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Purpose: Maxillomandibular fixation (MMF) can be performed using various techniques. Two common approaches used are arch bars and bone screws. Arch bars are the gold standard and inexpensive, but often require increased procedure time. Bone screws with wire fixation is a popular alternative, but more expensive than arch bars. The differences in costs of care, complications, and operative times between these 2 techniques are analyzed., Methods: A chart review was conducted on patients treated over the last 12 years at our institution. Forty-four patients with CPT code 21453 (closed reduction of mandible fracture with interdental fixation) with an isolated mandible fracture were used in our data collection. The operating room (OR) costs, procedure duration, and complications for these patients were analyzed., Results: Operative times were significantly shorter for patients treated with bone screws (P < 0.002). The costs for one trip to the OR for either method of fixation did not show any significant differences (P < 0.840). More patients with arch bar fixation (62%) required a second trip to the OR for removal in comparison to those with screw fixation (31%) (P < 0.068). This additional trip to the OR added significant cost. There were no differences in patient complications between these 2 fixation techniques., Conclusions: The MMF with bone screws represents an attractive alternative to fixation with arch bars in appropriate scenarios. Screw fixation offers reduced costs, fewer trips to the OR, and decreased operative duration without a difference in complications. Cost savings were noted most significantly in a decreased need for secondary procedures in patients who were treated with MMF screws. Screw fixation offers potential for reducing the costs of care in treating patients with minimally displaced or favorable mandible fractures.

Hepatitis B virus (HBV) reverse transcription requires coordinated function of the reverse transcriptase and ribonuclease H (RNaseH) activities of the viral polymerase protein. The reverse transcriptase has been biochemically characterized, but technical difficulties have prevented both assessment of the RNaseH and development of high throughput inhibitor screens against the RNaseH. Expressing the HBV RNaseH domain with both maltose binding protein and hexahistidine tags led to stable, high-level accumulation of the RNaseH in bacteria. Nickel-affinity purification in the presence of Mg(2+) and ATP removed co-purifying bacterial chaperones and yielded nearly pure monomeric recombinant enzyme. The endonucleolytic RNaseH activity required an DNA:RNA duplex ≥14 nt, could not tolerate a stem-loop in either the RNA or DNA strands, and could tolerate a nick in the DNA strand but not a gap. The RNaseH had no obvious sequence specificity or positional dependence within the RNA, and it cut the RNA at multiple positions even within the minimal 14 nt duplex. The RNaseH also possesses a processive 3'-5' exoribonuclease activity that is slower than the endonucleolytic reaction. These results are consistent with the HBV reverse transcription mechanism that features an initial endoribonucleolytic cut, 3'-5' degradation of RNA, and a sequence-independent terminal RNA cleavage. These data provide support for ongoing anti-RNaseH drug discovery efforts., (Copyright © 2016 Elsevier B.V. All rights reserved.)

OBJECTIVE The goal of this study was to identify the rate of neosuture formation in patients with craniosynostosis treated with endoscope-assisted strip craniectomy and investigate whether neosuture formation in sagittal craniosynostosis has an effect on postoperative calvarial shape. METHODS The authors retrospectively reviewed 166 cases of nonsyndromic craniosynostosis that underwent endoscope-assisted repair between 2006 and 2014. Preoperative and 1-year postoperative head CT scans were evaluated, and the rate of neosuture formation was calculated. Three-dimensional reconstructions of the CT data were used to measure cephalic index (CI) (ratio of head width and length) of patients with sagittal synostosis. Regression analysis was used to calculate significant differences between patients with and without neosuture accounting for age at surgery and preoperative CI. RESULTS Review of 96 patients revealed that some degree of neosuture development occurred in 23 patients (23.9%): 16 sagittal, 2 bilateral coronal, 4 unilateral coronal, and 1 lambdoid synostosis. Complete neosuture formation was seen in 14 of those 23 patients (9 of 16 sagittal, 1 of 2 bilateral coronal, 3 of 4 unilateral coronal, and 1 of 1 lambdoid). Mean pre- and postoperative CI in the complete sagittal neosuture group was 67.4% and 75.5%, respectively, and in the non-neosuture group was 69.8% and 74.4%, respectively. There was no statistically significant difference in the CI between the neosuture and fused suture groups preoperatively or 17 months postoperatively in patients with sagittal synostosis. CONCLUSIONS Neosuture development can occur after endoscope-assisted strip craniectomy and molding helmet therapy for patients with craniosynostosis. Although the authors did not detect a significant difference in calvarial shape postoperatively in the group with sagittal synostosis, the relevance of neosuture formation remains to be determined. Further studies are required to discover long-term outcomes comparing patients with and without neosuture formation.

Introduction: This biomechanical study aims to characterize the nasal mucosa during palatoplasty, thereby describing the soft tissue attachments at different zones and quantifying movement following their release., Methods: Palatal nasal mucosa was exposed and divided in the midline in 10 adult cadaver heads. Five consecutive maneuvers were performed: (1) elevation of nasal mucosa off the maxilla, (2) dissection of nasal mucosa from soft palate musculature, (3) separation of nasal mucosa from palatine aponeurosis, (4) release of mucosa at the pterygopalatine junction, and (5) mobilization of vomer flaps. The mucosal movements across the midline at the midpalate (MP) and posterior nasal spine (PNS) following each maneuver were measured., Results: At the MP, maneuvers 1-4 cumulatively provided 3.8 mm (36.9%), 4.9 mm (47.6%), 6.1 mm (59.2%), and 10.3 mm, respectively. Vomer flap (10.5 mm) elevation led to mobility equivalent to that of maneuvers 1-4 (p = 0.72). At the PNS, cumulative measurements after maneuvers 1-4 were 1.3 mm (10%), 2.4 mm (18.6%), 5.7 mm (44.2%), and 12.9 mm. Here, vomer flaps (6.5 mm) provided less movement (p < 0.001). Maneuver 4 yielded the greatest amount of movement of the lateral nasal mucosa at both MP (4.2 mm, 40.8%) and PNS (7.2 mm, 55.8%)., Conclusion: At the MP, complete release of the lateral nasal mucosa achieves as much movement as the vomer flap. At the hard-soft palate junction, the maneuvers progressively add to the movement of the lateral nasal mucosa. The most powerful step is release of attachments along the posterior aspect of the medial pterygoid., Competing Interests: Financial Disclosures: Dr. Patel is a consultant for Stryker CMF. Dr. Woo is a consultant for Osteomed. The other authors have no conflicts of interest to report., (Published by Elsevier Ltd.)

