Cardiac Anaesthesia

Chronic postthoracotomy pain in transapical transcatheter aortic valve replacement Brian R Gebhardt, Ankit Jain, Sarah A Basaham, Farhad Zahedi, Stefan Ianchulev, Larry H Brinckerhoff, John G Augoustides, Prakash A Patel, Andrea Tsai, Frederick C Cobey Annals of Cardiac Anaesthesia 2019 22(3):239-245 Objective: Chronic postthoracotomy pain (CPTP) is a persistent, occasionally debilitating pain lasting >2 months following thoracic surgery. This study investigates for the first time the prevalence and clinical impact of CPTP in patients who have undergone a transapical transcatheter aortic valve replacement (TA-TAVR). Design: This was a single-institution, prospective observational survey and a retrospective chart review. Setting: The study was conducted in the University Hospital. Participants: Patients. Materials and Methods: A survey of 131 participants with either a previous TA TAVR or transfemoral (TF) TAVR procedure was completed. A telephone interview was conducted at least 2 months following TAVR; participants were asked to describe their pain using the Short-Form McGill Pain Questionnaire. Measurements and Main Results: Odds ratio (OR) was calculated using the proportions of questionnaire responders reporting “sensory” descriptors in the TA-TAVR versus the TF-TAVR groups. Results were then compared to individual Kansas City Cardiomyopathy Questionnaire (KCCQ12) scores and 5-min walk test (5MWT) distances. A total of 119 participants were reviewed (63 TF, 56 TA). Among TA-TAVR questionnaire responders (n = 16), CPTP was found in 64.3% of participants for an average duration of 20.5-month postprocedure (OR = 10, [confidence interval (CI) 95% 1.91–52.5];P = 0.003). TA-TAVR patients identified with CPTP had significant reductions in 5MWT distances (−2.22 m vs. 0.92 m [P = 0.04]) as well as trend toward significance in negative change of KCCQ12 scores OR = 18.82 (CI 95% 0.85–414.99;P = 0.06) compared to those without CPTP. Conclusions: CPTP occurs in patients undergoing TA-TAVR and is possibly associated with a decline quality of life and overall function.

The perioperative effect of magnesium sulfate in patients with concentric left ventricular hypertrophy undergoing cardiac surgery: A double-blinded randomized study Rabie Soliman, Walid Abukhudair Annals of Cardiac Anaesthesia 2019 22(3):246-253 Objective: The objective of this study was to assess the cardioprotective effect of magnesium sulfate in patients with left ventricular concentric hypertrophy undergoing cardiac surgery. Design: The study was a double-blinded randomized study. Setting: This study was conducted at a cardiac center. Patients: The study included 250 patients. Intervention: The study included two groups (each = 125): Group M – the patients who received magnesium sulfate infusion (15 mg/kg/h). The infusion was started 20 min before induction, during surgery, and the first postoperative 24 h. Group C – the patients who received an equal amount of normal saline. Measurements: The variables included troponin I level, creatinine kinase-MB (CK-MB) level, electrocardiograph (ECG) with automatic ST-segment analysis (leads II and V), E/A peak ratio, end-diastolic volume, cardiac index (CI), heart rate, mean arterial blood pressure (MAP), mean arterial pulmonary pressure (mPAP), pulmonary and systemic vascular resistances, and pharmacological and mechanical support. Main Results: The troponin I level, CK-MB, and ECG changes were lower in Group M than Group C (P < 0.05). The E/A peak ratio and end-diastolic volume increased in Group M than Group C (P < 0.05). There was a significant increase in the CI and a decrease in the heart rate, mPAP, pulmonary vascular resistances, and pharmacological and mechanical support in Group M compared to Group C (P < 0.05). There were minimal changes in the MAP and systemic vascular resistance in Group M compared to Group C (P < 0.05). Conclusion: The magnesium sulfate provides a cardioprotective effect in patients with concentric ventricular hypertrophy undergoing cardiac surgery. It decreases the incidence of perioperative myocardial infarction and arrhythmia. Furthermore, it decreases the requirement of pharmacological and mechanical support.

Furosemide: Would it help to improve the lungs as evaluated by sonography and compliance during aortic coarctation surgery Ahmed Kareem Mohammed, Mai A Madkour, Hossam M Hassanien Annals of Cardiac Anaesthesia 2019 22(3):254-259 Background: We evaluated furosemide on attenuating lung injury and/or edema during coarctation repair surgery. We evaluated dynamic lung compliance. We measured the degree of lung edema by means of lung ultrasound (LUS). We recorded the (PaO2/FiO2ratio) as an indicator for oxygenation. Materials and Methods: A study was conducted on 56 patients. Patients were divided into two groups: control group (Group C) which did not receive furosemide and furosemide group (Group F) at a dose of 1 mg/kg at induction of anesthesia. Dynamic lung compliance was calculated at induction (Cdyn 1) and at the end of the surgery (Cdyn 2). The (PaO2/FiO2ratio) was calculated at start and end of surgery as (PF 1) and (PF 2), respectively. LUS was performed after induction (LUS 1) and at the end of the surgery. LUS 2 using the 12 regions method plotting the results on scale from 0 to 36. Mechanical ventilation days were recorded. Results: Administering furosemide attenuated the lung injury/edema and other pulmonary complications. Furosemide administration improved the dynamic lung compliance in the F Group compared to the C Group. Furthermore, it increased the (PaO2/FiO2ratio) in the F Group compared to the C Group. LUS scale values were lower in the F Group compared to the C Group. There was also less postoperative mechanical ventilation days. Conclusions: The use of furosemide was accompanied by improved lung injury/edema profile as indicated by a much less drop in dynamic lung compliance, better oxygenation, a more favorable LUS scale with less parenchymal lung affection.

Perioperative glycemic control and its outcome in patients following open heart surgery Khalid M Siddiqui, Muhammad A Asghar, Muhammad F Khan, Fazal H Khan Annals of Cardiac Anaesthesia 2019 22(3):260-264 Background: Diabetes is not uncommon in patients requiring cardiac surgery. These patients have a higher incidence of morbidity and mortality. Subsequently, diabetes represents a major medico-economic problem in both developed and developing countries. This study was designed to observe the association between glycemic control and outcome of patients after open heart surgery in adult population. Materials and Methods: Data was collected retrospectively in all patients who underwent open cardiac surgery (coronary artery bypass grafting, valve, or bypass grafting with valve surgery) and survived 72 hours postoperatively and had diabetes. The study was conducted from January 2015 to December 2016. Results: Of the 129 patients included in the study, male dominated 101 (78.3%). Most frequent surgery was coronary artery bypass grafting (CABG) 123 (95.3%), CABG plus aortic valve replacement 4 (3.1%), and CABG plus mitral valve replacement 2 (1.6%). Considering diabetes, only 3 (2.3%) were on diet control, 112 (86.8%) on oral hypoglycemic agents (OHA), whereas 9 (7%) had control on both insulin and OHA. Only 5 (3.9%) had type I diabetes. The mean fasting blood sugar (FBS) was 154.58 g/dl, and the mean duration of diabetic mellitus was observed 12.32 years. Microvascular and macrovascular complications were 26/129 (20.16%) and 17/129 (13.17%), respectively. Total 75 (58.1%) patients did not require insulin and 54 (41.9%) were treated with insulin intraoperatively to keep the blood glucose level less than 200 g/dl. Cardiac arrhythmias were frequent in the insulin group (P < 0.05), which was also associated with increased stay in the cardiac intensive care unit. Conclusion: Inadequate glycemic control during open cardiac surgery can possibly lead to increased perioperative morbidity and mortality and with decreased long-term survival and recurrent ischemic events. Therefore, aiming for blood glucose levels around 140 mg/dl appears reasonable. Further studies are required to define specific glucose ranges for a clearer definition of recommended blood glucose goals in postoperative cardiac patients for the best outcomes in patients with diabetes mellitus.

A randomized, double-blinded trial comparing the effectiveness of tranexamic acid and epsilon-aminocaproic acid in reducing bleeding and transfusion in cardiac surgery Jonathan Leff, Amanda Rhee, Singh Nair, Daniel Lazar, Sudheera Kokkada Sathyanarayana, Linda Shore-Lesserson Annals of Cardiac Anaesthesia 2019 22(3):265-272 Objectives: To compare the effectiveness of epsilon aminocaproic acid (EACA) to tranexamic acid (TA) in reducing blood loss and transfusion requirements in patients undergone cardiac surgery under cardiopulmonary bypass. Design: Randomized, double blinded study. Outcome variables collected included; baseline demographic characteristics, type of surgery, amount of 24 hour chest tube drainage, amount of 24 hour blood products administered, 30 day mortality and morbidity and length of stay. We analyzed the data using parametric and non-parametric tests as appropriate. Setting: Single center tertiary-care university hospital setting. Participants: 114 patients who had undergone cardiac surgery under cardiopulmonary bypass. Interventions: Standard dose of intra-operative EACA or TA was compared in patients undergone cardiac surgery under cardiopulmonary bypass. Results: There was no statistically significant difference between groups when analyzing chest tube drainage. However, there was a significant difference in the administration of any transfusion (PRBC's, FFP, platelets) intra-operatively to 24 hours postoperatively, with less transfusion in patients receiving EACA compared to TA (25% vs. 44.8%, respectively P = 0.027). Additionally, there was no significant difference in terms of adverse events during the one month follow up period. Conclusion: The findings of this study suggest that EACA and TA have similar effects on chest tube drainage but EACA is associated with fewer transfusions in CABG alone surgeries. Our results suggest that EACA can be used in a similar fashion to TA which may result in a cost and morbidity advantage.

