7× as likely to demonstrate <0.5 mm of change in MRD1 at week 1 (p < 0.05). When considering the 39.7% (n = 27) MMCR patients in this category, 59.3% (n = 16) went on to show an MRD1 increase >1 mm from the early postoperative to the late postoperative time points. CONCLUSIONS: Both external levator resection and MMCR can effectively elevate the eyelid in cases of primary involutional ptosis, and have similar late postoperative results. The authors found that MMCR cases undergo greater change between the early and late postoperative period, suggesting the process of eyelid elevation after MMCR may be dynamic, involving postoperative physiologic modification.

Gold in the balance: How does patient posture affect eyelid closure?

A retrospective audit was conducted of four patients with upper eyelid gold weights (inserted >5 years ago) as treatment for facial nerve palsy-related lagophthalmos. Each patient was presently examined for lagophthalmos ("opened" or "closed") at three different patient inclinations (lying flat at 0º, lying back at 45º, and sitting upright at 90º). In all four cases at 0º inclination, the upper eyelid remained "open" with significant lagophthalmos, and therefore the ocular surface was vulnerable. At other inclinations, 45º and 90º, the eyes were substantially "closed" and the ocular surface was protected. We discuss the mechanism by which this occurs. We suggest that patients fitted with upper eyelid gold weight implant who do not show adequate closure during postoperative clinical examination or signs of corneal show should try sleeping in a slightly upright position to aid ocular surface protection.

Blepharoplasty Basics for the Dermatologist.

Blepharoplasty is amongst the more frequently performed aesthetic procedures with surgery performed by physicians and surgeons across a variety of sub-specialities. This paper, aimed at a dermatology audience, describes patient selection, eyelid anatomy, clinical examination and surgical steps to achieve successful upper and lower lid blepharoplasty outcomes. Recommendations for minimising complications are made and photographs used to illustrate important clinical and surgical features.

Re-thinking 3D printing: A novel approach to guided facial contouring.

Rapid prototyped or three dimensional printed (3D printed) patient specific guides are of great use in many craniofacial and maxillofacial procedures and are extensively described in the literature. These guides are relatively easy to produce and cost effective. However existing designs are limited in that they are unable to be used in procedures requiring the 3D contouring of patient tissues. This paper presents a novel design and approach for the use of three dimensional printing in the production of a patient specific guide capable of fully guiding intraoperative 3D tissue contouring based on a pre-operative plan. We present a case where the technique was used on a patient suffering from an extensive osseous tumour as a result of fibrous dysplasia with encouraging results.

Severity of acute ocular involvement is independently associated with time to resolution of ocular disease in toxic epidermal necrolysis patients.

PURPOSE: Toxic epidermal necrolysis (TEN) is a severe, life-threatening mucocutaneous disorder that frequently involves the ocular surface. This study aims to investigate the natural history and resolution of acute ocular involvement in patients with TEN admitted to the intensive care unit (ICU). METHODS: Case notes of patients admitted to ICU with TEN at a tertiary referral centre in a 9-year period were retrospectively reviewed. Patients' characteristics, severity of ocular involvement, SCORTEN systemic severity score and treatment were correlated with resolution of ocular involvement and time to resolution. RESULTS: Nine out of 10 (90%) patients had ocular involvement with 4 graded as mild, 2 as moderate and 3 as severe. All had bilateral ocular disease. The median length of hospital stay was 28 days and the median time to resolution of ocular involvement was 19 days. Four out of 9 (44%) patients still had active ocular disease at the time of discharge. Only older age (p=0.032) and a milder grade of ocular disease (p=0.001) were significantly associated with resolution of ocular disease. In a multivariable Cox-regression model, only a milder grade of ocular disease remained independently associated with time to resolution of ocular disease (p=0.006). CONCLUSIONS: Grading of acute ocular disease severity does not reflect systemic disease severity and is significantly associated with resolution and time to resolution of ocular involvement in TEN. The high rate of ocular involvement in patients with TEN and relatively large proportion of patients with active disease on discharge reiterates the need for constant ophthalmological monitoring of these patients.

Clinical anatomy of the periocular region.

The aims of this article are twofold: (1) to provide the facial plastic surgeon with a comprehensive and up-to-date overview of periocular anatomy including the brow, midface, and temporal region and (2) to highlight important anatomical relationships that must be appreciated in order to achieve the best possible functional and aesthetic surgical outcomes.

The "bespoke" upper eyelid blepharoplasty and brow rejuvenation.

Blepharoplasty of the upper eyelids is one of the most commonly performed procedures in aesthetic plastic surgery. In this article, we describe our approach to the patient with aging of the periorbita. At all times, the approach is tailored to the individual's needs, trying to achieve a natural result that will not in any way affect the function of the eyelid. Our current approach and techniques for upper eyelid blepharoplasty and brow lifting are described.