Background: The infraorbital nerve (ION) is at risk for iatrogenic injury during orbital floor repair. The authors aim to anatomically characterize the intraosseous course of the ION between the inferior orbital fissure and infraorbital foramen., Methods: Ten cadaver heads (20 orbits) were dissected, with exposure of the orbital floor. The ION was identified from the infraorbital fissure to inferior orbital foramen. The presence and caliber of an osseous roof was noted. Distances measured were infraorbital foramen to infraorbital margin; length of the inferior orbital groove; length of the inferior orbital canal; length from the inferior orbital fissure to the infraorbital margin., Results: Three variations of the osseous anatomy around the ION were identified. Four cadavers had no identifiable groove (Type 1, 40%) and the ION was completely roofed throughout its course. Five specimens exhibited a thin, transparent osseous roof over the nerve before forming the true canal, which we describe as a "pseudocanal" (Type 2, 50%). A true groove was seen in both orbits from a single cadaver (Type 3, 10%). Each cadaver had an ION course of the same type on both sides. Mean ± SD intraorbital foramen to infraorbital margin distance was 7.1 ± 1.4 mm. Distance from the infraorbital fissure to the infraorbital margin was 28.5 ± 2.3 mm., Conclusions: The course of the infraorbital nerve can be described as Type 1 (true canal), Type 2 (pseudocanal), and Type 3 (groove and canal). The authors propose that this novel classification system will raise awareness of variations in orbital floor anatomy.

Purpose: Various palatoplasty techniques have limited incisions in the hard palate due to concerns that these incisions may limit maxillary growth. There is little convincing long-term evidence to support this. Our purpose is to determine incisal relationships, an indicator for future orthognathic procedure, in patients after repair of an isolated cleft of the secondary palate., Methods: Our craniofacial database was used to identify patients aged 10 years or greater with an isolated cleft of the secondary palate who underwent palatoplasty between 1985 and 2002. Data collected included age at palatoplasty and follow-up, cleft type, associated syndrome, Robin sequence, surgeon, repair technique, number of operations, and occlusion. Incisal relationship was determined through clinical observation by a pediatric dentist and orthodontist., Results: Seventy eligible patients operated on by 9 surgeons were identified. Class III incisal relationship was seen in 5 patients (7.1%). Palatoplasty techniques over the hard palate (63 of 70 patients) included 2-flap palatoplasty, VY-pushback, and Von Langenbeck repair. There was an association between class III incisal relationship and syndromic diagnosis (P <0.001). Other study variables were not associated with class III incisal relationships., Conclusion: In patients with an isolated cleft of the secondary palate, there was no association between class III incisal relationship and surgeon, age at repair, cleft type, palatoplasty technique, or number of operations. Increased likelihood of class III incisal relationship was associated primarily with syndromic diagnosis.

Introduction: Bariatric surgery has emerged as an effective method of combating the morbid obesity epidemic. However, the massive weight loss that follows may result in contour changes that can affect body image and quality of life. Our study examines the effects and consequences of bariatric surgery and subsequent body contouring on body image and quality of life., Methods: Patients were prospectively followed up through their experience with bariatric surgery and subsequent body contouring surgery. Using 2 validated survey instruments, the Multidimensional Body-Self Relations Questionnaire and the Short Form 36 (SF-36), patients completed questionnaires preoperatively and at 6, 12, and 24 months postoperatively. Mean scores were determined by repeated measures analyses of variance F tests., Results: One hundred seventy-five patients were surveyed before bariatric surgery, with noted declines in survey completion at 6, 12, and 24 months. Appearance Evaluation scores improved significantly at all intervals (P = 0.0033), as did Body Area Satisfaction Scale and Appearance Orientation scores (P = 0.0079 and P = 0.044, respectively). While Overweight Preoccupation and Self-Classified Weight scores decreased over time, only the latter was significant (P < 0.0001). The composite SF-36 score for patients awaiting bariatric surgery (54.1%) with postoperative scores at 6 (67.6%,), 12 (at 74.0%), and 24 (76.7%) months being significantly higher (P < 0.0001). The body contouring group consisted of 41 patients who primarily had lower body procedures, with 31 patients surveyed at 6 months and 27 patients at 12 months. For this cohort, Appearance Evaluation and Body Area Satisfaction Scale scores both improved significantly (P = 0.0001 and P = 0.0005, respectively) whereas Appearance Orientation scores declined significantly (P = 0.0055). Both Overweight Preoccupation and Self-Classified Weight scores decreased with only the latter being statistically significant (P = 0.0286). Postoperative SF-36 scores at 6 (72.9%) and 12 (64.5%) months were no different than patients awaiting body contouring (71.3%)., Conclusions: Using 2 validated survey instruments, we show that patients undergoing bariatric surgery have improvements in body image and quality of life. Subsequent postbariatric body contouring surgery results in further improvements in body image. Our findings provide measurable evidence for the value of body contouring after significant weight loss, which may favor greater insurance coverage for this patient population.

Background: The authors' purpose is to present changes in anthropometric fronto-orbital dimensions after surgical correction of metopic synostosis., Methods: The authors retrospectively analyzed craniometric dimensions in older patients with metopic synostosis corrected by fronto-orbital advancement performed by the senior author (J.B.M.). Preoperative and postoperative linear measures (frontal breadth, cranial width, and intercanthal distance) were taken by direct anthropometry. Interdacryon distance and width of the bandeau were also recorded intraoperatively, before and after widening. Follow-up anthropometric values were compared to age- and sex-matched normative data and standard (z) scores were calculated., Results: Sixteen patients met the inclusion criteria. Syndromic diagnosis was documented in five of 16 patients. Average age at the last postoperative evaluation was 8.9 ± 3.8 years (range, 4 to 16 years). Mean frontal width z-scores decreased postoperatively from 0.82 to -0.32 (p = 0.007), indicating diminished growth in this dimension. The last measured frontal width strongly correlated with the breadth of the bandeau after surgical correction but not with preoperative values. Postoperative mean cranial width diminished significantly to a more normal value. Mean intercanthal distance was normal preoperatively and remained so but was significantly greater in syndromic than in nonsyndromic cases., Conclusions: Frontal growth rate is diminished in the coronal plane after fronto-orbital advancement. The authors recommend primary techniques to overcorrect the width of the bandeau and frontal region, including zygomaticosphenoid osteotomies and interpositional cranial bone grafts to advance/widen the lateral orbital rim. Continued evaluation is required to assess whether overcorrection results in normal frontotemporal shape and breadth at skeletal maturity., Competing Interests: Dr. Patel is a consultant for Stryker CMF. The other authors have no conflicts of interest to report.

We evaluate the safety and efficacy of the transcaruncular approach for reconstruction of medial orbital wall fractures and the combined transcaruncular-transconjunctival approach for reconstruction of large orbital defects involving the medial wall and floor. A retrospective review of the clinical and radiographic data of patients who underwent either a transcaruncular or a combined transcaruncular-transconjunctival approach by a single surgeon for orbital fractures between June 2007 and June 2013 was undertaken. Seven patients with isolated medial wall fractures underwent a transcaruncular approach, and nine patients with combined medial wall and floor fractures underwent a transcaruncular-transconjunctival approach with a lateral canthotomy. Reconstruction was performed using a porous polyethylene implant. All patients with isolated medial wall fractures presented with enophthalmos. In the combined medial wall and floor group, five out of eight patients had enophthalmos with two also demonstrating hypoglobus. The size of the medial wall defect on preoperative computed tomography (CT) scan ranged from 2.6 to 4.6 cm(2); the defect size of combined medial wall and floor fractures was 4.5 to 12.7 cm(2). Of the 11 patients in whom postoperative CT scans were obtained, all were noted to have acceptable placement of the implant. All patients had correction of enophthalmos and hypoglobus. One complication was noted, with a retrobulbar hematoma having developed 2 days postoperatively. The transcaruncular approach is a safe and effective method for reconstruction of medial orbital floor fractures. Even large fractures involving the orbital medial wall and floor can be adequately exposed and reconstructed with a combined transcaruncular-transconjunctival-lateral canthotomy approach. The level of evidence of this study is IV (case series with pre/posttest).