Assessment of untreated fresh autologous pericardium as material for construction of heart valve: Result at 5 years Amitabh Arya, Navneet Kumar Srivastava, Shantanu Pande, Shashank Tripathi, Surendra Kumar Agarwal, Prabhat Tewari, Aditya Kapoor Annals of Cardiac Anaesthesia 2019 22(3):273-277 Introduction: Tetralogy of Fallot requiring transannular repair of the right ventricular outflow tract (RVOT) are exposed to free pulmonary insufficiency and hence inevitable right ventricular dysfunction. This study analyzes the function and structure of untreated autologous pericardium monocusp used to create a competent pulmonary valve. Materials and Methods: This is a retrospective analysis of 52 cases operated between December 2006 and December 2012. Untreated autologous pericardium was used for creating a competent pulmonary valve following a transannular patch. They are followed for functional and structural assessment of the pulmonary valve by echocardiography. Positron emission tomography (PET) with 18 fluorodeoxyglucose was performed in two cases for profiling the pulmonary valve. Results: Median age was 10.5 years (1–38). The follow-up was complete for 42 (80.76%) patients for 3 years and 25 (48.07%) patients for 5 years. The RVOT gradient was 42 mmHg (16–96) in the year of surgery, which reduced to 26 mmHg (10–58) and pulmonary insufficiency that was present in 8.3% of patients in 1st year was witnessed in 22.7% in the 5th year of follow-up. The monocusp patch was successful in creating a competent valve while maintaining its structure at 3 years; however, it became distorted and retracted at 5 years of follow-up. There was no calcification in any of the patients. PET-computed tomography confirmed the uptake of glucose by monocusp at 1 year of follow-up. Conclusion: The untreated autologous pericardium functioned well when it was used to create a competent pulmonary valve at short term and midterm. Although it changed in its structure; there was no calcification at 5 years of follow-up.

Refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation in coronary artery disease patients with and without diabetes Farzad Sahebjami, Fatemeh Rezvan Madani, Saeid Komasi, Behzad Heydarpour, Mozhgan Saeidi, Kobra Ezzati, Parvin Ezzati Annals of Cardiac Anaesthesia 2019 22(3):278-282 Background: Refractory angina is a clinical diagnosis which implies to chronic pain due to coronary artery insufficiency and it is often resistant to routine cardiac treatment. The present study conducted to compare changes in refractory angina frequencies during 7 weeks treatment by enhanced external counterpulsation (EECP) in coronary artery disease (CAD) patients with and without diabetes. Methods: In this retrospective study, 94 CAD patients (30 diabetics vs. 64 nondiabetics) who referred to cardiac rehabilitation department of Imam Ali Hospital of Kermanshah, Iran, during January 2006–2014 were assessed. The interventional method was EECP and medical records and frequencies of self-reported chest pain were research instruments. Data were analyzed through Chi-square test, mixed repeated measures, and Bonferroni test. Results: Frequencies of pain in both diabetic and nondiabetic groups during 7 weeks had linear reduction, but this reduction was significant only among nondiabetic patients (P < 0.0005). Furthermore, the significant reduction in frequencies of pain among this group begins after the 5th week. Discussion: Diabetes is one of the obstacles to the successful control of pain frequencies by the EECP in patients with CAD. Future studies may pay attention to the confounding role of diabetes in improving the severity of chest pain.

Aortic counterpulsation for myocardial support: Towards a new paradigm Arindam Choudhury Annals of Cardiac Anaesthesia 2019 22(3):283-284

Comparison of sedation between dexmedetomidine and propofol during transesophageal echocardiography: A randomized controlled trial Azin Alizadehasl, Anita Sadeghpour, Ziae Totonchi, Rasoul Azarfarin, Saeid Rahimi, Amir Hendiani Annals of Cardiac Anaesthesia 2019 22(3):285-290 Background: This study aimed to compare sedation characteristics of dexmedetomidine (Dex) and propofol during transesophageal echocardiography (TEE) in cardiac patients. Methods: This clinical trial was conducted on 65 cardiac patients, who underwent TEE in a referral heart hospital. The patients were randomly divided into two groups: Dex (n = 34) and propofol (n = 31). The depth of sedation in the patients was assessed at 5-min intervals until the end of the TEE examination. The patient, physicians' satisfaction was recorded. Furthermore, blood pressure, heart and respiratory rates, peripheral oxygen saturation, and the bispectral index (BIS) of the patients were measured. The occurrence of apnea, hypotension or bradycardia was documented. Results: Demographic variables were similar in both groups. Time from the beginning of sedation to the start of TEE was significantly longer in the Dex group (P = 0.01). Duration of the TEE examination was not different between the two groups. Interestingly, the recovery time was shorter in the Dex group than in the propofol group. There were no significant differences regarding patient and physician satisfaction with sedation quality. Hemodynamic profile was mainly similar in both groups. There was a significantly lower BIS level in the Dex group. There was no significant difference in the incidence of apnea or hypotension between the groups. Conclusions: Time from the beginning of sedation with Dex was longer than that with propofol. However, Dex was able to provide satisfactory sedation levels, hemodynamic stability, short recovery time, and acceptable patient and practitioner satisfaction during TEE in our cardiac patients.

Post-thoracotomy ipsilateral shoulder pain: What should be preferred to optimize it - phrenic nerve infiltration or paracetamol infusion? Sobia Manzoor, Talib Khan, Syed Amer Zahoor, Shaqul Qamar Wani, Jan Mohamad Rather, Shaista Yaqoob, Zulfiqar Ali, Zubair Ashraf Hakeem, Bashir Ahmad Dar Annals of Cardiac Anaesthesia 2019 22(3):291-296 Background: Post thoracotomy ipsilateral shoulder pain (PTISP) is a distressing and highly prevalent problem after thoracic surgery and has not received much attention despite the incidence as high as 85%. Objectives: To study the effect of phrenic nerve infiltration with Ropivacaine compared to paracetamol infusion on PTISP in thoracotomy patients with epidural analgesia as standard mode of incisional analgesia in both the groups. Study Design: Prospective Randomised and Double Blind Study. Methods: 126 adult patients were divided randomly into 2 groups, “Group A (Phrenic Nerve Infiltration Group) received 10 mL of 0.2% Ropivacaine close to the diaphragm into the periphrenic fat pad” and “Group B (Paracetamol Infusion Group) received 20mg/kg paracetamol infusion” 30 minutes prior to chest closure respectively. A blinded observer assessed the patients PTISP using the VAS score at 1, 4, 8, 12 and 24 hours (h) postoperatively. The time and number of any rescue analgesic medication were recorded. Results: PTISP was relieved significantly in Group A (25.4℅) as compared to Group B (61.9℅), with significantly higher mean duration of analgesia in Group A. The mean time for first rescue analgesia was significantly higher in Group A (11.1 ± 7.47 hours) than in Group B (7.40 ± 5.30 hours). The number of rescue analgesic required was less in Group A 1.6 ± 1.16 as compared to Group B 2.9 ± 1.37 (P value <0.5). Conclusions: Phrenic Nerve Infiltration significantly reduced the incidence and delayed the onset of PTISP as compared to paracetamol infusion and was not associated with any adverse effects.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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New for Acta Oto-Laryngologica and online now on Taylor & Francis Online: Article The efficacy of OK-432 sclerotherapy on thyroglossal duct cyst and the influence on a subsequent surgical procedure Tomoyasu Tachibana, Shin Kariya, Yorihisa Orita, Takuma Makino, Takenori Haruna, Yuko Matsuyama, Yasutoshi Komatsubara, Yuto Naoi, Michihiro Nakada, Yoji Wani, Soichiro Fushimi, Machiko Hotta, Katsuya Haruna, Tami Nagatani, Yasuharu Sato & Kazunori Nishizaki Pages: 1-5 | DOI: 10.1080/00016489.2019.1633019 Research Article Evolution of Meniere’s Disease from MD 1.0, via MD 1.5, to MD 2.0 Tsung-Che Lu & Yi-Ho Young Pages: 1-6 | DOI: 10.1080/00016489.2019.1632482 Is type 1 tympanoplasty effective in elderly patients? Comparison of fascia and perichondrium grafts Serkan Cayir, Serkan Kayabasi & Omer Hizli Pages: 1-5 | DOI: 10.1080/00016489.2019.1633018

New for Acta Oto-Laryngologica and online now on Taylor & Francis Online:

