Prospective observational study of clinical outcomes in using posterior interosseous free flap for finger defects.

Finger injuries are common in hand and plastic surgery practice. There are various options for reconstructing finger defects. Moderate sized skin defects of the fingers which need flaps are commonly covered using various abdominal flaps. These conventional workhorse flaps are thick, need two-staged procedures and require the hand to be kept in a cumbersome position. The radial artery or the ulnar artery flap need sacrifice a major vessel. To address the above, we have used the posterior interosseous artery free flap to cover finger defects. This was a prospective observational clinical study done on 15 patients admitted to a tertiary level hospital from July 2017 to July 2021. These patients had accidental industrial injuries with a loss of soft tissue on the fingers. There were finger fractures in 6 cases. These patients underwent posterior interosseous artery free flap cover. The flap size ranged from 6 × 3 cm to 10 × 4 cm. We had to cover the donor defects with skin graft in all our cases. Fourteen out of 15 flaps survived, with loss of one flap due to venous congestion. The mean two-point discrimination was 7.8 mm, with a total active motion percentage of more than 70% in 11 out of 15 cases. The posterior interosseous artery flap is a thin and pliable one stage flap, and may not need further flap thinning either, thereby establishing itself as a single stage procedure and moreover not requiring sacrifice a major vessel.

Efficacy of pedicled anterolateral thigh flap for reconstruction of regional defects - a record analysis.

BACKGROUND: The anterolateral thigh (ALT) flap was described as the fasciocutaneous flap. It can be harvested as a pedicled and/or free flap. Majority of the free flaps are harvested as a fasciocutaneous flap. Their use in head and neck reconstruction and limb trauma is well established. Apart from these advantages, this flap has various applications which are less utilized. ALT flap can be used as a myocutaneous flap along with vastus lateralis muscle. When muscle and fasciocutaneous flaps are required, both can be harvested as a chimeric flap which can cover two different regions of the wound. Moreover, harvest of the pedicled flap procedure is less time-consuming than that of a free flap. Since it has a long vascular pedicle, when used as pedicled flap, it can reach up to the gluteal region. To evaluate these less applied advantages of pedicled ALT flap, our study was undertaken. This study aimed to evaluate the efficiency of ALT flap in terms of the surface area of coverage, arc of rotation and the advantages of including vastus lateralis muscle as part of the flap. METHODS: A retrospective record analysis of all pedicled ALT flap reconstruction of trochanteric, upper thigh, gluteal and flank regions from 2016 to 2018 was undertaken; 7 patients with 8 defects were included. RESULTS: All the flaps healed successfully. There was no major necrosis of the flap and minor complications like wound gapping were found in three patients. CONCLUSION: The ALT-vastus lateralis flap dimensions can be very large and can be easily harvested in a very short time. Vastus lateralis muscle harvested can be used to fill the defect or can be used as chimera to cover the defect. The use of muscle over long standing infective pressure sores can sterilize the wound bed and help in preventing recurrence. The vascularity of this flap is robust and highly reliable. Even after a maximum arc of rotation (up to 170°) all the flaps survived without any major complications.

Necrotising Fasciitis: Appearances Can Be Deceptive.

BACKGROUND: Necrotizing fasciitis is a potentially fatal infection of ß hemolytic Group-A Streptococcus, often occurring in patients with other comorbidities, but can occur in healthy individuals as well. It commonly affects the extremities, perineum, and abdominal wall. The aim of this study was to highlight various presentations of necrotizing fasciitis in unusual anatomical sites with delayed diagnosis and treatment. METHODS: In a retrospective analysis, seven cases of unusual presentations of necrotizing fasciitis were enrolled during a period of five years treated in a tertiary centre. RESULTS: The patients were between 23 and 80 years. Four were males and three were females. Four out of seven were diabetic. All patients had septicemia (hypovolemic shock, with leucocytosis, thrombocytopenia and deranged coagulation parameters) on admission in the intensive care unit. All seven patients had minimal cutaneous manifestation and the remote primary pathology was diagnosed in two patients. Six patients out of seven survived and the morbid state continued in one patient in view of malignancy of rectum in one patient. The overall outcome was satisfactory in five out of seven cases. CONCLUSION: Pain disproportionate to the local inflammation with florid constitutional symptoms should raise suspicion of necrotizing fasciitis. Early diagnosis, of stabilization of hemodynamics, emergency fasciotomy, staged debridement and the initiation of broad spectrum antibiotics reduced the morbidity and mortality. The disease may manifest with uncommon presentations and sometimes lead to the diagnosis of primary aetiology.