Purpose: Mandibular fractures represent a substantial portion of facial fractures in the pediatric population. Pediatric mandibles differ from their adult counterparts in the presence of mixed dentition. Avoidance of injury to developing tooth follicles is critical. Simple mandibular fractures can be treated with intermaxillary fixation (IMF) using arch bars or bone screws. This report describes an alternative to these methods using silk sutures and an algorithm to assist in treating simple mandibular fractures in the pediatric population., Patients and Methods: A retrospective chart review was performed and the records of 1 surgeon were examined. Pediatric patients who underwent treatment for a mandibular fracture in the operating room from 2011 to 2015 were identified using Common Procedural Terminology codes. Data collected included age, gender, type of fracture, type of treatment used, duration of fixation, and presence of complications., Results: Five patients with a mean age of 6.8 years at presentation were identified. Fracture types were unilateral fractures of the condylar neck (n = 3), bilateral fractures of the condylar head (n = 1), and a unilateral fracture of the condylar head with an associated parasymphyseal fracture (n = 1). IMF was performed in 4 patients using silk sutures, and bone screw fixation was performed in the other patient. No post-treatment complications or malocclusion were reported. Average duration of IMF was 18.5 days., Conclusions: An algorithm is presented to assist in the treatment of pediatric mandibular fractures. Silk suture fixation is a viable and safe alternative to arch bars or bone screws for routine mandibular fractures., (Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

OBJECT The authors present a retrospective cohort study examining complications in patients undergoing surgery for craniosynostosis using both minimally invasive endoscopic and open approaches. METHODS Over the past 10 years, 295 nonsyndromic patients (140 undergoing endoscopic procedures and 155 undergoing open procedures) and 33 syndromic patients (endoscopic procedures in 10 and open procedures in 23) met the authors' criteria. Variables analyzed included age at surgery, presence of a preexisting CSF shunt, skin incision method, estimated blood loss, transfusions of packed red blood cells, use of intravenous steroids or tranexamic acid, intraoperative durotomies, procedure length, and length of hospital stay. Complications were classified as either surgically or medically related. RESULTS In the nonsyndromic endoscopic group, the authors experienced 3 (2.1%) surgical and 5 (3.6%) medical complications. In the nonsyndromic open group, there were 2 (1.3%) surgical and 7 (4.5%) medical complications. Intraoperative durotomies occurred in 5 (3.6%) endoscopic and 12 (7.8%) open cases, were repaired primarily, and did not result in reoperations for CSF leakage. Similar complication rates were seen in syndromic cases. There was no death or permanent morbidity. Additionally, endoscopic procedures were associated with significantly decreased estimated blood loss, transfusions, procedure length, and length of hospital stay compared with open procedures. CONCLUSIONS Rates of intraoperative durotomies and surgical and medical complications were comparable between endoscopic and open techniques. This is the largest direct comparison to date between endoscopic and open interventions for synostosis, and the results are in agreement with previous series that endoscopic surgery confers distinct advantages over open surgery in appropriate patient populations.

Pneumocystis pneumonia is a life threatening infection that usually presents with diffuse bilateral ground-glass infiltrates in immunocompromised patients. We report a case of a single nodular granulomatous Pneumocystis pneumonia in a male with diffuse large B-cell lymphoma after R-CHOP therapy. He presented with symptoms of productive cough, dyspnea, and right-sided pleuritic chest pain that failed to resolve despite treatment with multiple antibiotics. Chest X-ray revealed right lower lobe atelectasis and CT of chest showed development of 2 cm nodular opacity with ground-glass opacities. Patient underwent bronchoscopy and biopsy that revealed granulomatous inflammation in a background of organizing pneumonia pattern with negative cultures. Respiratory symptoms resolved but the solitary nodular opacity increased in size prompting a surgical wedge resection which revealed granulomatous Pneumocystis pneumonia infection. This case is the third documented report of Pneumocystis pneumonia infection within a solitary pulmonary nodule in an individual with hematologic neoplasm. Although Pneumocystis pneumonia most commonly occurs in patients with HIV/acquired immunodeficiency syndrome and with diffuse infiltrates, the diagnosis should not be overlooked when only a solitary nodule is present.

Background: To improve the rotation of Cupid's bow and achieve sufficient vertical lip height, several variations of the Millard rotation-advancement have incorporated a small laterally based triangular flap above the cutaneous roll. This study uses three-dimensional photogrammetry to evaluate the outcomes of unilateral cleft lip repairs performed with and without pennant flaps., Methods: Three-dimensional photographs were analyzed to assess postoperative lip height asymmetry in 90 unilateral cleft lip patients (58 complete and 32 incomplete) treated between 2001 and 2012. Cleft lip repairs were performed by three pediatric cleft surgeons using different techniques. Thirty-nine of 90 procedures (43 percent) used an inferiorly placed triangular flap. All patients were photographed at least 9 months postoperatively (mean, 4.2 years). Lip height asymmetry was based on the vertical distances from the subnasale to the peaks of Cupid's bow., Results: Regression analysis revealed that the use of a pennant flap was a significant predictor of postoperative lip height asymmetry (β = 4.2 percent, p = 0.015). The surgeon performing the repair was also a significant factor in patients with complete cleft lips (β = 3.6 percent, p = 0.005). All three surgeons achieved greater lip height symmetry when a pennant flap was performed., Conclusions: The results of unilateral cleft lip repairs are affected by both the surgeon and the surgical technique. Procedures that used a pennant flap showed better philtral height symmetry than nonpennant repairs., Clinical Question/level of Evidence: Therapeutic, III.

Objectives: Deformational plagiocephaly and/or brachycephaly (DPB) is a misshapen head presenting at birth or shortly thereafter, caused by extrinsic forces on an infant's malleable cranium. There are two treatment methods available for DPB: helmeting and repositioning. Little is known about the long-term outcomes of these two treatment options. The purpose of this study was to examine children who received helmeting or repositioning therapy for DPB as infants and compare the long-term head shape outcomes of the two groups., Methods: A longitudinal cohort study design was used to evaluate change in head shape of the two groups. One hundred children (50 helmeted, 50 repositioned) were initially evaluated at 6 months or younger for DPB. Anthropometric skull measurements taken as infants before treatment were compared with measurements taken for this study. Inclusion criteria included initial clinic visit at age 6 months or younger, evaluation by the same practitioner, and current age 2-10 years. Cephalic index and cranial vault asymmetry were calculated based on caliper measurements., Results: Data from 100 children were evaluated for this study. Significant differences between the treatment groups in the mean change in cephalic index (p = 0.003) and cranial vault asymmetry (p < 0.001) were found; the children that used helmet therapy demonstrated greater improvement., Conclusions: This is one of the larger published long-term outcome studies comparing children that used helmets and repositioning to treat their DPB as infants. The data suggest that infants will have more improvement in head shape with a helmet than with repositioning.