Article The efficacy of OK-432 sclerotherapy on thyroglossal duct cyst and the influence on a subsequent surgical procedure Tomoyasu Tachibana, Shin Kariya, Yorihisa Orita, Takuma Makino, Takenori Haruna, Yuko Matsuyama, Yasutoshi Komatsubara, Yuto Naoi, Michihiro Nakada, Yoji Wani, Soichiro Fushimi, Machiko Hotta, Katsuya Haruna, Tami Nagatani, Yasuharu Sato & Kazunori Nishizaki Pages: 1-5 | DOI: 10.1080/00016489.2019.1633019 Research Article Evolution of Meniere's Disease from MD 1.0, via MD 1.5, to MD 2.0 Tsung-Che Lu & Yi-Ho Young Pages: 1-6 | DOI: 10.1080/00016489.2019.1632482 Is type 1 tympanoplasty effective in elderly patients? Comparison of fascia and perichondrium grafts Serkan Cayir, Serkan Kayabasi & Omer Hizli Pages: 1-5 | DOI: 10.1080/00016489.2019.1633018 The efficacy of OK-432 sclerotherapy on thyroglossal duct cyst and the influence on a subsequent surgical procedure Tomoyasu Tachibana ORCID Icon, Shin Kariya ORCID Icon, Yorihisa Orita, Takuma Makino, Takenori Haruna, Yuko Matsuyama,  show all Received 24 Apr 2019, Accepted 09 Jun 2019, Published online: 04 Jul 2019 Download citation  https://doi.org/10.1080/00016489.2019.1633019     Select Language▼ Translator disclaimer Abstract Background: Although there are studies regarding the efficacy of OK-432 sclerotherapy on thyroglossal duct cyst (TDC), its effects on surgical procedure following this therapy have not been properly described. Objectives: The present study aimed to delineate the prognostic factors of OK-432 sclerotherapy in patients with TDC and investigate its influence on subsequent surgical procedure and the histological characteristics in patients with poor response to OK-432 sclerotherapy. Material and methods: We conducted a retrospective analysis of the medical records of 20 TDC patients treated with OK-432 sclerotherapy. Results: Of the 20 patients, OK-432 sclerotherapy was effective in 5 patients (25.0%). OK-432 showed a lower effective rate in multilocular cysts (9.1%) than in unilocular cysts (44.4%), although not significantly. Five cases were treated with surgery following OK-432 sclerotherapy. There was no significant difference in the operating time and the amount of bleeding between patients with and without OK-432 sclerotherapy. From the results of the histological examination of the cyst wall, two cases had stratified squamous epithelium and two cases showed the absence of lymphocyte infiltration. Conclusion and significance: OK-432 sclerotherapy is an acceptable initial treatment for TDC, especially in unilocular cysts, because of lack of influence on surgical procedure. Chinese abstract 背景：虽然有关于OK-432硬化疗法对甲状舌管囊肿（TDC）疗效的研究, 但其对该疗法后外科手术的影响尚未得到适当描述。 目的：本研究旨在描述TDC患者OK-432硬化治疗的预后因素, 并探讨其对OK-432硬化治疗反应差的患者的后续手术程序和组织学特征的影响。 材料和方法：我们对20例使用OK-432硬化疗法治疗的TDC患者的病历进行了回顾性分析。 结果：20例患者中, OK-432硬化治疗有效5例（25.0％）。 OK-432对多房囊肿的有效率（9.1％）低于单房囊肿（44.4％）, 尽管不显著。 OK-432硬化剂治疗后, 5例患者接受手术治疗。接受和没有接受OK-432硬化疗法的患者的手术时间和出血量没有显著差异。根据囊壁组织学检查结果, 2例患者出现层状鳞状上皮, 2例未见淋巴细胞浸润。 结论和意义：OK-432硬化疗法是TDC的一种可接受的初始治疗方法, 特别是对于单房囊肿, 因为对手术过程没有影响。 Keywords: OK432 sclerotherapy, thyroglossal duct cyst, surgical results Evolution of Meniere's Disease from MD 1.0, via MD 1.5, to MD 2.0 Tsung-Che Lu & Yi-Ho Young ORCID Icon Received 25 Mar 2019, Accepted 03 Jun 2019, Published online: 04 Jul 2019 Download citation  https://doi.org/10.1080/00016489.2019.1632482     Select Language▼ Translator disclaimer Abstract Background: Elder Meniere's disease (MD) patients ultimately lose their vestibular function. Objective: This study utilized an inner ear test battery to investigate evolution of MD. Methods: Total 278 elder MD patients aged >65 years were divided into three groups. Ninety-four patients with bilateral MD (188 ears) were assigned to Group A. The remaining 184 patients with unilateral MD were further divided into two groups. Group B consisted of 20 affected ears with normal vestibular function on the opposite ears, while Group C indicated 184 unaffected ears. All patients underwent an inner ear test battery. Results: Inner ear deficits in Group B declined from the cochlea via the saccule, utricle to semicircular canals. In contrast, Groups A and C did not significantly differ in the abnormality rates of cervical vestibular-evoked myogenic potential (cVEMP), ocular VEMP and caloric tests, indicating that Group C (unaffected ears) may partly share the same mechanism like Group A (affected ears), namely aging and hydropic effects. Conclusion and significance: Evolution of MD may progress from unilateral MD (MD 1.0), via unilateral MD coupled with asymptomatic hydrops on opposite ear (MD 1.5), toward bilateral MD (MD 2.0), where the number 1.0-2.0 means the number of clinically affected ears. Chinese abstract 背景：老年梅尼埃病（MD）患者最终会失去前庭功能。 目的：本研究利用内耳测试电池来探讨MD的演变。 方法：将278名年龄大于 65岁的MD患者分为3组。将94例双侧MD（188耳）患者分到A组。其余184例单侧MD患者进一步分为两组。 B组由20只受影响的耳朵组成, 对侧耳朵具有正常的前庭功能, 而C组则由184只未受影响的耳朵组成。所有患者均接受内耳测试电池。 结果：B组内耳缺陷从耳蜗经球囊、囊体到半规管一路减轻。相反, A组和C组在颈前庭诱发肌源性潜能（cVEMP）、眼VEMP和热量测试的异常率方面没有显著差异, 表明C组（未受影响的耳朵）可能部分地具有与A组（受影响的耳朵）相同的机制, 即衰老和积水效应。 结论和意义：MD的变化可能从单侧MD（MD 1.0）, 单侧MD加对侧耳无症状水肿（MD 1.5）, 发展成双侧MD（MD 2.0）, 其中数字1.0-2.0代表临床受影响的耳朵数。 Keywords: Aging effect, asymptomatic hydrops, cervical vestibular-evoked myogenic potential (cVEMP), ocular vestibular-evoked myogenic potential (oVEMP), Meniere's disease, the elderly Is type 1 tympanoplasty effective in elderly patients? Comparison of fascia and perichondrium grafts Serkan Cayir ORCID Icon, Serkan Kayabasi ORCID Icon & Omer Hizli ORCID Icon Received 02 May 2019, Accepted 09 Jun 2019, Published online: 04 Jul 2019 Download citation  https://doi.org/10.1080/00016489.2019.1633018     Select Language▼ Translator disclaimer Abstract Background: Tympanoplasty is regularly performed in various ages but data about the procedure in elderly is insufficient. Objectives: To compare the success rates and hearing outcomes of fascia and perichondrium grafts used for tympanoplasty in patients >65 years and to evaluate the prognostic factors affecting the success of tympanoplasty. Methods: Reviewing records of 49 elderly patients underwent tympanoplasty, two groups were constituted: perichondrium (25 patients) and fascia (24 patients) groups. Ages, genders, perforation sides, type and location of perforation, graft success rates, functional success rates and air–bone gap (ABG) gains were compared. Results: Overall graft success rate was 85.7%. After a mean follow-up of 23.3 ± 8.32 months, overall mean ABG gain was 11.33 ± 8.42 dB. Overall median postoperative ABG value (9 dB) was significantly lower compared to the median preoperative value (24 dB) (p < .001). Graft success rate was higher in perichondrium group (96%) compared to fascia group (75%) (p = .04). Functional success rate did not significantly differ between perichondrium (68%) and fascia groups (62.5%) (p = .68). Conclusion and significance: Tympanoplasty is an effective procedure with a graft success rate of 85.7% in elderly. Both fascia and perichondrium are suitable materials; however, perichondrium had higher success rate. Chinese abstract 背景：鼓室成形术通常对不同年龄段的患者进行, 但有关老年人手术的资料不足。 目的：比较用于65岁以上患者鼓室成形术的筋膜和软骨膜移植物的成功率和听力结果, 并评估影响鼓室成形术成功的预后因素。 方法：回顾49例接受鼓室成形术的老年患者的记录, 分为两组：软骨膜组（25例）和筋膜组（24例）。比较年龄、性别、穿孔侧、穿孔类型和位置、移植成功率、功能成功率和气骨间隙（ABG）增益。 结果：总移植成功率为85.7％。平均随访23.3±8.32个月后, 总体平均ABG增益为11.33±8.42 dB。总术后中位数ABG增益值（9 dB）显著低于术前中位值（24 dB）（p <.001）。与筋膜组（75％）相比, 软骨膜组（96％）的移植成功率更高（p = 0.04）。功能成功率在软骨膜（68％）和筋膜组（62.5％）之间没有显著差异（p = .68）。 结论和意义：鼓室成形术是一种有效的方法。老年人的移植成功率为85.7％。筋膜和软骨膜都是合适的材料；然而, 软骨膜的成功率更高。 Keywords: Elderly, tympanoplasty, fascia, perichondrium, success