Moriarty's sign - predictor of skin graft take.

BACKGROUND: Resurfacing wound beds with split skin graft is the most common procedure in plastic surgery. Association of more pain in the donor site than in the recipient site has been used as a predictor of successful graft take by Stark in 1962 who termed it Moriartys sign. PURPOSE: The aim of the study was: 1) to predict the successful take of skin graft by eliciting Moriartys sign; 2) to decide the day of first graft inspection based on Moriartys sign. METHODS: The authors hereby present a prospective study in 100 patients who underwent wound resurfacing with split thickness skin graft at the Department of Plastic Surgery in a tertiary care center between January 2014 and June 2015. The area with more pain, absence of pain or equivocal response at the graft donor site was recorded on the visual analog scale for 10 days. RESULTS: In this study, 80 patients had positive Moriartys sign, 12 patients had equivocal responses and 8 patients showed a negative sign. Patients with positive Moriartys sign underwent their first graft inspection on 10th postoperative day and showed 100% graft take. Twelve patients with equivocal response underwent first graft inspection on 5th day and had 70-80% graft take.  In 8 patients, with negative Moriartys sign first graft inspection done on 3rd day, the graft take was < 50%. CONCLUSION: The study demonstrates that Moriartys sign is a reliable clinical predictor of split thickness skin graft take and may be useful as a guide to determine the day of first graft inspection. It is an effective method even for junior members of the surgical and nursing team to monitor parameters in relation to this sign. It can be practiced in a smaller group of hospitals, too. Hence, the authors recommend to integrate this clinical assessment in routine practice.

Phage Therapy for a Multidrug-Resistant Acinetobacter baumannii Craniectomy Site Infection.

In the era of antibiotic resistance, alternative treatment options for multidrug-resistant bacterial infections are being explored. We present a case of multidrug-resistant Acinetobacter baumannii infection treated with bacteriophages. Clinical trials are needed to further investigate bacteriophage therapy as an option to treat multidrug-resistant bacterial infections.

Torsion of partial cleft of ear lobule.

INTRODUCTION: Torsion is a well-known phenomenon involving organs with long mesentery. Torsion in the ear lobule is rare. Ear lobule is very well vascularized. In cases of partial cleft ear lobule, there is a small segment of lobule inferior to the cleft which is vascularized through the pedicles on either side of the cleft. CASE REPORT: A lady aged 89 years presented with discoloration of the ear lobule. She was diagnosed as having gangrene of the central part of lobule. The segment of the lobule had undergone more than 360° torsion. She underwent debridement of gangrenous part and lobuloplasty. DISCUSSION AND CONCLUSION: In our case laxity of the stretched lobule caused the torsion of the segment followed by gangrene. This rare complication indicates the need for correction of the cleft lobule not only for esthetic purpose, but also for the prevention of torsion.

Synchronous adenocarcinomas of the papilla major and minor.

CONTEXT: Synchronous malignancies affecting both the major and minor papilla are rare and are usually of endocrine origin. CASE REPORT: A 60-year-old female presented with a two-week history of progressive jaundice and pruritus. Evaluation revealed features of a periampullary malignancy. A Whipple pancreaticoduodenectomy was done. There was a growth in the ampulla of Vater and another in the region of the minor duodenal papilla. On histopathology, both lesions were adenocarcinomas. CONCLUSION: Although rare, synchronous adenocarcinomas can occur in the major and minor papilla.

Synthesis and Activity Evaluation of 2-(1-naphtho[2,1-b]furan-2-yl-carbonyl)-3,5-disubstituted-2,3-dihydro-1H-pyrazoles.

Ethyl naphtho[2,1-b]furan-2-carboxylate (2) on reaction with hydrazine hydrate in presence of acid catalyst in ethanol medium affords naphtho[2,1-b]furan-2-carbohydrazide (3). The reaction of substituted acetophenones (4a-c) with aromatic aldehydes (5a-e) produces chalcones (6a-o) via the Claisen condensation. The reaction of naphtho[2,1-b]furan-2-carbohydrazide (3) with chalcones (6a-6o) in presence of acetic acid as catalyst in dioxane produces 1-(naphtho[2,1-b]furan-2-yl-carbonyl)-3,5-disubstituted-2,3-dihydro-1H-pyrazoles (7a-o). The structures of newly synthesized compounds have been established by elemental analysis and spectral studies. The compounds 7a-o have been evaluated for their antimicrobial activity and some selected compounds evaluated for antiinflammatory, analgesic, anthelmintic, diuretic and antipyretic activities.

