Nasal Measurements in Indian Population of North-East Region: Angular Parameters with Literature Review.

Background: Just like linear nasal parameters, angular nasal parameters form the basis of any rhinoplasty, especially in various ethnic groups to maintain the specific racial characteristics while creating an aesthetic nose. The objective of this study was to measure and study the outcomes of angular nasal parameters in north-east Indians and to contrast them with available literature on Oriental, Caucasian and Indian population in general. Methods: This cross-sectional study was carried out in 150 young adults from north-east region of India. Surface landmarks were marked, and standard photographs were taken. Nine angular parameters were measured from the left lateral and basal view photographs of the face using computer software. Data were analysed by Student's 't'-test for parametric data and Mann-Whitney U-test for non-parametric data using SPSS v.25. Results: All the angular measurements were found to be greater in females except nasofacial angle, columella tip angle and interaxial angle. Differences in nasofrontal angle, columella labial angle, nasofacial angle and columella tip angle between males and females were statistically significant. Nasofrontal and columella labial angles were more acute in the study population compared to Caucasians, Orientals and other Indians while nasofacial, interaxial and interalar angles were larger. Conclusion: The north-east Indian nose is dissimilar to that of rest of the country as well as that of Caucasians and Orientals with respect to angular parameters.

Perceived usefulness of trauma audit filters in urban India: a mixed-methods multicentre Delphi study comparing filters from the WHO and low and middle-income countries.

OBJECTIVE: To compare experts' perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness. DESIGN: A mixed-methods approach using a multicentre online Delphi technique. SETTING: Two large tertiary hospitals in urban India. METHODS: Filters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments. RESULTS: 26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity. CONCLUSIONS: Audit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

A huge pleomorphic adenoma of the submandibular salivary gland.

The most common tumour of salivary gland is pleomorphic adenoma (PA). They are benign, painless, can grow into big tumours but usually do not affect nerves or lymph nodes. PA most commonly occurs in the parotid gland but it may involve submandibular, lingual and minor salivary glands also. They can attain giant proportions and weigh several kilograms. We report a giant PA arising in the submandibular gland and treated by complete surgical excision without any complication. A female patient presented with a tumour in the submandibular region and front of neck with a history of more than 18 years. The weight of the resected mass was 4.35 kg. Patient's fear of surgery and lack of awareness were the main reasons for her long-standing swelling. Such giant PAs of the submandibular gland are very rare in medical literature.

A new paradigm in facial reanimation for long-standing palsies?

BACKGROUND: A chance observation of return of excellent facial movement, after 18 months following the first stage of cross-face nerve grafting, without free functional muscle transfer, in a case of long-standing facial palsy, lead the senior author (RBA) to further investigate clinically. PATIENTS AND METHODS: This procedure, now christened as cross-face nerve extension and neurotization, was carried out in 12 patients of very long-standing facial palsy (mean 21 years) in years 1996-2011. The mean patient age and duration of palsy were 30.58 years and 21.08 years, respectively. In patients, 1-5 a single buccal or zygomatic branch served as a donor nerve, but subsequently, we used two donor nerves. The mean follow-up period was 20.75 months. RESULTS: Successive patients had excellent to good return of facial expression with two fair results. Besides improved smile, patients could largely retain air in the mouth without any escape and had improved mastication. No complications were encountered except synkinesis in 1 patient. No additional surgical procedures were performed. CONCLUSION: There is experimental evidence to suggest that neurotization of a completely denervated muscle can occur by the formation of new ectopic motor end plates. Long-standing denervated muscle fibres eventually atrophy severely but are capable of re-innervation and regeneration, as validated by electron microscopic studies. In spite of several suggestions in the literature to clinically validate functional recovery by direct neurotization, the concept remains anecdotal. Our results substantiate this procedure, and it has the potential to simplify reanimation in longstanding facial palsy. Our work now needs validation by other investigators in the field of restoring facial animation.

A novel route for placing free flap pedicle from a palatal defect.

One of the better options available to repair a large palatal defect is by employing a free flap. Almost all the times such free flaps are plumbed to facial vessels. The greatest challenge in such cases is the placement of the pedicle from palatal shelf to recipient vessels because there is no direct route available. As majority of large palatal fistulae are encountered in operated cleft palates there is a possibility of routing the pedicle through a cleft in the maxillary arch or via pyriform aperture. When such a possibility doesn't exist the pedicle is routed behind the maxillary arch. We describe a novel technique of pedicle placement through a maxillary antrostomy, in this case report, where a large palatal fistula in a 16 year old boy was repaired employing a free radial artery forearm flap. The direct route provided by maxillary antrostomy is considered the most expeditious of all possibilities mentioned above.