Rehabilitation Research

Trajectories of functional performance and muscle strength recovery differ after total knee and total hip replacement: a performance-based, longitudinal study Total joint replacement is indicated to alleviate pain and disability associated with hip and knee osteoarthritis. Arthroplasty outcomes are typically reported together, or anecdotal comparisons are made between total knee arthroplasty (TKA) and total hip arthroplasty (THA) recovery. Limited data quantifies differences in recovery trajectories, especially with respect to performance-based outcomes. Seventy-nine people undergoing total knee or THA were followed over 6 months. Functional performance was measured using the stair climb test, timed-up-and-go test, and 6-min walk test. Surgical limb isometric strength was also measured. All outcomes significantly declined 1 month after surgery. Participants in the TKA group showed a greater decline in climbing stairs (P < 0.001), timed-up-and-go (P = 0.01), and 6-min walk distance (P < 0.01). Further, the TKA group lost more strength (P < 0.001) and were weaker than those after THA (P < 0.001). Differences in postoperative outcomes between groups at 3 and 6 months were also observed. The TKA group experiences a greater decline in measured outcomes than the THA group, and muscle strength and functional recovery occurred differently in each group. These findings should be considered in rehabilitation priorities after arthroplasty surgery. Received 25 January 2019 Accepted 15 February 2019 Correspondence to Dana L. Judd, PT, DPT, PhD, Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Mail Stop C244, Aurora, CO 80045, USA Tel: +1 303 724 8814; fax: +1 303 724 9016; e-mail: dana.judd@ucdenver.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The effect of Tai Chi and Qigong on health-related quality of life in Parkinson's disease: a systematic review and meta-analysis of systematic reviews The overall aim of the treatment in Parkinson's disease is to optimize functional independence, safety, well-being and thereby health-related quality of life. Tai Chi and Qigong are widely used exercises in Parkinson's disease, but there is insufficient evidence to support or refute the efficacy of Tai Chi and Qigong, especially on health-related quality of life in patients with Parkinson's disease. The aim of this study was to conduct a systematic review and a meta-analysis from the systematic reviews that evaluate the effectiveness of Tai Chi and Qigong on health-related quality of life in Parkinson's disease. A comprehensive literature search was conducted to identify the systematic reviews and meta-analyses by using Cochrane Library, MEDLINE, PubMed, etc., databases up to the end of November 2018. From 1504 articles, seven fulfilled the inclusion criteria and were included in our study. Five of the included systematic reviews were about Tai Chi, and two of them were about both Tai Chi and Qigong. According to our meta-analysis, there was no significant effect of Tai Chi and Qigong on health-related quality of life in patients with Parkinson's disease, when compared to the control group (standardized mean difference −0.166, 95% confidence interval −0.676 to 0.344; P = 0.523). In conclusion, our systematic review and meta-analysis showed no significant effect of Tai Chi and Qigong statistically on health-related quality of life in patients with Parkinson's disease, but the small effect size in our study favoured the potential benefit of Tai Chi and Qigong on health-related quality of life in Parkinson's disease. Received 14 March 2019 Accepted 7 May 2019 Correspondence to Bahar Aras, PhD, PT, Assist Prof, Faculty of Health Sciences, Evliya Celebi Campus, Kutahya Health Sciences University, Kutahya, Turkey, Tel: +90 274 2652191/1462; fax: +90 274 2652191; e-mail: dpuaras@yahoo.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Body weight supported treadmill vs. overground gait training for acute stroke gait rehabilitation The purpose of this study was to evaluate the clinical efficacy of body weight supported treadmill training for acute post-stroke rehabilitation, relative to conventional therapy. Forty individuals were randomized to receive either body weight supported treadmill training or conventional therapy as part of standard care at an acute rehabilitation facility. As part of normal care patients were evaluated using the Functional Independence Measure; gait units and length of stay were also recorded. Within 48 hours of discharge, participants were evaluated using a Qualisys motion capture system to measure spatiotemporal gait parameters. Participants allocated to the body weight supported treadmill training group had a significantly lower admission Functional Independence Measure, but had a longer length of stay, and did not have significantly different discharge Functional Independence Measure scores. Gait speed was the only spatiotemporal outcome that was significantly different at discharge, and was lower for the body weight supported treadmill training group. As seen in previous literature, the clinical efficacy of body weight supported treadmill training seems to be similar to that of conventional overground therapy. Accounting for difference in admission scores the body weight supported treadmill training and conventional therapy groups, both methods performed comparably. Received 26 February 2019 Accepted 2 May 2019 Correspondence to Derek J. Lura, PhD, Assistant Professor, Department of Bioengineering, Florida Gulf Coast University, 10501 FGCU Boulevard South, Fort Myers, FL 33965–6565, USA, Tel: +1 239 590 7832; fax: +1 239 590 7304; e-mail: dlura@fgcu.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Some thoughts on bibliometrics, usage metrics and altmetrics concerning the International Journal of Rehabilitation Research No abstract available

Predictors of community reintegration and quality of life after hip fracture among community-dwelling older adults We aim to explore factors contributing to community reintegration and health-related quality of life (HRQoL) among community-dwelling older adults three months after discharge from inpatient rehabilitation following hip fracture. We performed a prospective cohort study with follow-up. Thirty-three consecutive patients (age 66–89) after surgery for hip fracture repair were recruited from an inpatient rehabilitation unit. Participants were 65+ years old, did not have dementia, and were independent in basic activities of daily living (BADL) at discharge. We examined the contribution of independent variables measuring BADL, cognition, emotional status, pain and social support to the explained variance of two main outcomes: the Reintegration to Normal Living Index (RNLI), measuring self-reported ability to participate in activities and return to life roles; and the Medical Outcomes Study Short-Form Health Survey (SF-12), assessing mental and physical aspects of HRQoL. Stepwise regression analyses revealed that: social support and pain while walking significantly explained 42.1% of variance in the RNLI; social support significantly explained 31.1% of the variance in the SF-12-physical subscale; the number of falls in the previous year, social support and executive functions assessed by the clock drawing test significantly explained 61.9% of the variance in the SF-12 mental subscale. Social support, pain while walking and the number of falls in the previous year can predict community reintegration and HRQoL among older adults three months after discharge from rehabilitation following a surgical hip fracture repair. These factors need to be addressed in rehabilitation programs. The work submitted is our own and copyright has not been breached in seeking its publication. The submitted work and its essential substance have not previously been published and are not being considered for publication elsewhere. Received 10 March 2019 Accepted 18 April 2019 Correspondence to Yafit Gilboa, OT, PhD, Faculty of Medicine, School of occupational therapy, Hebrew University of Jerusalem, Mount Scopus, Jerusalem 91240, Israel, Tel: +972 2 5845312; fax: +972 2 5324985; e-mail: Yafit.gilboa@mail.huji.ac.il Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Prosthetic Mobility Questionnaire, a tool for assessing mobility in people with lower-limb amputation: validation of PMQ 2.0 in Slovenia The aim of this study was to examine the metric properties of the Prosthetic Mobility Questionnaire, an outcome measure of mobility following lower-limb amputation, in Slovene outpatients undergoing rehabilitation. The 12-item Prosthetic Mobility Questionnaire was administered to 148 Slovene adults (74% men) with unilateral lower-limb amputation since >12 months and regularly wearing a prosthesis. The psychometric analysis included classical test theory methods and Rasch models. Rasch analysis disclosed two pairs of locally dependent items (same task but in opposite directions: walk up/down stairs; walk up/down a hill). Thus, we devised a new version (PMQ 2.0) assessing all 12 Prosthetic Mobility Questionnaire items but calculating the global score on only 10, i.e. considering–for each pair of locally dependent items–just the item with worst performance. The PMQ 2.0 demonstrated correct functioning of rating scale categories, construct validity (item fit, hierarchy of item difficulties), convergent validity, high-reliability indices and unidimensionality. In conclusion, the new 10-item PMQ 2.0 shows good reliability and validity, and an excellent overall metric quality for measuring perceived mobility capabilities in people with lower-limb amputation. Received 8 April 2019 Accepted 16 April 2019 Correspondence to Franco Franchignoni, MD, Istituti Clinici Scientifici Maugeri, IRCCS, Via Mons. Bernasconi, 16, 20851 Lissone (MB), Italy, Tel: 39 039 46571; e-mail: franco.franchignoni@icsmaugeri.it Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Simple and choice reaction times of healthy adults and patients after stroke during simulated driving We examined whether driving-related reaction times differ between 26 healthy adults (university students) and 26 patients after stroke, and how distractors and leg-dominance affect reaction time and correctness of reactions of healthy adults. Reaction times were measured with the Fiat Mediatester driving simulator using 18-lamps reaction test (simple reaction time measurement) and choice reaction test (scored as reaction time and number of correct reactions). There was no statistically significant difference between the groups in simple reaction time. As expected, choice reaction times of the healthy adults were shorter on average and their reactions more accurate than those of the patients. Under the influence of distractors, healthy adults had statistically significantly longer choice and simple reaction times and made fewer correct choices compared to normal conditions. Leg dominance statistically significantly affected choice reaction times and correctness of reactions, but not simple reaction times. Our results confirm validity and usefulness of the Fiat Mediatester driving simulator for research purposes. Received 6 March 2019 Accepted 2 April 2019 Correspondence to Gaj Vidmar, University Rehabilitation Institute, Republic of Slovenia, Linhartova 51, 1000 Ljubljana, Slovenia, Tel: +386 1 4758 440; fax: +386 1 4376589; e-mail: gaj.vidmar@ir-rs.si Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Prediction of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation As the survival rate of traumatic brain injury increases, the burden of care for patients with traumatic brain injury is emerging as a socioeconomic issue and the discharge destination is one of the important outcome measures in the post-acute rehabilitation unit. To investigate the predictors of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation. A retrospective review was performed on 86 patients who were admitted to the rehabilitation unit between January 2010 and June 2017. Multiple regression analysis was used as a statistical method to identify the factors affecting Modified Barthel Index and discharge destination. The number of days from traumatic brain injury onset to rehabilitation unit admission (odds ratio = 0.959, P = 0.049), brain surgery for traumatic brain injury management (odds ratio = 0.160, P = 0.021), initial Glasgow Coma Scale score (odds ratio = 1.269, P = 0.022) and Mini-Mental State Examination score at admission (odds ratio = 1.245, P < 0.001) were the predictive factors for higher Modified Barthel Index after rehabilitation. Underlying vascular risk factors (odds ratio = 0.138, P = 0.015), Modified Barthel Index score after rehabilitation (odds ratio = 1.085, P < 0.001) and deductible-free insurance (odds ratio = 0.211, P = 0.032) were the predictive factors of home discharge. The functional outcome of patients with traumatic brain injury after rehabilitation was related to the severity of initial injury, cognitive function at admission and rehabilitation timing. The discharge destination after rehabilitation was related to functional outcome, insurance issues and underlying vascular risk factors. Received 29 March 2019 Accepted 8 April 2019 Correspondence to Sung-Bom Pyun, MD, PhD, Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul 02841, Korea, Tel: +82-2-920-6483; fax: +82-2-929-9951; e-mail: rmpyun@korea.ac.kr Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Backward walking observational training improves gait ability in patients with chronic stroke: randomised controlled pilot study Backward walking has a positive effect on gait ability. Action observational training is an effective treatment method for stroke neurological disorders. This randomised comparator-controlled pilot study aimed to evaluate the feasibility of backward walking observational training on the gait ability of chronic stroke patients. Fourteen chronic stroke participants were randomly allocated to the experimental group (backward walking observation; n = 7) and control group (landscape observation; n = 7). Both groups performed conventional therapy 5 days/week; then the backward walking observation and landscape observation + backward walking training groups performed the observational training 3 days/week for 4 weeks. The primary outcome was measured dynamic gait index, 10-m walking test, and timed up and go test time. Both groups showed significant increases in dynamic gait index, 10-m walking test, and timed up and go test time. The experimental group showed more significant improvements in dynamic gait index (P = 0.04, η2 = 0.336), 10-m walking test (P = 0.04, η2 = 0.306), and timed up and go test time (P = 0.03, η2 = 0.334) than the control group. This pilot study demonstrated that conventional therapy with backward walking observational training improves gait ability. Our findings suggest that observing an action may have a positive effect on chronic stroke patients. Received 23 January 2019 Accepted 5 April 2019 Correspondence to Youngsook Bae, PT, PhD, Department of Physical Therapy, College of Health Science, Gachon University, 191, Hambangmoe-ro, Yeonsu-gu, Incheon 21936, Republic of Korea, Tel: +82 32 820 4324; fax: +82 32 820 4420; e-mail: baeys@gachon.ac.kr Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Home visits by occupational therapists in acute hospital care: a systematic review The aim of this review was to determine the utility of home visits by occupational therapists before and after a patient is discharged from an acute care hospital. All relevant published studies were identified by searching the CENTRAL, MEDLINE, EMBASE, Occupational Therapy Systematic Evaluation of Evidence, and WHO International Clinical Trials Registry Platform databases. Randomized controlled trials were included regardless of sex, age, disease, and duration of acute hospitalization. The intervention was predischarge and postdischarge home visits made by an occupational therapist. The primary outcome was the ability to perform activities of daily living at 1 month after the intervention. We identified eight trials (including 1029 patients) that were eligible for inclusion. More than half of the trials had a low risk of bias in random sequence generation, and allocation concealment and the other half had a high risk of bias with regard to blinding of participants. However, the risk of bias in terms of blinding for outcomes assessment was low in more than half the studies. We found that home visits by an occupational therapist in a single study significantly reduced the prevalence of falls but had no significant effects on ability to perform activities of daily living, quality of life, or mood. We could not find adequate evidence to support routine home visits by an occupational therapist in the acute care. In the future, studies with larger sample sizes are needed to validate home visits by occupational therapists in patients after acute care hospitalization. Received 11 February 2019 Accepted 1 April 2019 Correspondence to Ryo Momosaki, Department of Rehabilitation Medicine, Teikyo University School of Medicine University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-ku, Kawasaki, Kanagawa 213–8507, Japan, Tel: +81 44 844 3333; fax: +81 44 844 3201; e-mail: momosakiryo@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Craniofacial Surgery

