Vertical Strut Ossiculoplasty: A Versatile Alternate to Conventional Techniques—A Randomized study

IntroductionVarious ossicular reconstruction materials and techniques have been described in literature using autologous ossicle, cortical bone, autologous cartilage, synthetic materials and implants like total/partial ossicular replacement prosthesis (TORP/PORP) etc., but it has always been a topic of controversy in terms of the efficacy, longevity and complications of the material or method used.Material and MethodsThis is a prospective, interventional, comparative, double-blind randomized control study which was done at a tertiary care center to compare outcomes of conventional and carved conchal cartilage (vertical strut) type III Tympanoplasty in terms of graft uptake and hearing gain. A total number of 52 cases were enrolled, randomized and allocated to 2 groups (26 each) i.e. group A (conventional type III) and group B (vertical strut technique).ResultsGraft uptake was seen in 25 (96.16%) patients in group B while it was observed in 23 (88.5%) cases in group A. Hearing gains were also better in group B.ConclusionThis study suggests that Vertical Strut technique can be studied further as it gives better gains in Air Conduction threshold and A-B Gap along with graft uptake as it provides better middle ear space and ossicular / tympanic membrane interface resulting in better hearing.     

Short-Duration Prednisolone in Children with Nephrotic Syndrome Relapse: A Noninferiority Randomized Controlled Trial

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Association between insurance status and in‐hospital outcomes in patients with out‐of‐hospital ventricular fibrillation arrest

BackgroundLack of health insurance is associated with adverse clinical outcomes; however, the association between health insurance status and in‐hospital outcomes after out‐of‐hospital ventricular fibrillation (OHVFA) arrest is unclear.HypothesisLack of health insurance is associated with worse in‐hospital outcomes after out‐of‐hospital ventricular fibrillation arrest.MethodsFrom January 2003 to December 2014, hospitalizations with a primary diagnosis of OHVFA in patients ≥18 years of age were extracted from the Nationwide Inpatient Sample. Patients were categorized into insured and uninsured groups based on their documented health insurance status. Study outcome measures were in‐hospital mortality, utilization of implantable cardioverter defibrillator (ICD), and cost of hospitalization. Inverse probability weighting adjusted binary logistic regression was performed to identify independent predictors of in‐hospital mortality and ICD utilization and linear regression was performed to identify independent predictors of cost of hospitalization.ResultsOf 188 946 patients included in the final analyses, 178 005 (94.2%) patients were insured and 10 941 (5.8%) patients were uninsured. Unadjusted in‐hospital mortality was higher (61.7% vs. 54.7%, p < .001) and ICD utilization was lower (15.3% vs. 18.3%, p < .001) in the uninsured patients. Lack of health insurance was independently associated with higher in‐hospital mortality (O.R = 1.53, 95% C.I. [1.46–1.61]; p < .001) and lower utilization of ICD (O.R = 0.84, 95% C.I [0.79–0.90], p < .001). Cost of hospitalization was significantly higher in uninsured patients (median [interquartile range], p‐value) ($) (39 650 [18 034‐93 399] vs. 35 965 [14 568.50‐96 163], p < .001).ConclusionLack of health insurance is associated with higher in‐hospital mortality, lower utilization of ICD and higher cost of hospitalization after OHVFA.     

Oncologic clearance with preservation of reconstructive options: literature review and the ‘delayed reconstruction after pathology evaluation (DRAPE)’ technique

Intraoperative frozen section and Mohs' micrographic surgery (MMS) are two techniques used to ensure oncological clearance without resorting to unnecessarily wide margins that might compromise reconstructive options for definitive wound closure. In addition to some technical issues, these techniques are suboptimal for resection of tumours such as melanoma, where specific tissue margins at histopathology are required to ensure minimal risk of local recurrence. We describe a technique that minimizes the amount of tissue excised and uses definitive paraffin sections interpreted in a pathology laboratory in order to delay reconstruction until after clear oncologic margins are obtained. This ‘delayed reconstruction after pathology evaluation (DRAPE)’ technique is particularly directed at extensive and complicated skin lesions, located in areas of the body that can be difficult to reconstruct and are prone to disfigurement and/or loss of function. A review of the literature is undertaken, establishing the role of each technique in achieving clear surgical margins. A case example is presented, highlighting the role of the DRAPE approach. The DRAPE technique is presented as a useful option for high‐risk lesions, especially within aesthetically sensitive regions or for complex reconstructions, and when reconstruction can be reasonably delayed while tumour clearance is established.     

Rhabdomyolysis with acute kidney injury in deceased donors is not a contraindication for kidney donation

Purpose

Deceased patients with acute kidney injury (AKI) from rhabdomyolysis can be considered as potential kidney donors.

Methods

We performed a retrospective chart review from January 2005 to January 2011 of three donors with AKI from rhabdomyolysis and the four recipients of the donated kidneys. Three donors had AKI from rhabdomyolysis as evidenced by elevated serum creatinine levels, myoglobinuria, and plasma creatinine kinase levels greater than five times the upper limit of normal. All grafts were maintained on pulsatile machine perfusion (MP) prior to transplantation. In one of the patients, serial venous perfusate myoglobin levels were measured from the donor kidney while on MP.

Results

Three of the four recipients had delayed graft function, but all had normalized creatinine function after 1?month. One recipient had a creatinine of 1.2 after 79?months, the longest documented follow-up of this kind. Although we measured venous perfusate myoglobin levels from one of the grafts, we found the levels to decrease with increasing time spent on MP.

Conclusion

Potential donors with AKI secondary to rhabdomyolysis should not be restricted from the donor pool. MP may play a role in minimizing the effects of AKI in these types of donors.     