Total upper eyelid reconstruction by single staged malar-cheek flap.

We report a case of total upper eyelid reconstruction by a new technique after excision of an eyelid tumour. The eyelid was reconstructed by a horizontal, laterally based flap from just under the lower eyelid combined with a chondro-mucosal graft from the nasal septum. Surgical outcome was an excellent aesthetically reconstructed eyelid, which was mobile and properly gliding on the globe to achieve complete eye closure.

Securing aesthetic outcomes for composite grafts to alar margin and columellar defects: A long term experience.

INTRODUCTION: Composite grafts for nasal reconstruction have been around for over a century but the opinion on its virtues and failings keeps vacillating with a huge difference on the safe size of the graft for transfer. Alar margin and columellar defects are more distinct than dorsal nasal defects in greater difficulty in ensuring a good aesthetic outcome. We report our series of 19 consecutive patients in whom a composite graft was used to reconstruct a defect of alar margin (8 patients), alar base (7 patients) or columella (4 patients). PATIENTS AND METHODS: Patient ages ranged from 3-35 years with 5 males and 14 females. The grafts to alar margin and base ranged 0.6-1 cm in width, while grafts to columella were 0.7-1.2 cm. The maximum dimension of the graft in this series was 0.9 mm x 10 mm. Composite grafts were sculpted to be two layered (skin + cartilage), three layered wedges (skin + cartilage + skin) or their combination (two layered in a portion and three layered in another portion). All grafts were cooled in postoperative period for three days by applying an indigenous ice pack of surgical glove. The follow up ranged from 3-9 months with an average of 4.5 months. RESULTS: All of our 19 composite grafts survived completely but they all shrank by a small percentage of their bulk. Eleven patients rated the outcome between 90-95% improvement. We noticed that composite grafts tended to show varied pigmentation in our patients, akin to split skin grafts. CONCLUSION: In our opinion, most critical to graft survival is its size and the ratio of the marginal raw area to the graft bulk. We recommend that graft width should not exceed 1 cm to ensure complete survival even though larger sized grafts have been reported to survive. We recommend cooling of the graft and justify it on the analogy of 'warm ischemia time' for a replantation, especially in warmer climes like ours in India. We have outlined several considerations in the technique, with an analysis of differing opinions that should facilitate a surgeon in making an informed choice.

A comparative analysis of liquefied petroleum gas (LPG) and kerosene related burns.

Previous studies from our department reflected a trend of decreasing incidence of burns culminating from rising income levels, which were bringing about a change in the cooking fuel in many urban households [1,2]. These studies also indicated a changing scenario of increased incidence of burns from LPG mishaps [2]. In the absence of much information on the subject we felt it rather imperative to comparatively study the pattern of burn injuries resulting from LPG and kerosene. This prospective study was conducted on the clinical database of consecutive patients admitted with burns sustained due to LPG and kerosene from 1st January 2009 to 31st May 2010 (17 months). Data recorded for each patient included; age, gender, religion, socioeconomic status, literacy level, type of family unit, marital status, type of dwelling unit, mode of injury and its exact mechanism, place of incident, level of cooking stove, extent of burns (%TBSA), presence of features of inhalation injury, number of patients affected in a single mishap, size of LPG cylinder used, length of hospital stay and mortality. Of 731 flame burn patients in this study, 395 (54%) were due to kerosene burns and 200 (27.4%) from LPG mishaps. Significantly, the majority of injuries, in both the groups, occurred in lower middle class families living as nuclear units, in a single room dwelling, without a separate kitchen. Majority of LPG burns (70.5%, 141 patients) resulted from a gas leak and 25.5% were from cooking negligence (51 patients). 50.5% of kerosene accidents were from 'stove mishaps' and 49% due to cooking negligence. In all kerosene accidents the stove was kept at floor level but in LPG group 20.6% had the stove placed on a platform. There was a slight difference in mean TBSA burns; 51% in kerosene group compared to 41.5% TBSA in LPG group. There were nine episodes in LPG group in which there were more than three burn victims admitted for treatment. Very importantly, 77% patients in LPG group were from a large cylinder (14.2 kg), which uses a rubber connecting tube. Mortality in kerosene group (50.6%) was far higher than in LPG group (33.5%). This study, from 200 LPG burn admissions, for the first time details the profile from LPG mishaps. It is very interesting to note that of all burns in the world the inequitable distribution bias towards LMICs (low and middle income countries) extends further towards low middle class families within the LMIC. A major risk factor is constrained living condition of a single room dwelling unit. Almost all burns from LPG mishaps were potentially preventable if more care had been practiced to ensure safety. Since majority of LPG mishaps were from gas leaks, either from the rubber tube (Fig. 1) or the stove valve, the observation of floor level cooking in 79.4% of LPG cases may be an economic compulsion of a single room dwelling unit without much impact on the injury pattern. The small LPG cylinder (5 kg) in which the burner is placed directly over the cylinder, as one unit without a connecting tube, is safer because it reduces the chances of a gas leak from an ill-fitting or a cracked rubber connecting tube (Fig. 2).