The Surgical Treatment of a Large Cortical Atherosclerotic Middle Cerebral Artery Aneurysm Presenting With Parietal Lobe Infarction Distal MCA aneurysms are rarely seen in daily neurosurgical practice and they are, more commonly associated with infectious processes. Here, the authors present a 65-year-old, patient who had an atherosclerotic M4 segment located aneurysm. It was confirmed, that the aneurysm was not related with any infectious process. The patient had, presented clinically by a parietal infarction and she had been successfully operated. The neuronavigation system for this particular case aided us for a precise localization of the aneurysm and gave a chance for a smaller craniotomy. Address correspondence and reprint requests to Gulden Demirci Otluoglu, MD, Merdivenkoy Mah. 23 Nisan Sk. No: 17, 34732. Kadiköy, Istanbul, Turkey; E-mail: guldendemirci@gmail.com Received 16 April, 2019 Accepted 4 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Anatomical Location of the Infraorbital Foramen in Infant Dry Skulls: Implications for Cleft Surgery Background: Infraorbital foramen (IOF) is an important anatomical landmark in cleft lip surgery. The location of IOF within the maxilla of infants is different from adults. However, little information about anatomy of IOF in infants exists in the literature. This study aims to determine the location of IOF in infant dry skulls based on key surgical landmarks. Methods: All dry skulls under age 2 years old were selected from the Hamann-Todd Human Osteological Collection at the Cleveland Museum of Natural History (Cleveland, OH). Specimens without cranial bones or complete maxilla were excluded. Seven anatomical measurements were taken on each side of the face for each individual skull (14 measurements for each skull). Anatomical landmarks used for the measurements included infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary buttress, anterior nasal spine (ANS), and inferolateral corner of the aperture piriformis. Results: Twenty-seven halves of 14 dry skulls were included in the final analysis. The mean age of specimens was 0.57 years. Mean distances from infraorbital foramen to infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary, and ANS buttress were 4.11 ± 0.82, 9.4 ± 1.62, 12.7 ± 2.71, 11.7 ± 1.54, and 18.4 ± 2.11 mm, respectively. Conclusion: This study also shows that the infraorbital foramen in infants is located at the level of the ANS or within 2 mm higher and that the distance between the infraorbital rim and foramen is only 3 to 4 mm. These findings should be applied to the cleft population with discretion. Address correspondence and reprint requests to Fatma Betul Tuncer, MD, 30 N 1900 E Rm, Salt Lake City, UT 84132; E-mail: fatma.tuncer@hsc.utah.edu, fbetultuncer@gmail.com Received 17 February, 2019 Accepted 22 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Characteristics of Lower Eyelid "Reverse Ptosis" After Reconstruction of Orbital Floor Wall Fracture Using Transconjunctival Approach The purpose of this study was to evaluate the changes of lower eyelid position and the incidence of reverse ptosis after reconstruction of orbital floor fracture. The authors retrospectively reviewed the clinical records of patients who received reconstruction of orbital floor wall fractures between 2014 and 2017. Digital photographs were taken preoperatively, and at 1 week, 1 month, and 3 months postoperatively. Main measurements were marginal reflex distance 2 (MRD 2), which was measured by analyzing the digital photographs using ImageJ software. Among 264 patients with orbital wall fracture, The authors enrolled 32 eyes (18 right eyes and 14 left eyes) of 32 patients (21 males and 11 females) with a mean age of 32.1 years (range, 16–57 years). 7 (21.9%) of 32 patients had reverse ptosis at postoperative 3 months. When MRD2 of affected eye was compared based on the fellow eye, 7 patients with reversed ptosis showed a definite MRD 2 decrease (>1 mm) of affected eye from postoperative 1 month. Age showed a significant negative correlation with the difference of MRD2 between affected and fellow eye at postoperative 1 and 3 months (r = −0.378, P = 0.033 and r = −0.372, P = 0.036, respectively). Postoperative complications were not observed in all patients. The transconjunctival access in orbital floor wall surgery is a safe and useful surgical approach. However, some may have a reverse ptosis postoperatively, especially older patients. Reverse ptosis is a major clinical finding that should not be overlooked in post-operative follow-up. Address correspondence and reprint requests to Sehyun Baek, Department of Ophthalmology, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul 02841, Korea; E-mail: shbaek6534@korea.ac.kr Received 8 October, 2018 Accepted 8 May, 2019 Conception and design of the study, conduct of study, collection and management of data, data analysis, data interpretation, preparation, review, and approval of the manuscript by JP, SK, and SB. The study was approved by the Institutional Review Board of Korea University Guro Hospital. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Brow Ptosis: Is Transblepharoplasty Internal Browpexy Suitable for Everyone? Purpose: Transcutaneous internal browpexy can provide patients with mild-to-moderate lateral brow ptosis, stabilization and modest lift of the lateral brow. Questions regarding effectiveness of this procedure and appropriate indications remain. Methods: The authors measured consecutive patients who underwent upper eyelid blepharoplasty with transblepharoplasty internal browpexy (TIB) September 2014 to December 2017. Pre- and postoperative brow elevation was assessed based on before and after photographs of each patient. Patient photographs were assessed for medial and lateral brow elevation, brow contouring and asymmetry. Optimal lateral brow elevation was classified as bilateral symmetrical and above the supraorbital rim for women, and symmetrical and at the supraorbital rim for men. Results: A total of 239 patients underwent bilateral TIB and 39 underwent unilateral TIB (517 eyelids in total). Pre- and post-operative measurements were taken in 98 patients (41%), with an average elevation of the lateral brow position of 2.54 mm. Six patients had an underlying infection in the first postoperative week that resolved completely. Three patients underwent a second stage direct brow lift repair and 3 needed unrecognized ptosis repair as a second stage. Conclusions: Transblepharoplasty internal browpexy is an important tool that can be used in most patients with lateral and central brow ptosis, asymmetric brow ptosis and irregular contour of the brow. Additionally, browpexy adds to the success and longevity of upper blepharoplasty, while preventing early recurrence of lateral upper eyelid hooding. Patients with significant ptosis, heavy brows, medial greater than lateral ptosis, and post-facial palsy may not be good candidates for this procedure. Address correspondence and reprint requests to Arie Y. Nemet, MD, Department of Ophthalmology, Meir Medical Center, Kfar Sava, Israel; E-mail: nemet.arik@gmail.com Received 27 December, 2018 Accepted 24 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Incidence of Preventable Nonfatal Craniofacial Injuries and Implications for Facial Transplantation Introduction: The number of patients who may benefit from evaluation for face transplantation in the United States (US) remains largely unknown. The goal of our study was to better delineate the pool of patients who might benefit from face transplant evaluation based on the characteristics and mechanisms of injury of previously reported face transplant recipients. Methods: The authors utilized data from the National Electronic Injury Surveillance System-All Injury Program in this study. The US Census Bureau data were used for population estimates. Inclusion and exclusion criteria were determined based on the characteristics of face transplant recipients to date, and the mechanisms of injury they sustained ultimately necessitating face transplantation. Statistical significance was reached if P <0.05. Results: The estimated annual incidence of preventable craniofacial injuries from firearms (44,266–58,299; 31.7% increase), burns (5712–19,433; 240.2% increase), and animal attacks (5355–14,666; 173.9% increase) increased from 2005 to 2014, whereas the estimated annual incidence of craniofacial injuries from machinery (3927–2933; 25.3% decrease) decreased between 2005 and 2014. The authors estimate the annual incidence rate to fall between 32.1 per 100,000 and 58.1 per 100,000 among individuals aged 20 to 64 in the US. Conclusion: In this study, the authors estimate the annual incidence rate of individuals aged 20 to 64 in the US who may benefit from face transplant evaluation and believe that this quantification has the potential to initiate actionable discussions regarding geographical and financial factors affecting access to care in this patient population. Address correspondence and reprint requests to Eduardo D. Rodriguez, MD, DDS, Hansjörg Wyss Department of Plastic Surgery, Helen L. Kimmel Professor of Reconstructive Plastic Surgery NYU Langone Health, 305 East 33rd Street, New York City, NY, 10016; E-mail: Eduardo.Rodriguez@nyumc.org Received 7 November, 2018 Accepted 8 May, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Application of a Layered Muscle Flap Technique for the Reconstruction of the Cupid's Bow and Vermilion in the Repair of Secondary Cleft Lip Deformities In the repair of unilateral cleft lip, the Cupid's bow, and vermilion on the affected side are sometimes lowered excessively. Methods involving skin and mucosa flaps have been used to correct this issue, but they pose some risk of scarring. The authors here describe a layered muscle flap technique that was based on the anatomical research of nasal-labial muscles, especially the levator labii superioris alaeque nasi muscle. This technique can be used to suspend the Cupid's bow and vermilion in secondary unilateral cleft lip repair. Forty-five patients with secondary unilateral cleft lip with excessively lowered Cupid's bows and vermilion on the affected side were included in this study, which lasted 3 years. These patients were treated using the layered muscle flap surgical technique. The heights of specific bilateral landmarks were measured on patient photos and used to define the symmetry of bilateral Cupid's bow and vermilion. The comparison between post-operative and pre-operative symmetries was used to evaluate the post-operative results, and most of them were satisfactory. The results were also mostly well retained in follow-up investigations. This layered muscle flap technique could be effective in selected cases. Address correspondence and reprint requests to Bin Guo, MD, Department of Stomatology, General Hospital of Chinese People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, China; E-mail: guobin0408@126.com Received 17 August, 2018 Accepted 8 May, 2019 This work did not receive funding from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI) and other(s). The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Patient-Specific Reconstruction Utilizing Computer Assisted 3D Modelling for Partial Bone Flap Defect in Hybrid Cranioplasty Purpose: Decompressive craniectomy is a life-saving procedure in the setting of malignant brain swelling. Patients who survive require cranioplasty for anatomical reconstruction and cerebral protection. Autologous cranioplasty remains the commonest practice nowadays, but partial bone flap defects are frequently encountered. The authors, therefore, seek to develop a new technique of reconstruction for cranioplasty candidate with partial bone flap defect utilizing computer-assisted 3D modeling and printing. Methods: A prospective study was conducted to evaluate the outcome of a new reconstruction technique that produces patient-specific hybrid polymethyl methacrylate-autologous cranial implant. Computer-assisted 3D modeling and printing was utilized to produce patient-specific molds, which allowed real-time reconstruction of bone flap with partial defect intra-operatively. Results: Outcome assessment for 11 patients at 6 weeks and 3 months post-operatively revealed satisfactory implant alignment with favorable cosmesis. The mean visual analog scale for cosmesis was 91. Mean implant size was 50cm2, and the mean duration of intra-operative reconstruction was 30 minutes. All of them revealed improvement in quality of life following surgery as measured by the SF-36 score. Cost analysis revealed that this technique is more cost-effective compared to customized cranial prosthesis. Conclusion: This new technique and approach produce hybrid autologous-alloplastic bone flap that resulted in satisfactory implant alignment and favorable cosmetic outcome with relatively low costs. Address correspondence and reprint requests to Peh Hueh Low, MBBS, MS, Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia; E-mail: peh.hueh@gmail.com; Dasmawati Mohamad, PhD, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan, Universiti Sains Malaysia, Malaysia; E-mail: dasmawati@usm.my Received 22 March, 2019 Accepted 7 May, 2019 This study was supported by the Universiti Sains Malaysia (USM) Research University Grant (RUT grant) (1001/PPSG/852004) from Universiti Sains Malaysia (USM), Kubang Kerian, Kelantan, Malaysia. The third author was supported by USM fellowship scheme. The authors of this manuscript have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript. The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