Background: Preoperative severity and postoperative success for patients with sagittal synostosis are measured by cephalic index, but this metric does not describe the appropriateness of euryon location. The authors hypothesize that cephalic index in patients with sagittal synostosis is an inaccurate measure of scaphocephaly., Methods: Preoperative and 1-year postoperative cranial computed tomographic scans of children with sagittal synostosis treated before 6 months of age by either total calvarial reconstruction or endoscope-assisted craniectomy and helmet therapy (n = 10 for each) were reviewed retrospectively. The location of euryons in age-matched controls was measured as a fraction of the glabella-opisthocranion distance (horizontal point of maximum width) and as the fraction of the nasion-vertex vertical distance (vertical point of maximum width). Cephalic index at this ideal location (normative cephalic index) and traditional cephalic index were determined in all patients., Results: Ideal euryon location from preoperative controls was 56 percent by the horizontal point of maximum width and 56 percent by the vertical point of maximum width. Normative cephalic index (0.60) was significantly less than traditional cephalic index (0.66) in patients preoperatively (p < 0.001) and remained smaller postoperatively (0.68 versus 0.73) for patients who underwent open reconstruction (p < 0.001). Patients treated endoscopically also had a smaller normative cephalic index (0.71) than traditional cephalic index (0.76) postoperatively (p < 0.001)., Conclusions: Anterocaudal displacement of euryon in patients with sagittal synostosis influences cephalic index. Normative cephalic index, assessed at ideal euryon location, is a more accurate measure of preoperative severity and postoperative outcome., Clinical Question/level of Evidence: Diagnostic, III.

Measurement of cranial vault asymmetry (CVA) is a common feature in the treatment of patients with deformational plagiocephaly (DP). In many cases, this measure is the primary marker of improvement. CVA is typically measured with calipers and is subject to interrater variability. There is little research comparing results of calipers with those of three-dimensional (3D) photogrammetry.Fifty nine visits were made by 51 children previously diagnosed with DP. Thirty eight were male and 13 were female. Thirty one of the visits included a 3D photograph. Direct measures were obtained by 2 experienced anthropometrists and included head length, width, circumference, and CVA. Their results were compared to digital measures including measures unobtainable with calipers, asymmetry of head circumference and global asymmetry.The interrater reliability of all caliper measures was excellent (intraclass correlation coefficients > 0.94). Caliper and digital measures of length, width, cephalic index, and circumference were strongly correlated (R > 0.90). There was a consistent bias, caliper measures being 1 to 4 mm shorter than their digital analogues. Caliper measured CVA was highly correlated (R > 0.90) with the directly corresponding digital measures. It was poorly correlated with measures of overall hemispheric asymmetry (R < 0.10).The cranial measurements of children with DP taken independently by 2 experienced anthropometrists showed excellent interrater reliability. Caliper measures are consistently smaller than the digital measures, presumably due to pressure of the calipers and/or the use of skullcaps during photography. Like circumference and other assessments, cranial vault asymmetry measures correlate well with their analogous digital measurements.

Objective: To determine a correlation between the width of the cleft palate measured at the time of lip adhesion, definitive lip repair, and palatoplasty and the subsequent occlusal classification of patients born with unilateral cleft lip and palate., Design: Retrospective, observational study., Setting: Referral, urban, children's hospital Participants : Dental models and records of 270 patients were analyzed., Interventions: None., Main Outcome Measure: Angle occlusion classification., Results: The mean age at which occlusal classification was determined was 11 ± 0.3 years. Of the children studies, 84 were diagnosed with Class I or II occlusion, 67 were diagnosed with Class III occlusion, and 119 were lost to follow up or transferred care. Mean cleft widths were significantly larger in subjects with Class III occlusion for all measures at time of lip adhesion and definitive lip repair (P < .02). At time of palatoplasty, cleft widths were significantly greater at the alveolus (P = .025) but not at the midportion of the hard palate (P = .35) or posterior hard palate (P = .10)., Conclusion: Cleft widths from the lip through to the posterior hard palate are generally greater in children who are diagnosed with Class III occlusion later in life. Notably, the alveolar cleft width is significantly greater at each time point for patients who went on to develop Class III occlusion. There were no significant differences in cleft widths between patients diagnosed later with Class I and Class II occlusions.

Background: Previous studies have shown that open cranial vault remodeling does not fully address the endocranial deformity. This study aims to compare endoscopic-assisted suturectomy with postoperative molding helmet therapy to traditional open reconstruction by quantifying changes in cranial base morphology and posterior cranial vault asymmetry., Methods: Anthropometric measurements were made on pre- and 1-year postoperative three-dimensionally reconstructed computed tomography scans of 12 patients with unilateral lambdoid synostosis (8 open and 4 endoscopic-assisted). Cranial base asymmetry was analyzed using: posterior fossa deflection angle (PFA), petrous ridge angle (PRA), mastoid cant angle (MCA), and vertical and anterior-posterior (A-P) displacement of external acoustic meatus (EAM). Posterior cranial vault asymmetry was quantified by volumetric analysis., Results: Preoperatively, patients in the open and endoscopic groups were statistically equivalent in PFA, PRA, MCA, and A-P EAM displacement. At 1 year postoperatively, open and endoscopic patients were statistically equivalent in all measures. Mean postoperative PFA for the open and endoscopic groups was 6.6 and 6.4 degrees, PRA asymmetry was 6.4 and 7.6%, MCA was 4.0 and 3.2 degrees, vertical EAM displacement was -2.3 and -2.3 millimeters, and A-P EAM displacement was 6.8 and 7.8 millimeters, respectively. Mean volume asymmetry was significantly improved in both open and endoscopic groups, with no difference in postoperative asymmetry between the 2 groups (P = 0.934)., Conclusions: Patients treated with both open and endoscopic repair of lambdoid synostosis show persistent cranial base and posterior cranial vault asymmetry. The results of endoscopic-assisted suturectomy with postoperative molding helmet therapy are similar to those of open calvarial vault reconstruction.