A comparative analysis of cetirizine, gabapentin and their combination in the relief of post-burn pruritus.

Post-burn pruritis is a very distressing symptom having a reported incidence between 80 and 100%. The mainstay of management of post-burn itch has been with antihistaminics and emollients but the treatment is ineffective in a very large percentage of patients. With the recognition of a distinct itch specific neuronal pathway, which has a complex interaction with pain pathway, a fresh approach to itch management has surfaced with the use of gabapentin. Gabapentin is an antiepileptic drug which has been successfully used to manage neuropathic pain, and is reporting to be successful in management of all forms of itch. With a paucity of randomized trials evaluating the role of gabapentin in post-burn itch management the current study was undertaken to individually evaluate gabapentin, cetirizine and their combination in relieving itch. Twenty patients were randomly recruited in each of the three groups and administered the respective drug(s) in doses determined by initial VAS (visual analog scale) scores. There was no significant difference in all the three groups with respect to mean age, sex distribution, mean percentage of TBSA burn and mean VAS score on day 0. VAS scores were evaluated over next 28 days (days 3, 7, 14, 21 and 28), and no emollients were prescribed for the study period. The initial mean VAS score reduced 95% in gabapentin group compared to 52% for the cetirizine group, which was highly significant (p<0.01). There was a 94% reduction in mean VAS score in the combination group which was comparable to the relief observed with gabapentin alone (p>0.05). Even the onset of action with gabapentin was significantly faster than the cetirizine group as evident from the mean VAS scores on day 3, which decreased 74% in gabapentin group compared to 32% in cetirizine group (p<0.01). Whereas all patients receiving gabapentin (either as monotherapy or in combination with cetirizine) reached an itch free status (VAS score 0-1) by day 28 only 3/20 patients reached this level with cetirizine alone. It is quite evident from this study that gabapentin is significantly better than cetirizine as monotherapy in relieving post-burn itch and it also has a faster action. The hypothetical combination of a centrally acting drug with a peripherally acting agent did not result in any better control of post-burn itch than monotherapy with gabapentin. No side effects were reported with gabapentin administration but all patients receiving cetirizine reported sedation. There is now a need to relook at the antipruritic protocols in burn management.

Dextran carrier macromolecule for colon specific delivery of celecoxib.

The colon specific polymeric conjugates of celecoxib were prepared with dextran of different molecular weight Mr approximately 40 000, 70 000, and 100 000 (CSD-40, CSD-70 and CSD-100). Succinic acid was used as linker between the drug and dextran. The prepared conjugates were characterized by UV, IR, 1H NMR and HPLC. The maximum degree of substitution 3.9+/-0.20 % was found with the dextran CSD-100 conjugates. The percent release of drug obtained by in-vitro hydrolysis studies, was found to be 24.37+/- 0.6, 23.0 +/- 0.5 and 20.13+/- 0.8 in simulated colonic fluid (SCF) pH 6.8 while 17.90 +/- 0.4, 16.8+/- 0.75 and 15.47 +/- 0.5 in simulated intestinal fluid (SIF) pH 7.4 for CSD-40, CSD-70 and CSD-100, respectively, in both medium. The drug release from the conjugates was observed for 24 h in 3% w/v rat caecal content and found to be 41.77 +/- 1.2, 39.03 +/- 1.0 and 35.26 +/- 1.09 for CSD-40, CSD-70 and CSD-100 conjugates, respectively. The half life of conjugates was determined and was found to be short in 3% w/v rat caecal content. No amount of drug was released in simulated gastric fluid pH 1.2 and stomach homogenate in 2 h. The amount of drug released from small intestine homogenate was 3.4+/- 0.1 percent in 12 h for the CSD-40. The above result suggests that dextran could be used as a macromolecular carrier for colon specific drug delivery of celecoxib.

Pre-hospital care in burn injury.

The care provided to the victims of burn injury immediately after sustaining burns can largely affect the extent and depth of the wound. Although standard guidelines have been formulated by various burn associations, they are still not well known to public at large in our country. In burn injuries, most often, the bystanders are the first care providers. The swift implementation of the measures described in this article for first aid in thermal, chemical, electrical and inhalational injuries in the practical setting, within minutes of sustaining the burn, plays a vital role and can effectively reduce the morbidity and mortality to a great extent. In case of burn disasters, triage needs to be carried out promptly as per the defined protocols. Proper communication and transport from the scene of the accident to the primary care centre and onto the burn care facility greatly influences the execution of the management plans.