The Healthcare Cost of Mandibular Nonunions The aim of this retrospective cohort study was to compare the costs and characteristics between isolated mandible fractures and mandibular nonunions. From October 2015 to December 2016, the National Inpatient Sample (NIS) was searched for patients admitted with a primary diagnosis of a mandible fracture. The sample was divided between those admitted for an initial evaluation of an isolated fracture and a fracture nonunion. Demographic descriptors, injury characteristics, and inpatient factors were recorded. A total of 1432 patients were included in the final sample, of whom 51 (3.6%) were admitted for a nonunion. Nonunion patients were significantly older (P < 0.01), and nonunions were more often localized to the body (24 vs 11%; P = 0.02). Compared to that of isolated fractures, a greater proportion of nonunions required open reduction and internal fixation (86 vs 59%; P < 0.01) and bone grafting (37 vs 1.4%; P < 0.01), and nonunions imparted +32.6% greater hospitals costs (median: $10,680 vs 14,162; P < 0.01). In conclusion, compared to isolated mandible fractures, mandibular nonunions occurred in older patients, had a higher frequency in body of the mandible, and utilized significantly more hospital resources per admission. Address correspondence and reprint requests to Kevin C. Lee, DDS, MD, 630 West 168th Street, New York, NY 10032; E-mail: kcl2136@cumc.columbia.edu Received 4 March, 2019 Accepted 25 April, 2019 There are no conflicts of interest declared by any of the authors. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Evaluation of the Foramen Magnum Area Calculated by Different Methods: A Radioanatomic Study Purpose: The main objective of the study was to evaluate the probable diversity in the area of the foramen magnum (FM) calculated by different measuring methods. Methods: The study was conducted on 24 dry skulls, present in the collection of the Anatomy Department, Faculty of Medicine, Mersin University. The area of FM was calculated by different measurement methods including automatic field setting, Teixeria and Radinsky formulas obtained from anatomic (ASM), photographic (PSM) and radiologic (RSM) skull measurements. Results: The areas of FMs calculated by Teixeria formula in RSM, PSM, and ASM were as follows: 857.96 ± 99.97 mm2, 796.68 ± 105.08 mm2, and 820.86 ± 96.40 mm2, respectively. The areas calculated by Radinsky formula in RSM, PSM, and ASM were as follows: 851.37 ± 99.68 mm2, 792.63 ± 104.18 mm2, and 814.85 ± 94.99 mm2, respectively. Lastly, the areas calculated by the automatic field setting of RSM and PSM software were as follows: 799.75 ± 103.38 mm2 and 752.83 ± 105.60 mm2, respectively. Conclusion: Statistical significance was observed between the areas of FM obtained from RSM, ASM, and PSM when calculated by the automatic field setting, Teixeria formula, and Radinsky formula. The authors think that considering the amorphous shape of FM, the automatic field setting of the software should be used to obtain the most accurate numerical data related to the area of FM. Address correspondence and reprint requests to Orhan Beger, Mersin University Faculty of Medicine, Department of Anatomy, Ciftlikkoy Campus, 33343, Mersin, Turkey; E-mail: obeger@gmail.com Received 27 February, 2019 Accepted 12 May, 2019 The authors declare no conflict of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Surgical Management of Large Odontogenic Cysts of the Mandible Introduction: Odontogenic cysts are defined as those cysts that arise from odontogenic epithelium and occur in the tooth-bearing regions of the jaws. Cystectomy, marsupialization, or decompression of odontogenic cyst are the most common treatments proposed for this pathology. The aim of this study is to retrospectively evaluate the result of decompression based on the volumetric reduction of the cystic cavity and new bone formation by cone beam computerized tomography (CBCT). Methods: The 16 patients affected by a large odontogenic mandibular cyst were enrolled in the study. All the patients underwent a surgical decompression of the cyst followed by the enucleation after a follow-up ranging from 6 to 9 months according to the volume's reduction and new bone formation. All the patients were evaluated with a CBCT before and after the surgical decompression to measure and analyze the percentage of reduction of the cystic volume before proceeding with the enucleation. Results: The decompression of the cyst showed a reduction of the cystic volume ranging from 38.2% to 54.4% proportionally to the treatment duration. The highest percentage of volume reduction observed was 54.4% in 1 patient followed-up for 9 months, before the surgical enucleation. Conclusion: In our experience, the decompression seems to be the most suitable technique for the primary treatment of large odontogenic cyst of the jaws followed by the enucleation after 6 to 9 months. The CBCT is an objective method to evaluate the cystic volume reduction after the decompression and helps the surgeon with the surgical planning. Address correspondence and reprint requests to Giovanni Dell'Aversana Orabona, Via Pansini 5, Naples, Italy; E-mail: dellaversana@unina.it Received 2 April, 2019 Accepted 9 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Dermatology

