Human facial allotransplantation: patient selection and pertinent considerations

Devastating facial deformities can cause significant functional and psychosocial injury. Significant facial disfigurement can preclude meaningful human interaction. Allotransplantation of facial tissues for reconstruction of devastating deformities has become a clinical reality, with 15 transplants performed at various centers around the world. Restoration of aesthetics and functionality has been superior to that achieved by conventional reconstruction, without the morbidity of multiple surgeries. Unlike solid organ transplantation which can be life saving, facial transplantation is considered by many to be life enhancing, highlighting the ethical argument against justification of these procedures given the risks of lifelong immunosuppression. Meticulous patient selection is mandatory, and a multidisciplinary team approach is key for the program's success. The overriding goal of screening for candidacy is to identify and select subjects who have the best chance for a positive immunologic, functional, and quality-of-life outcome. This article reviews the pertinent considerations and screening approach for appropriate patient selection in facial tissue transplantation.     

Effect of occlusal splint therapy on maximum bite force in individuals with moderate to severe attrition of teeth

ObjectiveThe purpose of the pilot study was to determine the effect of restoring lost occlusal vertical dimension (OVD) due to attrition on maximum bite force in humans.MethodologyA total of 124 subjects in age range of 25–40 years, with moderate to severe attrition, having full complement of teeth were screened according to inclusion and exclusion criteria. After consent, occlusal vertical dimension was assessed by employing mechanical and physiological methods in the experimental group and a maxillary canine guided hard splint was fabricated for each subjects fulfilling inclusion criteria and with positive consent (78). Bite force in experimental group was measured before, immediately after delivery of splint and subsequently at an interval of four, eight, and twelve weeks. Due loss during follow up, only 50 subjects could be available for bite force recording till 12 weeks. Bite force of age, gender, height and weight matched controls with no signs of attrition was also measured for comparison.ResultsBite force of the experimental group was found to be significantly less than the matched controls (P = 0.000) initially. After delivery of splint, bite force values increased progressively till twelve weeks. However comparison of bite force values of experimental group with control group showed no significant difference at end of eight (P = 0.008) and twelve weeks (P = 0.162).ConclusionIt was concluded that maximum bite force increases with restoration of lost vertical using splint therapy. A time period of 8–12 weeks is required to restore the maximum bite force value approximately similar to matched controls.     

Direct Metal Laser Sintering: A Digitised Metal Casting Technology

Dental technology is undergoing advancements at a fast pace and technology is being imported from various other fields. One such imported technology is direct metal laser sintering technology for casting metal crowns. This article will discuss the process of laser sintering for making metal crowns and fixed partial dentures with a understanding of their pros and cons.     

Unusual presentation of Rapunzel syndrome

Background

The Rapunzel syndrome is an unusual form of trichobezoar found in patients with a history of psychiatric disorders, trichotillomania (habit of hair pulling) and trichophagia (morbid habit of chewing their hair) who subsequently develop gastric bezoars. The principal symptoms are vomiting and epigastric pain.

Case presentation

A 15-year-old female presented with a two-month history of continuous dull aching epigastric pain, vomiting, loss of appetite and weight loss. Further examination and imaging showed a large trichobezoar. Nevertheless, the patient refused any intervention. A few days later, she presented to the emergency department with features of peritonitis. After adequate resuscitation, she was taken for exploratory laparotomy. Her postoperative course was uneventful.

Conclusion

Delayed treatment of Rapunzel syndrome can lead to a complication such as gastric perforation which albeit extremely rare, could prove catastrophic.     

Evolving electroanatomic substrate and intra-atrial reentrant tachycardia late after Fontan surgery

Atrial Remodeling After the Fontan Operation. Introduction: The prevalence of intra‐atrial reentrant tachycardia (IART) increases with age in Fontan patients. This study aimed to characterize the atrial electroanatomic substrate for IART late after Fontan surgery. Methods and Results: Detailed electroanatomic mapping of the right atrium (RA) was performed in 11 consecutive patients (33 ± 9 years) with older style Fontan circulation (atriopulmonary and atrioventricular connection) who underwent their first radiofrequency catheter ablation (RFCA) for IART. A comparative group of 30 non‐Fontan congenital heart disease (CHD) patients were also studied. Fontan patients had larger RA (P = 0.004), larger low‐voltage area ≤0.5 mV (P = 0.01), and more fractionated potentials (P < 0.001) than non‐Fontan CHD patients. RA enlargement correlated significantly with both low‐voltage zones (Spearman ρ= 0.68, P < 0.001) and fractionated potentials (Spearman ρ= 0.48, P = 0.001). Among Fontan patients, both age and time since Fontan surgery were significantly correlated to the amount of low‐voltage areas (Spearman ρ= 0.87, P < 0.001; Spearman ρ= 0.63, P = 0.04, respectively). Successful RFCA was accomplished in 30 (73%) patients and was less likely in Fontan patients (54% vs 83%, P = 0.04). Larger RA was significantly associated with a lower success rate (P = 0.04). During a follow‐up duration of 2.3 ± 1.6 years, IART recurred in 47% of patients. Larger RA size and larger low‐voltage areas predicted IART recurrence after RFCA. Conclusion: Fontan patients demonstrate progressive adverse atrial electrical remodeling with increasing age and time since surgery. Newer strategies beyond surgical incisions, such as pharmacotherapies that retard the progression of atrial fibrosis, may be required to reduce the long‐term risk of atrial arrhythmias.     

Factors influencing adherence to antiretroviral treatment in Asian developing countries: a systematic review

Objective To systematically review the literature of factors affecting adherence to Antiretroviral treatment (ART) in Asian developing countries. Methods Database searches in Medline/Ovid, Cochrane library, CINAHL, Scopus and PsychINFO for studies published between 1996 and December 2010. The reference lists of included papers were also checked, with citation searching on key papers. Results A total of 437 studies were identified, and 18 articles met the inclusion criteria and were extracted and critically appraised, representing in 12 quantitative, four qualitative and two mixed‐method studies. Twenty‐two individual themes, including financial difficulties, side effects, access, stigma and discrimination, simply forgetting and being too busy, impeded adherence to ART, and 11 themes, including family support, self‐efficacy and desire to live longer, facilitated adherence. Conclusion Adherence to ART varies between individuals and over time. We need to redress impeding factors while promoting factors that reinforce adherence through financial support, better accessible points for medicine refills, consulting doctors for help with side effects, social support and trusting relationships with care providers.