Background: Management of the levator veli palatini with intravelar veloplasty has been shown to improve speech resonance. The senior author has introduced a more aggressive procedure where the levator is separately dissected, overlapped, and tightened. This study compares resonance results from four levator management protocols: non-intravelar veloplasty, Kriens intravelar veloplasty, radical intravelar veloplasty, and overlapping intravelar veloplasty., Methods: Retrospective chart review was conducted on 252 patients who underwent primary palatoplasty with speech follow-up at 3 years of age. Velopharyngeal function was evaluated with perceptual speech examinations, and subjects were scored on a four-point scale (0 = normal resonance; 1 = occasional hypernasality/nasal emission/turbulence/grimacing, no further assessment warranted; 2 = mild hypernasality/intermittent nasal turbulence/grimacing, velopharyngeal imaging suggested; and 3 = severe hypernasality, surgical intervention recommended). Fisher's exact test was used to compare outcomes., Results: A single surgeon performed all the non-intravelar veloplasty (n = 92), Kriens intravelar veloplasty (n = 103), and radical intravelar veloplasty (n = 31), whereas the senior author performed the overlapping intravelar veloplasty (n = 26). Cleft severity proportions were equivalent across the four methods (p = 0.28). Patients who underwent overlapping intravelar veloplasty demonstrated significantly better velopharyngeal function, and none required further imaging or secondary surgery compared with the other three procedures (p < 0.001)., Conclusions: Speech resonance outcomes at 3 years of age are improved and need for secondary velopharyngeal dysfunction management is reduced with more aggressive levator dissection and reconstruction during primary one-stage palatoplasty. Results were best when the muscle was overlapped., Clinical Question/level of Evidence: Therapeutic, III.

We recently demonstrated that incorporation of 4-amino-4-deoxy-l-arabinose (l-Ara4N) to the lipid A moiety of lipopolysaccharide (LPS) is required for transport of LPS to the outer membrane and viability of the Gram-negative bacterium Burkholderia cenocepacia. ArnT is a membrane protein catalyzing the transfer of l-Ara4N to the LPS molecule at the periplasmic face of the inner membrane, but its topology and mechanism of action are not well characterized. Here, we elucidate the topology of ArnT and identify key amino acids that likely contribute to its enzymatic function. PEGylation assays using a cysteineless version of ArnT support a model of 13 transmembrane helices and a large C-terminal region exposed to the periplasm. The same topological configuration is proposed for the Salmonella enterica serovar Typhimurium ArnT. Four highly conserved periplasmic residues in B. cenocepacia ArnT, tyrosine-43, lysine-69, arginine-254 and glutamic acid-493, were required for activity. Tyrosine-43 and lysine-69 span two highly conserved motifs, (42)RYA(44) and (66)YFEKP(70), that are found in ArnT homologues from other species. The same residues in S. enterica ArnT are also needed for function. We propose these aromatic and charged amino acids participate in either undecaprenyl phosphate-l-Ara4N substrate recognition or transfer of l-Ara4N to the LPS.

Introduction: To study the incidence of hearing loss among children and to determine and confirm the distribution of common risk factors in children with hearing loss presenting at a tertiary care hospital in India., Materials and Methods: Babies underwent hearing screening using Transient Evoked Otoacoustic Emission (TEOAE) and Automated Auditory Brainstem Response (AABR) from November 2009 to September 2011. It was a cross-sectional study carried out at our institute involving 500 babies (≤2 y). To identify the high risk babies, Joint Committee on Infant Hearing (2007) High risk registry was used., Results: In our study 110 (22%) babies belonged to high risk category and 11(2.2%) of total screened babies had significant hearing loss. Total number of babies who passed the initial screening with TEOAE was 284 (56.8%). On diagnostic AABR screening of TEOAE REFERRED babies, the babies with no risk factor showed normal AABR tracings whereas from among those with one or multiple risk factors (110 babies), 11(10%) showed different levels of hearing impairment. Hearing loss was highly associated with Neonatal Intensive Care Unit (NICU) admission i.e. 8/11(72.7%), followed by Low Birth Weight (LBW) and hypoxia (6/11 i.e. 54.5% each)., Conclusion: Hearing loss is more common in those babies with risk factors (majority being NICU admission, LBW and hypoxia). OAE and ABR screening of infants at risk for significant hearing loss is a clinically efficient and cost effective approach for early detection of significant hearing loss.

Background: Patients with metopic craniosynostosis are traditionally treated with fronto-orbital advancement to correct hypotelorism and trigonocephaly. Alternatively, endoscopic-assisted treatment comprises narrow ostectomy of the fused suture followed by postoperative helmet therapy. Here we compare the preoperative and 1-year postoperative results in open versus endoscopic repairs., Methods: We reviewed preoperative and 1-year postoperative three-dimensional reconstructed computed tomography scans of patients treated for nonsyndromic metopic craniosynostosis by either open (n = 15) or endoscopic (n = 13) technique. Hypotelorism was assessed by interzygomaticofrontal distance and intercanthal distance. Trigonocephaly was assessed by 2 independent angles: first, an axial-plane two-dimensional angle between zygomaticofrontal suture bilaterally and the glabella (ZF(R)-G-ZF(L)); second, an interfrontal angle (IFA) between the most anterior point from a reconstructed midsagittal plane and supraorbital notch bilaterally. Age-matched scans of unaffected patients (n = 28) served as controls for each postoperative scan., Results: Patients with open repair (9.5 ± 1.8 months) were older at time of surgery than patients with endoscopic repairs (3.3 ± 0.4 months) (P = 0.004). Male-to-female ratios were equivalent at roughly 7:3 in both groups. Preoperatively, the endoscopic group had worse hypotelorism and ZF(R)-G-ZF(L) than the open group (P ≤ 0.04). After accounting for preoperative differences, all of the postoperative measurements (ie, interzygomaticofrontal distance, intercanthal distance, ZF(R)-G-ZF(L) angle, IFA) of the 2 groups were statistically equivalent (P ≥ 0.135). Trigonocephaly was significantly improved after repair in both the open (8 degrees [ZF(R)-G-ZF(L)] and 18 degrees [IFA]) and endoscopic (13 degrees [ZF(R)-G-ZF(L)] and 16 degrees [IFA]) groups (P < 0.001). Postoperative measures in both groups were equivalent to controls (0.12 < P < 0.89). Intrarater reliability ranged from 0.93 to 0.99 for all measurements., Conclusion: Our retrospective series shows that endoscopic and open repairs of metopic craniosynostosis are equivalent in improving hypotelorism and trigonocephaly at 1-year follow-up. Additional studies are necessary to better define minor differences in morphology, which may result from the different techniques.

Hepatic cirrhosis is one of the leading causes of death worldwide, especially if complicated by ascites. This chronic condition can be related to the classical disease entity jalodara in Traditional Indian Medicine (Ayurveda). The present paper aims to evaluate the general potential of Ayurvedic therapy for overall clinical outcomes in hepatic cirrhosis complicated by ascites (HCcA). In form of a nonrandomized, uncontrolled, single group, open-label observational clinical study, 56 patients fulfilling standardized diagnostic criteria for HCcA were observed during their treatment at the P. D. Patel Ayurveda Hospital, Nadiad, India. Based on Ayurvedic tradition, a standardized treatment protocol was developed and implemented, consisting of oral administration of single and compound herbal preparations combined with purificatory measures as well as dietary and lifestyle regimens. The outcomes were assessed by measuring liver functions through specific clinical features and laboratory parameters and by evaluating the Child-Pugh prognostic grade score. After 6 weeks of treatment and a follow-up period of 18 weeks, the outcomes showed statistically significant and clinically relevant improvements. Further larger and randomized trials on effectiveness, safety, and quality of the Ayurvedic approach in the treatment of HCcA are warranted to support these preliminary findings.