Post-burn scars and scar contractures.

The mortality and morbidity from burns have diminished tremendously over the last six to seven decades. However, these do not truly reflect whether the victim could go back to society as a useful person or not and lead a normal life because of the inevitable post-burn scars, contractures and other deformities which collectively have aesthetic and functional considerations. This article gives an overview of the post-burn scars and scar contractures, especially their prevention, minimisation and principles of management.

Body contouring surgery in a massive weight loss patient: An overview.

The number of patients with history of extreme overweight and massive weight loss (MWL) has risen significantly. Majority of patients are left with loose, ptotic skin envelopes, and oddly shaped protuberances, subsequent to weight loss. Redundant skin and fat can be seen anywhere on the body following MWL. This group of population presents many unique problems and challenges. Body contouring surgery after MWL is a new and exciting field in plastic surgery that is still evolving. Conventional approaches do not adequately cater to the needs of these patients. Complete history, detailed physical examination, clinical photographs and lab investigations help to plan the most appropriate procedure for the individual patient. Proper counseling and comprehensive informed consent for each procedure are mandatory. The meticulous and precise markings based on the procedure selected are the cornerstones to achieve the successful outcome. Lower body contouring should be performed first followed six months later by breast, lateral chest and arm procedures. Thighplasty is usually undertaken at the end. Body contouring operations are staged at few months' intervals and often result in long scars. Staging is important as each procedure can have positive impact on adjacent areas of the body. Secondary procedures are often required. However, proper planning should lead to fewer complications and improved aesthetic outcome and patient satisfaction.

A study of regional nerve blocks and local anesthetic creams (Prilox) for donor sites in burn patients.

BACKGROUND: Burn patient requires multiple visits to the operation theatres and undergoing anesthesia with its attendant risks and post anesthesia recovery. It is possible now with the availability of local anesthetic creams like Prilox to conduct these procedures in the minor OT without any discomfort to the patient. MATERIALS AND METHODS: Hundred patients of post burn raw areas were selected. These patients had at least one area of healthy skin on anterior, medial or lateral thigh. No patient had a known drug allergy. The age group varied from 5 to 75 years with no bias towards any sex. These patients were then given anesthesia according to the group, and were assessed for the ease of grafting, amount of graft being harvested, subjective pain score, post operative pain relief and any post operative complication. The nerve block technique being used was either femoral and/or LCT block or 3-in-1 block and popliteal fossa block. RESULTS: Both the group of patients had a virtual painless process of skin grafting. It is safe in selected patients to combine the two techniques in order to harvest larger areas. DISCUSSION: Both techniques of local anesthestic creams and nerve block are safe and convenient to use. Nerve blocks are more useful where larger grafts are required, the creams being more useful in children and where less graft is required.

2-(4-aminophenyl) benzothiazole: a potent and selective pharmacophore with novel mechanistic action towards various tumour cell lines.

2-(4-aminophenyl) benzothiazole (CJM -126) (Table 1 (1) and its analogues represent a potent and highly selective class of antitumor agents. These compounds in nanomolar range elicit potent growth inhibition in human-derived breast, colon, ovarian and renal tumour cell lines. Metabolism of benzothiazole plays a central role in its mode of action. Cytocrome P450 isoform, CYP1A1, biotransforms benzothiazoles, to active, as well as inactive metabolites. In vitro studies had confirmed that N-oxidation and N-acetylation (only 3' halogen congener) as main active metabolic transformation (generating cytotoxic electrophilic species), while C-6 oxidation and N-acetylation (except 3' halogen congener) as inactive metabolic transformation pathway. Generation of an inactive metabolite 2-(4-aminophenyl)-6-hydoxybenzothiazole [6-OH 126, (Table 1) (10)] is blocked by fluorinated analogue, substituted around benzothiazole nucleus, especially at 5-position. National Cancer Institute (NCI), USA, confirms this series as a unique mechanistic class distinct from clinically used chemotherapeutic agents. Benzothiazoles are potent aryl hydrocarbon receptor (AhR) agonists, binding to AhR results in induction of CYP1A1, causes generation of electrophilic reactive species which forms DNA adduct, ultimately resulting in cell death by activation of apoptotic machinery. To overcome the poor physiochemical and pharmaceutical properties (bioavailability problem) of this compounds, prodrug of benzothiazole derivatives were synthesized, which are introduced in clinical trails.