Diagnostic accuracy of transient elastography in diagnosing clinically significant portal hypertension in patients with chronic liver disease: a systematic review and meta-analysis

Purpose

Liver stiffness measurement using transient elastography (TE-LSM) is a promising noninvasive alternative to hepatic venous pressure gradient (HVPG) for diagnosing clinically significant portal hypertension (CSPH). However, previous studies have yielded conflicting results. We evaluated the correlation between TE-LSM and HVPG and the performance of TE-LSM in diagnosing CSPH (HVPG?≥?10 mmHg).

Methods

We conducted a systematic review and meta-analysis by searching PubMed and Scopus databases for relevant literature evaluating the clinical usefulness of TE for diagnosing CSPH in patients with chronic liver disease.

Results

Twenty-six studies (4337 patients with valid TE and HVPG) met our inclusion criteria. The median correlation coefficient of TE with HVPG was 0.70 (range 0.36–0.86). The weighted mean of optimal cut-off of liver stiffness value for diagnosing CSPH was 22.8 kPa (95% CI 22.7–23.0 kPa). The summary sensitivity and specificity were 79% (95% CI 74–84%) and 88% (95% CI 84–91%), respectively. The area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.91 (95% CI 0.88–0.93) according to the bivariate model. One limitation of the study was significant heterogeneity in the results of summary sensitivity and specificity (I² 83 and 74%, respectively). The heterogeneity could be explained by the variable liver stiffness cut-offs used in studies. The meta-regression plot revealed that as the optimal cut-off increased, the sensitivity decreased, the specificity increased, and vice versa.

Conclusions

Liver stiffness measurement using TE correlates well with HVPG, and a liver stiffness cut-off value of 22.8 kPa shows a high accuracy for diagnosing CSPH. Thus, use of TE should be integrated into clinical practice for noninvasive diagnosis of CSPH.

     

A Proposal for a Quality System for Herbal Products

Today, there is an increasing worldwide demand for botanicals. Developing countries heavily rely on plant-derived medicines for their primary healthcare. One reason amongst many is the relatively inexpensive process economics and the lack of stringent product governance associated with the exploitation of traditional plant medicines compared with modern medicine. Developed countries impose stringent good manufacturing practices and quality control measures on drug products derived from any manufacturing process, regardless of the primary raw material. However, several factors hamper the full-scale application of traditional plant medicines: lack of implementation of effective quality assurance in the manufacturing process; lack of traceability in the supply chain and associated value additions; and inefficient identification of molecular species that affect the therapeutic efficacy of the final product. There lacks an assessable, causative, and prognostic relationship between the raw materials, the manufacturing process and the final product quality. This article suggests some solutions that may be adopted by the phytodrug industry to widen its global reach and retain its credibility. Primarily among them is the implementation of hazards analysis and critical control point in the manufacturing process and employment of process analytical technology for ensuring minimal deviation from the manufacturing process of phytotherapeutics.     

Multiple indicator cluster survey 2003 in Afghanistan: outdated sampling frame and the effect of sampling weights on estimates of maternal and child health coverage

Due to an urgent need for information on the coverage of health service for women and children after the fall of Taliban regime in Afghanistan, a multiple indicator cluster survey (MICS) was conducted in 2003 using the outdated 1979 census as the sampling frame. When 2004 pre-census data became available, population-sampling weights were generated based on the survey-sampling scheme. Using these weights, the population estimates for seven maternal and child healthcare-coverage indicators were generated and compared with the unweighted MICS 2003 estimates. The use of sample weights provided unbiased estimates of population parameters. Results of the comparison of weighted and unweighted estimates showed some wide differences for individual provincial estimates and confidence intervals. However, the mean, median and absolute mean of the differences between weighted and unweighted estimates and their confidence intervals were close to zero for all indicators at the national level. Ranking of the five highest and the five lowest provinces on weighted and unweighted estimates also yielded similar results. The general consistency of results suggests that outdated sampling frames can be appropriate for use in similar situations to obtain initial estimates from household surveys to guide policy and programming directions. However, the power to detect change from these estimates is lower than originally planned, requiring a greater tolerance for error when the data are used as a baseline for evaluation. The generalizability of using outdated sampling frames in similar settings is qualified by the specific characteristics of the MICS 2003-low replacement rate of clusters and zero probability of inclusion of clusters created after the 1979 census.     

Survival estimates and risk factors for failure of palatal and buccal mini-implants

ObjectivesThe primary objective was to compare the success and survival rates of palatal and buccal mini-implants for different locations and treatment requirements. The secondary objective was to evaluate risk factors influencing the survival of mini-implants.Materials and MethodsIn this retrospective cohort, records of 127 orthodontic patients with 257 mini-implants were included after imposing inclusion/exclusion criteria. Along with the implant failure data, factors such as age, sex, transverse location, anteroposterior location, and purpose of mini-implants were recorded. Kaplan–Meier survival analysis was used to draw the curves and a Nathan Mantel-David Cox test to compare variables.ResultsThe failure rate of palatal mini-implants was 8.5%, whereas the failure rate for buccal shelf mini-implants was 68.7% (P < .0001). A significant difference was that the survival rates of palatal mini-implants were dependent on the purpose of the mini-implants and, for the buccal mini-implants, they were dependent on the skeletal malocclusion and location type of mini-implants (P < .05).ConclusionsThe overall survival rate of palatal mini-implants was high, at 91.5%. Of the buccal mini-implants, inter-radicular mini-implants had the highest survival rate for 12 (75.5%) and 24 (71.9%) months, while buccal shelf mini-implants had the lowest success and survival rates for 12 (31.3%) and 24 (20.8%) months. Class III malocclusion had the lowest survival rate for the buccal mini-implants (65.3% and 54.2%) for 12 and 24 months.