Background: There have been conflicting reports on how sagittal synostosis affects cranial vault volume (CVV) and which surgical approach best normalizes skull volume. In this study, we compared CVV and cranial index (CI) of children with sagittal synostosis (before and after surgery) with those of control subjects. We also compared the effect of repair type on surgical outcome., Methods: Computed tomography scans of 32 children with sagittal synostosis and 61 age- and sex-matched control subjects were evaluated using previously validated segmentation software for CVV and CI. Sixteen cases underwent open surgery, and 16 underwent endoscopic surgery. Twenty-seven cases had both preoperative and postoperative scans., Results: Age of subjects at computed tomography scan ranged from 1 to 9 months preoperatively and 15 to 25 months postoperatively. Mean age difference between cases and matched control subjects was 5 days. The mean CVV of cases preoperatively was nonsignificantly (17 mL) smaller than that of control subjects (P = 0.51). The mean CVV of postoperative children was nonsignificantly (24 mL) larger than that of control subjects (P = 0.51). Adjusting for age and sex, there was no significant difference in CVV between open and endoscopic cases postoperatively (β = 48 mL, P = 0.31). The mean CI increased 12% in both groups. There was no significant difference in mean postoperative CI (P = 0.18) between the 2 groups., Conclusions: Preoperatively, children with sagittal synostosis have no significant difference in CVV compared with control subjects. Type of surgery does not seem to affect CI and CVV 1 year postoperatively. Both open and endoscopic procedures result in CVVs similar to control subjects.

A method is described for using plate lids to reduce evaporation in low-volume vapor-diffusion crystallization experiments. The plate lids contain apertures through which the protein and precipitants were added to different crystallization microplates (the reservoir was filled before fitting the lids). Plate lids were designed for each of these commonly used crystallization microplates. This system minimizes the dehydration of crystallization droplets containing just a few nanolitres of protein and precipitant, and results in more reproducible diffraction from the crystals. For each lid design, changes in the weight of the plates were used to deduce the rate of evaporation under different conditions of temperature, air movement, droplet size and precipitant. For comparison, the state of dehydration was also visually assessed throughout the experiment. Finally, X-ray diffraction methods were used to compare the diffraction of protein crystals that were conventionally prepared against those that were prepared on plates with plate lids. The measurements revealed that the plate lids reduced the rate of evaporation by 63-82%. Crystals grown in 5 nl drops that were set up with plate lids diffracted to higher resolution than similar crystals from drops that were set up without plate lids. The results demonstrate that plate lids can be instrumental for improving few-nanolitre crystallizations.

Craniosynostosis and its associated abnormalities can pose unique challenges to surgeons caring for these patients. Cephalohematomas, although rare, add to the complexities of managing a patient with craniosynostosis. Here, we present the case of a 4-month-old male infant with concurrent sagittal craniosynostosis and a calcified cephalohematoma who underwent an endoscopic-assisted strip craniectomy and management of the hematoma with good results.

Purpose: This study investigates the anatomic relationship between the superior sagittal sinus (SSS) and the sagittal suture in infants with uncorrected unicoronal synostosis. The morphology of the SSS is also evaluated postoperatively to assess whether normalization of intracranial structures occurs following reconstruction., Methods: The study sample consisted of 20 computed tomography scans (10 preoperative, 6 postoperative, and 4 unaffected controls) obtained between 2001 and 2013. The SSS and the sagittal suture were outlined using Analyze imaging software. These data were used to measure the maximum lateral discrepancy between the SSS and the sagittal suture preoperatively and to assess for postoperative changes in the morphology of the SSS., Results: In children with uncorrected unicoronal synostosis, the SSS deviates to the side of the patent coronal suture posteriorly and tends to follow the path of the sagittal and metopic sutures. The lateral discrepancy between the SSS and the sagittal suture ranged from 5.0 to 11.8 mm, with a 99.9 % upper prediction bound of 14.4 mm. Postoperatively, the curvature of the SSS was statistically decreased following surgical intervention, though it remained significantly greater than in unaffected controls., Conclusions: The SSS follows a predictable course relative to surface landmarks in children with unicoronal synostosis. When creating burr holes for craniotomies, the SSS can be avoided in 99.9 % of cases by remaining at least 14.4 mm from the lateral edge of the sagittal suture. Postoperative changes in the path of the SSS provide indirect evidence for normalization of regional brain morphology following fronto-orbital advancement.

Background: After repair of cleft lip and nasal deformity, a lateral vestibular web is often evident on submental view. The authors describe the five components of this web (i.e., piriform rim, upper lateral cartilage, lower lateral cartilage, vestibular lining, and alar base) and present their technique for primary nasal correction and prevention., Methods: Labial repair follows the Millard rotation-advancement principle. Nasal correction addresses the vestibular web: (1) centralization of deviated anterocaudal septum; (2) elevation of inferiorly positioned medial crus in the C-flap; (3) endonasal advancement and fixation of displaced alar base; (4) excision of excess vestibular lining; (5) release of tethered lateral crus from the piriform ligament; and (6) anatomical fixation of dislocated lower lateral cartilage to the contralateral middle crus and ipsilateral upper lateral cartilage., Results: Intraoperative dissection exposes the framework of the vestibular web as the lower (caudal) edge of the displaced lateral crus lying beneath expanded vestibular lining.Sixty-two consecutive patients had primary cleft nasal repair focused on the architectural components of the vestibular web. Nostril stenting was not used; the nostril rim scar was hidden and no patients had nostril stenosis., Conclusion: The vestibular web seen after repair of a cleft lip has bony, cartilaginous, and soft-tissue elements and can be prevented during primary correction of the cleft nasal deformity.

Background and Purpose: Modic type 1 degenerative signal changes can mimic/suggest infection, leading to additional costly and sometimes invasive investigations. This retrospective study analyzes the utility and accuracy of a novel, diffusion-weighted "claw sign" for distinguishing symptomatic type 1 degeneration from vertebral diskitis/osteomyelitis., Materials and Methods: Seventy-three patients with imaging features resembling type 1 degeneration were classified clinically into 3 groups: true degenerative type 1 changes (n = 33), confirmed diskitis/osteomyelitis (n = 20), and radiologically suspected infection later disproved clinically (n = 20). A claw sign was defined on DWI as well-marginated, linear, regions of high signal situated within the adjacent vertebral bodies at the interface of normal with abnormal marrow. Two blinded neuroradiologists independently rated the presence of the claw sign, along with T2 disk signal and disk and endplate enhancement to determine the utility of each for identifying degeneration versus infection., Results: When the 2 neuroradiologists identified a definite claw, 38 of 39 patients (97%) and 29 of 29 patients (100%) proved to be infection-free. When the readers identified a probable claw, 14 of 14 patients (100%) and 16 of 19 patients (84%) proved to be infection-free. Conversely, when the readers identified the absence of claw sign (diffuse DWI pattern), there was proved infection in 17 of 17 cases (100%) and 13 of 14 cases (93%)., Conclusions: In patients with type 1 signal changes of the vertebral disk space, a claw sign is highly suggestive of degeneration and its absence strongly suggests diskitis/osteomyelitis., (© 2014 by American Journal of Neuroradiology.)