A randomized, double-blind study of amorolfine 5% nail lacquer with oral fluconazole compared with oral fluconazole alone in the treatment of fingernail onychomycosis Somodyuti Chandra, Karan Sancheti, Indrashis Podder, Anupam Das, Tushar Kanti Sarkar, Moitreyee Chowdhury, Amrita Sil, Susmita Bhattacharya, Nilay Kanti Das Indian Journal of Dermatology 2019 64(4):253-260 Background: It is a challenge to treat onychomycosis due to frequent treatment failures and relapses. Systemic and topical therapies need to be combined to improve cure rates. Antifungal susceptibility might play a role in the treatment resistance of onychomycosis. Aims: To compare the safety and effectiveness of amorolfine 5% nail lacquer + oral fluconazole versus only oral fluconazole in the treatment of fingernail onychomycosis. Methodology: In this double-blind trial (CTRI/2015/02/005369), patients were randomized (1:1) into amorolfine 5% nail lacquer + fluconazole and dummy lacquer + fluconazole. Treatment was given for 3 months with monthly follow-ups. Antifungal sensitivity was carried out for Candida. Effectiveness was assessed by reduction in the number and percentage area of nails involved and mycological cure. At the end of 3-month treatment period, the association between drug sensitivity and treatment response was explored for the Candida infections. Results: Among 30 study participants, the combination group showed significantly lower number of nail involvement (P = 0.004) and percentage nail involvement (P = 0.005) than only fluconazole group. Pretreatment fungal culture showed a comparable number of dermatophytes, Candida, Aspergillus in both the groups. Sensitivity testing was done for the isolated Candida species. Antifungal sensitivity for Candida (n = 11) was tested, and 8 (72.7%) of the organisms were sensitive to fluconazole (minimum inhibitory concentration [MIC] 1.25 ± 1.19 μg/ml), 100% were sensitive to itraconazole (MIC 0.0726 ± 0.021 μg/ml), and 3 (27.3%) were susceptible-dose dependent (S-DD) to fluconazole (MIC 16 μg/ml). Fluconazole only group patients with Candida who showed resistance to fluconazole did not respond to therapy; however, patients in the combination group showed moderate improvement (reduction in area involvement = 55.56 ± 35.36%). Conclusion: The combination of amorolfine/fluconazole achieved a higher cure rate not only for sensitive fungus but also for those which were S-DD to fluconazole.

Changing trend of superficial mycoses with increasing nondermatophyte mold infection: A clinicomycological study at a tertiary referral center in Assam Debeeka Hazarika, Nazneen Jahan, Ajanta Sharma Indian Journal of Dermatology 2019 64(4):261-265 Background: Superficial mycosis is the commonest infections affecting human globally. Though they do not cause mortality, their clinical significance lies in their morbidity, recurrence, and cosmetic disfigurement, thus creating a major public health problem. The infections are more prevalent in the tropical regions. The etiological agents are also seen to vary with time and geographical location. Aim: This study was carried out to find out the trend of superficial mycosis in Assam, along with a clinicomycological correlation. Materials and Methods: A total of 130 clinically diagnosed cases of superficial mycoses attending the outpatient department (OPD) of a tertiary hospital in Assam for a period of 1 year were taken up for the study. After taking the informed consent and a proper history, the clinical materials like skin scrapings, nail clippings, and infected hair were sent for mycological examination. Results: The infection was found to be more prevalent among males than females (M:F, 3:2) and among the farmers and laborers (24.61%). Tinea corporis was the commonest clinical type (21.5%). Among the fungal isolates, dermatophytes were the most frequent isolates (43.54%), out of which Trichophyton rubrum was commonest. nondermatophyte moulds like Fusarium, Aspergillus, Scopulariopsis, Trichosporon, and Penicillium spp. were isolated. Conclusion: The epidemiology of fungal infection and the causative fungi is seen to vary geographically and with time. This study reflects the changing trend of fungal infection in the north eastern region with a high rate of isolation of nondermatophyte moulds as the causative agent.

Profile of dermatophytosis in a tertiary care center in Kerala, India Mary Vineetha, S Sheeja, MI Celine, MS Sadeep, Seena Palackal, PE Shanimole, S Saranya Das Indian Journal of Dermatology 2019 64(4):266-271 Background: The incidence of dermatophytosis is increasing over the last few years and there are many cases which are recurrent and chronic. Aim: The aim was to study the host and pathogen factors in dermatophytosis, to identify the species responsible, and to study the histopathological features of chronic dermatophytosis. Materials and Methods: It was a descriptive study conducted in the Department of Dermatology for a period of 1 year and all patients who were clinically diagnosed as dermatophytosis were included. Isolated hair, and nail involvement were excluded from the study. Epidemiological parameters and treatment history were analyzed, scrapings, and fungal culture were done in all patients. Histopathological examination was done in patients with chronic dermatophytosis who had applied topical steroids. Results: Chronic dermatophytosis was seen in 68%; tinea corporis was the most common presentation; topical steroid application was seen in 63%; azoles were the most common antifungals used; varied morphologies such as follicular and nonfollicular papules, arciform lesions, pseudoimbricata were seen in steroid modified tinea. Trichophyton rubrum and Trichophyton mentagrophytes were the most common species isolated in culture, but rare species such as Trichophyton tonsurans, Trichophyton schoenleinii, Epidermophyton floccosum, and Microsporum audouinii were also isolated from chronic cases. Histopathology showed perifolliculitis in steroid modified tinea. Minimal inhibitory concentration was lowest for itraconazole in susceptibility studies. Conclusion: Chronicity in dermatophytosis is due to various factors such as topical steroid application, noncompliance, and change in predominant species.

Clinicomycological and histopathological profile of onychomycosis: A cross-sectional study from South India K Chetana, Roshni Menon, Brinda G David, MR Ramya Indian Journal of Dermatology 2019 64(4):272-276 Background: Onychomycosis (OM) is a fungal infection of the finger or toenails caused by dermatophytes, yeasts, or nondermatophyte molds (NDMs) and can involve any component of the nail unit. OM, apart from being asymptomatic, is a chronic disease and warrants long-term treatment. Aims: The aim was to study the clinicoepidemiological features of OM and to evaluate the mycological and histopathological features among patients attending the dermatology outpatient department. Subjects and Methods: A cross-sectional hospital-based study was performed in 500 patients with symptoms related to the nails and nail folds. OM was confirmed in 284 patients by potassium hydroxide (KOH) mount, fungal culture, or biopsy. Descriptive analysis of the data was undertaken. Results: The study included 284 confirmed cases of OM of which 117 (41.1%) were positive for fungal elements by KOH mount, 168 (59.1%) samples showed positivity in fungal culture, and 62 (21.8%) samples had positive nail biopsy results. Distolateral subungual OM was the most common clinical type (47.6%). Among the fungal isolates, a predominance of dermatophytes was observed followed by yeasts and NDMs. The most common dermatophytic fungal isolate in the culture was Trichophyton rubrum (45%). Conclusion: Our study implies the importance of laboratory diagnosis of OM as it can mimic diverse nail disorders. As the role of NDMs and yeasts is on the rise for etiology of OM, investigations such as KOH examination, culture, or nail biopsy becomes essential for correct diagnosis and management.

A study of In vitro antifungal susceptibility patterns of dermatophytic fungi at a tertiary care center in Western India Shital Poojary, Autar Miskeen, Jimish Bagadia, Saurabh Jaiswal, Priya Uppuluri Indian Journal of Dermatology 2019 64(4):277-284 Background: Recent years have seen an alarming rise in the prevalence of recalcitrant and relapsing dermatophyte infections in India associated with lack of clinical response to standard antifungal regimens. Aims and Objectives: A study was undertaken to identify the antifungal susceptibility patterns of dermatophyte species isolated from lesions of dermatophytoses in patients examined at our center. Materials and Methods: A total of 85 patients with clinically diagnosed dermatophytoses were subjected to skin scrapings for potassium hydroxide mount (microscopic examination) and culture using Sabouraud's agar medium containing chloramphenicol and cycloheximide (incubated at 30°C). Antifungal susceptibilities [minimum inhibitory concentration-90 (MIC-90)] of the identified dermatophytes were tested for seven systemic and topical antifungal agents (terbinafine, griseofulvin, itraconazole, fluconazole, sertaconazole, ketoconazole, and clotrimazole) using Clinical and Laboratory Standards Institute broth microdilution method (M38-A). Results: Trichophyton rubrum (50%) and Trichophyton mentagrophytes complex (47.2%) were the two major species isolated. Isolates of both showed downy and granular forms (61.11%, 38.89% and 32.35%, 67.65%, respectively). The overall in-vitro susceptibility profiles (MIC-90 ranges in μg/mL) of the seven drugs for T. rubrum and T. mentagrophytes complex respectively were as follows: terbinafine (0.008–0256, 0.016–0.256), griseofulvin (0.03-1, 0.06–1), itraconazole (0.125-2, 0.25–2), fluconazole (0.125–1, 0.25–32), sertaconazole (0.03-1, 0.03-1), ketoconazole (0.06–1, 0.125–1), and clotrimazole (0.03–2, 0.06–1). Conclusions: This study indicates a rising proportion of T. mentagrophytes complex with increased proportion of granular form (T. mentagrophytes var. mentagrophytes). This study represents the current antifungal susceptibility profile of dermatophytic infections in a tertiary care medical center in western India with rising MICs to terbinafine and itraconazole.