Antioxidant, cytotoxic and genotoxic evaluation of alcoholic extract of Polyalthia cerasoides (Roxb.) Bedd.

Antioxidative potential of alcohol extract of Polyalthia cerasoides was evaluated using 1,1-diphenyl-2-picrylhydrazyl (DPPH), hydroxyl radical, superoxide anion scavenging, and reducing power assays were performed. The extract showed significant reactive oxygen species (ROS) scavenging activity in all in vitro antioxidant assays and contained high level of total phenolic content. For in vivo genotoxic evaluation, Swiss albino mice were treated with alcohol extract at the concentration of 40mg/kg body weight. Frequency of aberration was compared with control. Both the sets did not showed genotoxic effect. Further the extract was subjected to cytotoxic study using 3-(4,5-dimethyl thiazol-2-yl)-2,5-diphynyl tetrazolium bromide (MTT) assay, the extract confirmed to show moderate cytotoxicity against L929 cell line.

Epidemiology and patterns of care for invasive breast carcinoma at a community hospital in Southern India.

BACKGROUND: Breast cancer incidence in India is on rise. We report epidemiological, clinical and survival patterns of breast cancer patients from community perspective. METHODS: All breast cancer patients treated at this hospital from July 2000 to July 2005 were included. All had cytological or histological confirmation of breast cancer. TNM guidelines for staging and Immunohistochemistry to assess the receptor status were used. Either lumpectomy with axillary lymph node dissection or Modified radical mastectomy (MRM) was done for operable breast cancer, followed by 6 cycles of adjuvant chemotherapy with FAC or CMF regimens to patients with pT >1 cm or lymph node positive or estrogen receptor negative and radiotherapy to patients after breast conservation surgery, pT size > 5 cm, 4 or more positive nodes and stage IIIB disease. Patients with positive Estrogen receptor or Progesterone receptor were advised Tamoxifene 20 mg per day for 3 years. Descriptive analysis was performed. Independent T test and Chi-square test were used. Overall survival time was computed by Kaplan - Meier method. RESULTS: Of 1488 cancer patients, 122 (8.2%) had breast cancer. Of 122 patients, 96.7% had invasive breast carcinoma and 3.3% had sarcoma. 94% came from the rural and semi urban areas. Premenopausal women were 27%. The median age was 50 years. Stage I-6.8%, II-45.8%, III-22%, IV-6.8%, Bilateral breast cancer - 2.5%. The mean pT size was 3.9 cm. ER and PR were positive in 31.6% and 28.1% respectively. MRM was done in 93.8%, while 6.3% patients underwent breast conservation surgery. The mean of the lymph nodes dissected were 3. CMF and FAC regimens were used in 48.8% and 51.2% of patients respectively. FAC group were younger than the CMF group (43.6 yr vs. 54 yrs, P = 0.000). Toxicities were more in FAC than CMF group, alopecia (100% vs. 26.2%), grade2 or more emesis (31.8% vs. 9.2%), grade2 or more fatigue (40.9% vs.19%), anemia (43.1% vs. 16.6%). Median Survival for the cohort was 50.8 months. ER positive patients had better median survival (P = 0.05). CONCLUSION: MRM was the most frequent surgical option. CMF and FAC showed equivalent survival. FAC chemotherapy was more toxic than CMF. ER positive tumors have superior survival. Overall 3 year survival was 70 percent.

Sustainability appraisal in infrastructure projects (SUSAIP): Part 1. Development of indicators and computational methods.

The process of translating strategic sustainability objectives into concrete action at project-specific levels is a difficult task. The multi-dimensional perspectives of sustainability such as economy, society, environment, combined with a lack of structured methodology and information at various hierarchical levels, further exacerbate the problem. This paper (Part 1 of a two-part series) proposes an analytical decision model and a structured methodology for sustainability appraisal in infrastructure projects. The paper uses the 'weighted sum model' technique in multi-criteria decision analysis (MCDA) and the 'additive utility model' in analytical hierarchical process (AHP) for multi-criteria decision making, to develop the model from first principles. It discusses the development of key performance indicators encapsulated within the analytical model. It concludes by discussing other potential applications of the proposed model and methodology for process automation as part of integrated sustainability appraisal in infrastructure design and construction. Part 2 uses a case study to demonstrate the model application in infrastructure sustainability appraisal at design stages. The paper also discusses the challenges for sustainability research, and gives recommendations.