Nucleos(t)ide analog drugs profoundly suppress Hepatitis B virus (HBV) replication but rarely cure the infection, so therapy is usually life-long. The nucleos(t)ide analogs inhibit the viral DNA polymerase and often push HBV to the brink of extinction, so it may be possible to eradicate HBV by suppressing HBV replication further. The HBV ribonuclease H (RNaseH) is a logical new drug target because it is the second of only two viral enzymes essential for viral replication. We recently developed a low throughput screening pipeline for inhibitors of the HBV RNaseH and viral replication. Here, we screened a series of twenty-three nitrogen-based polyoxygenated heterocycles including sixteen 2-hydroxyisoquinoline-1,3(2H,4H)-dione derivatives for anti-HBV RNaseH activity. Nine compounds inhibited the HBV RNaseH, but activity was marginal for eight of them. Compound #1 [2-hydroxyisoquinoline-1,3(2H,4H)-dione, HID] was the best hit with an IC50 of 28.1μM and an EC50 of 4.2μM. It preferentially suppressed accumulation of the viral plus-polarity DNA strand in replication inhibition assays, indicating that replication was blocked due to suppression of HBV RNaseH activity. It had a CC50 of 75μM, yielding a therapeutic index of ∼18. The EC50 value was 7-fold lower than the IC50, possibly due to cellular retention or metabolism of the compound, or higher affinity for the full-length enzyme than the recombinant form used for screening. These data indicate that the 2-hydroxyisoquinoline-1,3(2H,4H)-diones will have different structure-activity relationships for the HBV and HIV RNaseHs. Therefore, HID compounds may provide a foundation for development of more effective RNaseH inhibitors of HBV replication., (Copyright © 2014 Elsevier B.V. All rights reserved.)

The esthetic success of sagittal synostosis reconstruction is measured by cephalic index (CI). This limited measure does not fully account for the abnormal head shape in sagittal synostosis. In this retrospective study, we investigate a new objective measure, point of maximum width (PMW) of the skull from a vertex view, to determine where the head is widest for children with sagittal synostosis as compared with normal controls. Preoperative computed tomography (CT) scans of 27 children with sagittal synostosis and 14 postoperative CT scans at least 8 months after surgery were obtained. Normal CT scans were matched for age, sex, and race. Three-dimensional renderings were standardized for orientation. Mean (SE) PMW in patients with sagittal synostosis was 53% (1%) compared with 57% (1%) in controls (P < 0.001). Mean (SE) CI in patients with sagittal synostosis was 66.8% (0.8%) compared with 83.3% (1.0%) in controls (P < 0.001). The correlation between PMW and CI was weak in both controls (r2 = 0.002, P = 0.824) and uncorrected cases (r2 = 0.083, P = 0.145). After surgical correction, both CI and PMW significantly improved. Mean (SE) PMW in patients after surgical release of sagittal synostosis was 58% (1%) compared with 58% (1%) in controls (P = 0.986). The PMW is not a surrogate for CI but is a novel, valid measure of skull shape, which aids in quantifying the widest region of the skull. It is significantly more anterior in children with sagittal synostosis and exhibits a consistent posterior shift along the cranium after surgery, showing no difference compared with healthy children.

Background: Deformational plagiocephaly (DP) is an asymmetry of the skull caused by extrinsic compression. With the advent of the Back to Sleep campaign, DP is of increased interest to parents and healthcare providers. Traditionally, this asymmetry has been assessed by caliper measurements. However, little consensus exists as to which caliper measures (linear) give the most accurate representation of DP. The purposes of this study are to examine different measures and to determine which have the greatest validity in the assessment of skull asymmetry., Methods: Six linear measures were assessed using 31 three-dimensional photographs of 26 children diagnosed with DP. These measurements were compared with more encompassing measures: a head perimeter measurement, a global three-dimensional measure of hemispheric asymmetry, and the radial symmetry index. These 3 broader measures were used to determine which linear, caliper-style measurements most accurately reflect overall DP., Results: Intrarater reliability of the measurements varied widely (intraclass correlation coefficients from 0.42 to 0.99). Correlations between the measures also varied widely (0.10 < r < 0.95). The linear measure that best correlated with the inclusive measures of asymmetry was FZ-EU, the distance from the frontozygomaticus to the contralateral eurion (r ≥ 0.90)., Conclusions: These data introduce 2 digital measures that might serve as standards against which linear measures of asymmetry may be tested: Global asymmetry and head perimeter measures were strongly correlated to each other. When these 2 parameters were compared against linear measures, FZ-EU was noted to be the best linear measure of asymmetry based on these benchmarks.

The anatomy of the palate has been extensively described, with a predominant focus on palatal musculature. There are no biomechanical studies investigating the effects of surgical maneuvers on the palate to aid cleft closure. This study aims to describe the soft tissue attachments at different zones and quantify the movement following their release. Fourteen adult cadaver heads were dissected. The palates were split in the midline and five maneuvers described: Step 1, over the hard palate; Step 2, around the greater palatine pedicle; Step 3, over the palatine aponeurosis; Step 4, over the hamulus; and Step 5, resulting in a hamulus fracture. The movements across the midline at the posterior nasal spine following each maneuver were measured. The age range of the 14 heads was between 60 -75 years. Completion of steps 1 and 2 over the hard palate obtained a mean release of 2.6 and 2.0 mm, respectively. The largest movements occurred at Step 3 (5.7 mm) and Step 4 (3.5 mm), after releasing attachments at the posterior hard palate and palatine aponeurosis. Steps 3 and 4 dissections exhibited cumulative release, with a maximum movement with Step 3 (p < 0.05). Isolated fracture of the hamulus (Step 5) yielded a mean movement of 1.4 mm. Individual steps of dissection are described with respect to releasing soft tissue attachments. Medial movement of the oral mucosa is quantified with each step of dissection. The greatest release occurred with dissection overlying the palatine aponeurosis posterior to the hard/soft palate junction. Additional dissection along the hamulus (without fracture) added significantly to this release., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Object: The surgical management of infants with sagittal synostosis has traditionally relied on open cranial vault remodeling (CVR) techniques; however, minimally invasive technologies, including endoscope-assisted craniectomy (EAC) repair followed by helmet therapy (HT, EAC+HT), is increasingly used to treat various forms of craniosynostosis during the 1st year of life. In this study the authors determined the costs associated with EAC+HT in comparison with those for CVR., Methods: The authors performed a retrospective case-control analysis of 21 children who had undergone CVR and 21 who had undergone EAC+HT. Eligibility criteria included an age less than 1 year and at least 1 year of clinical follow-up data. Financial and clinical records were reviewed for data related to length of hospital stay and transfusion rates as well as costs associated with physician, hospital, and outpatient clinic visits., Results: The average age of patients who underwent CVR was 6.8 months compared with 3.1 months for those who underwent EAC+HT. Patients who underwent EAC+HT most often required the use of 2 helmets (76.5%), infrequently required a third helmet (13.3%), and averaged 1.8 clinic visits in the first 90 days after surgery. Endoscope-assisted craniectomy plus HT was associated with shorter hospital stays (mean 1.10 vs 4.67 days for CVR, p < 0.0001), a decreased rate of blood transfusions (9.5% vs 100% for CVR, p < 0.0001), and a decreased operative time (81.1 vs 165.8 minutes for CVR, p < 0.0001). The overall cost of EAC+HT, accounting for hospital charges, professional and helmet fees, and clinic visits, was also lower than that of CVR ($37,255.99 vs $56,990.46, respectively, p < 0.0001)., Conclusions: Endoscope-assisted craniectomy plus HT is a less costly surgical option for patients than CVR. In addition, EAC+HT was associated with a lower utilization of perioperative resources. Theses findings suggest that EAC+HT for infants with sagittal synostosis may be a cost-effective first-line surgical option.