A clinico-epidemiological study of scalp hair loss in children (0–18 years) in Kota Region, South-East Rajasthan Manoj Kumar Sharma, Savera Gupta, Ramesh Kumar, Anil Kumar Singhal, Suresh Kumar Jain, Mukul Sharma Indian Journal of Dermatology 2019 64(4):285-291 Background: Currently, the studies related to hair loss in children showed the variable prevalence of different clinical patterns and causes of scalp hair loss, that had regional variation. Aims: The aim of this study is to evaluate the epidemiology and clinical pattern of scalp hair loss in children (0–18 years age group). Materials and Methods: A total of 300 children presenting with scalp hair loss were studied during a period of 1 year from April 2015 to March 2016. The results were recorded and analyzed. Results: The most common disorder found in this study was tinea capitis seen in 166 (55.33%) cases followed by alopecia areata, seborrheic dermatitis, pediculosis with secondary infection. Other uncommon causes were lichen planopilaris, tractional alopecia, telogen effluvium, nevus sebaceous, occipital neonatal alopecia, ectodermal dysplasia, scalp psoriasis, trichotillomania, and alopecia due to nutritional deficiency. Several other rare causes were identified in this study. Conclusion: This study showed that hair loss in children in our region is not an uncommon problem and results from a variety of causes. Early diagnosis and treatment are needed to prevent further hair loss and to avoid irreversible hair loss and scarring alopecia. As has been observed in this study, hair problem may be due to important nutritional deficiency. We should be aware of such presentation. These may be a clue to the diagnosis of systemic illness.

Weekly azathioprine pulse versus betamethasone oral mini-pulse in the treatment of moderate-to-severe alopecia areata Prashant Gupta, Kaushal K Verma, Sujay Khandpur, Neetu Bhari Indian Journal of Dermatology 2019 64(4):292-298 Background: Corticosteroids are the most common agents used in the treatment of alopecia areata (AA), however, their long-term use is associated with severe side effects. Therefore, other immunosuppressive agents have been tried and azathioprine appears to be an effective and promising alternative. Objective: The main objective of this study was to compare the efficacy of 300 mg once weekly azathioprine pulse (WAP) and 5 mg betamethasone on 2 consecutive days every week in the management of AA. Materials and Methods: In this open-label, randomized comparative study, 50 patients of AA with >10% scalp area involvement were treated with either 300 mg WAP or 5 mg betamethasone on 2 consecutive days every week for 4 months or till complete scalp hair regrowth and followed up for next 5 months. Primary efficacy parameters were average percentage scalp hair regrowth and change in average Severity of Alopecia Tool (SALT) score at 4 months. Results: Twenty patients in WAP group and 21 patients in betamethasone group completed the study. The median percent scalp hair regrowth and the median change in SALT score was 44.52 and 9.5 in WAP group compared to 71.43 and 14 in betamethasone group at 4-month, respectively, which were statistically similar in two groups, however, side effects were significantly higher in betamethasone group. On further follow-up at 9 months, 10 (50%) patients in WAP group and 13 (62%) patients in betamethasone group achieved complete hair regrowth. Lack of control group was a limitation of our study. Conclusion: WAP and betamethasone therapy, both appear to be effective in the treatment of AA. However, betamethasone caused several side effects; therefore, WAP can be used as a better alternative to corticosteroids in AA.

Eruptive lichen planus, a marker of metabolic syndrome Gopalan Geetharani, Sundararaj Sumithra, Sendurpandian Devaprabha, Rajagopalan Kothandaramasamy Indian Journal of Dermatology 2019 64(4):299-302 Background: Chronic inflammatory diseases take an important place in dermatology and their effects range from mild itching to grave metabolic complications. In psoriasis, association with metabolic syndrome (MS) has been proved in many studies. Chronic inflammation is a trigger of MS, and in turn, the components of MS, namely obesity and dyslipidemia, promote a pro-inflammatory milieu. Thus, chronic inflammation causes MS and vice versa. Hence, the study focuses on association of MS with lichen planus (LP), another chronic inflammatory disease. Aim: The aim of this study is to find the association of MS with all variants of LP. Materials and Methods: An observational study for MS in all patients with LP who attended skin outpatient department (OPD) for 6 months from February 2016. International Diabetes Federation criteria 2005 were used. The confounding variables of MS such as smoking, alcohol, and physical activity were assessed for its significance in the association of LP with MS. Results: Out of 113 cases, 21 cases were found to be associated with MS. Among them, 8 cases (38.09%) were of eruptive LP, which showed significant association with MS when compared to other variants. MS cases were significantly high in females and in the age group of 41–50 (57.1%). Due to unequal distribution of smoking and alcohol habits, they were not taken into account for analysis. Physical activity had no significant association with MS in our study population. Waist circumference (WC) being the mandatory criterion in all variants associated with MS, dyslipidemia was the next frequently encountered criteria except in eruptive LP. High BP was less commonly noted criteria. Conclusion: Eruptive LP showed significant association with MS. Further studies with large sample size in each variant and control group are needed to confirm it which are the limitations in our study.

Metabolic syndrome and dyslipidemia among Nigerians with lichen planus: A cross-sectional study Ifeanyi Chibuzor Okpala, Adeolu Oladayo Akinboro, Ifeanyi Ogochukwu Ezejoifor, Abel N Onunu, Benson Uchechukwu Okwara Indian Journal of Dermatology 2019 64(4):303-310 Background: Lichen planus (LP) is an inflammatory skin disease of unknown etiology associated with chronic inflammation, oxidative stress induction, and cardiovascular risk factors. Objectives: To document the prevalence of metabolic syndrome (MetS), dyslipidemia, and associated factors in Nigerian patients with LP. Methods: A cross-sectional design was made to evaluate 90 patients with LP and 90 controls for MetS and dyslipidemia in two Nigerian teaching hospitals. Diagnosis of LP was made with the aid of histology, and MetS and dyslipidemia were diagnosed using the National Cholesterol Education Program Adult Treatment Panel III criteria. Results: The prevalence of MetS was insignificantly higher in LP than in control (18.9% vs. 13.5, P = 0.311), and dyslipidemia was significantly associated with LP (60% vs. 40%, P = 0.007). LP was associated with higher mean of serum triglyceride (1.21 ± 0.34 vs. 1.08 ± 0.32 mmol/L, P = 0.003), low-density lipoprotein cholesterol (3.47 ± 0.89 vs. 3.12 ± 0.77 mmol/L, P = 0.007), and T-cholesterol (5.32 ± 0.88 vs. 4.92 ± 0.86, P = 0.002). LP patients with MetS were older (P < 0.001) and less likely to have Wickham's striae (P = 0.028) compared to those without MetS. Female LP patients were older (P = 0.047), obese (P = 0.043), and had insignificant increase in MetS prevalence compared to the males. Hypertrophic LP was more frequent in patients with dyslipidemia (63.0% vs. 27.8%, P = 0.002), and the family history of diabetes mellitus (DM) was an independent predictor of MetS in LP patients (odds ratio: 4.4, confidence interval: 1.0–19.1, P = 0.047). Limitation: Availability of fund is a significant factor that limited the sample size to the minimum required as always in a poor-resource setting. Conclusions: LP has an insignificant association with MetS and a significant association with dyslipidemia among Nigerians. The family history of DM is an independent predictor of MetS in LP patients. LP patients should be routinely screened for MetS and its components.

A novel contrast stain for the rapid diagnosis of dermatophytoses: A cross-sectional comparative study of chicago sky blue 6b stain, potassium hydroxide mount and culture Kavya Baddireddy, Shital Poojary Indian Journal of Dermatology 2019 64(4):311-314 Background: The current upsurge of complicated dermatophytosis in India and other parts of the world has necessitated the development of rapid and accurate diagnostic techniques. Conventional methods such as potassium hydroxide (KOH) mount lack color contrast and require a trained eye, whereas fungal culture is laborious and costly. Chicago sky blue 6B (CSB) a new contrast stain promises to be a reliable and rapid diagnostic method. It contains 1% CSB stain and is used with 10% KOH as clearing agent. Aims and Objectives: The objective of this study is to compare the efficacy of a novel contrast stain (CSB) and KOH mount in the diagnosis of dermatophytoses with culture as the reference method. Methods: The infected skin scrapings, nail clippings, and hair specimens from 100 patients, with clinically diagnosed dermatophytoses, were subjected to KOH mount, CSB stain, and culture on Sabouraud's dextrose agar. Using fungal culture as the reference standard, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CSB stain and KOH mount were determined. An inter-rater reliability analysis was performed using the Cohen's κ statistic to determine agreement amongst the different diagnostic modalities. Results: Of the 100 cases, the CSB stain and KOH mount were positive in 85 (85%) and 70 (70%) cases, respectively. Cultures on Sabouraud's agar yielded growth in 59 (59%) cases. The sensitivity, specificity, PPV, NPV, and accuracy of CSB stain were 98%, 34%, 68%, 93%, and 72%, respectively. The same for KOH mount were 71%, 32%, 60%, 43%, and 55%, respectively. Conclusion: CSB stain is a simple, rapid, sensitive, accurate, and inexpensive office-based method with qualitatively superior demonstration of dermatophytes compared to KOH mount.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com