Background: Craniosynostosis causes significant cranial deformity in the pediatric population. Open and endoscopic-assisted surgeries have led to increasingly successful management of this condition. Following surgical reconstruction, subsequent development of postnatal synostosis of previously patent sutures have been described and noted to be most frequently associated with multisuture synostosis patients with syndromic diagnoses. Very rarely, postsurgical new sutural fusion has been identified in nonsyndromic patients who initially present with isolated single-suture synostosis. The purpose of this study was to evaluate the incidence of new synostosis among patients who had undergone craniosynostosis reconstruction with either the open or endoscopic technique., Methods: Patients undergoing open and endoscopic surgery for nonsyndromic craniosynostosis were reviewed. Preoperative and postoperative imaging and clinical information were reviewed, and cases showing progressive cranial deformity were identified., Results: Three (2.1%) of 145 patients undergoing open craniosynostosis surgery and 2 (1.7%) of 121 patients undergoing endoscopic surgery developed delayed fusion of an additional suture during follow-up. This was identified at a median of 16.4 months after initial surgery in the open group and 15.25 months after surgery in the endoscopic group. In patients undergoing open surgery, each patient developed new sagittal synostosis after initial presentation of coronal synostosis in 1 patient and metopic synostosis in 2 patients. In patients undergoing endoscopic surgery, each patient developed new coronal synostosis after sagittal repair., Conclusions: Management of craniosynostosis has evolved over time with increasing availability of effective and safe treatments. During long-term follow-up, a small number of patients may develop premature closure of a different suture that did not undergo surgical manipulation. In our case, series, we identified 3 patients undergoing open surgery and 2 patients undergoing endoscopic surgery for nonsyndromic, single-suture craniosynostosis. This finding supports the necessity of long-term clinical follow-up and the utility of delayed imaging when clinical suspicion indicates.

Background: Genital tuberculosis (GTB) is one of the major causes for severe tubal disease leading to infertility. Unlike pulmonary tuberculosis (TB), the clinical diagnosis of GTB is difficult because in the majority of cases the disease is either asymptomatic or has varied clinical presentation. Routine laboratory tests are of little value in the diagnosis. The objective of this study was to compare the modalities of polymerase chain reaction (PCR) technique, acid fast bacilli (AFB) culture and AFB staining., Materials and Methods: The women visiting in vitro fertility center during December 2012 and May 2013 were included in this study. A total of 227 aseptically collected endometrial tissue samples were processed. AFB staining, AFB culture and PCR were carried out using standard procedures., Result: Out of 227 patients suspected of GTB, 133 were found to be positive either by AFB smear microscopy, culture or PCR. Out of 133 samples, two samples (1.5%) were found to be positive by all three methods, i.e. microscopy, culture and PCR, 11 (4.8%) were found to be positive by both PCR and culture, whereas 126 (86%) samples were found to be positive only by PCR. The PCR has failed to detect seven cases that were positive by conventional culture method., Conclusion: Our study showed that the conventional methods of diagnosis like microscopy and culture are less sensitive when compared with PCR. PCR also helped in early diagnosis of infection. However simultaneously, false negative results were an important limitation of this method. PCR negative samples were found to be positive by culture methods. Deoxyribose nucleic acid PCR is not reliable for TB due to false positive or negative result. Thus, we suggest both culture and PCR as important diagnostic methods for detection of GTB.

Background: Common variations in morphology of the medial crura have been described. The authors' observation is that changes in nasal tip projection depend on the shape and strength of the medial crura. The authors investigated how differences in medial crura shape affect tip projection after surgical intervention., Methods: Seventeen cadaver heads were dissected with an open rhinoplasty approach. Nasal tip projection and columellar length and width were measured. Medial crura shape was noted and classified. Anthropometric measurements were made preoperatively and after each of the following procedures: (1) elevation of skin envelope and closure of the columellar incision, (2) interdomal and medial crural sutures, and (3) placement and fixation of a floating columellar strut., Results: Three anatomical variations of the medial crura were noted: type 1, asymmetric parallel (n = 7); type 2, flared symmetric (n = 5); and type 3, straight symmetric (n = 5). A significant difference in tip projection after elevation of the skin envelope and closure was discovered between types 1 and 3 (p = 0.004). Type 2 medial crura were found to have a mean reduction of 1.0 mm. Suture techniques resulted in return to baseline tip projection for types 1 and 2. Columellar strut placement increased tip projection in all types., Conclusions: Changes in tip projection after an open rhinoplasty depend on the shape of the medial crura. Straight symmetric (type 3) cartilages can maintain tip projection without any additional intervention during an open rhinoplasty. Asymmetric parallel (type 1) or flared symmetric (type 2) variants will require interdomal and medial crural sutures to maintain baseline tip projection.

Background: The aim of this study was to study clinical profile with bacterial spectrum and susceptibility patterns of pathogens in culture positive febrile neutropenic (FN) patients of hematological malignancies., Materials and Methods: We retrospectively reviewed the medical records of 23 hematological malignancy patients admitted with chemotherapy induced febrile neutropenia with culture positive results, at our institute between June 2011 and December 2011., Results: A total of 23 patients were studied 12 males and 11 females, with a median age of 35 years. Most common diagnosis was acute leukemia (78%) with the majority of patients developing febrile neutropenia during the induction phase of treatment. Most common presenting symptoms were fever, cough, dyspnea, and diarrhea. Primary site of infection was not found in 47% of patients while the rest had lung, gastro-intestinal and skin/soft-tissue infection. Overall 23 organisms were isolated during the study period, from blood (56%), sputum (46%), stool (23%), and nasal swab from one patient. Gram negative bacteria accounted for 78% of organisms while gram positive organisms accounted for 22% of the total isolates. The most common organisms were: Escherichia coli (43%), Staphylococcus aureus (22%), Pseudomonas aeruginosa (17.4%) and Klebsiella pneumonia (17.4%). Antibiotic sensitivity patterns of these bacteria were studied. Gram negative bacterial infections were associated with higher mortality (89%)., Conclusions: Induction phase of treatment in acute leukemia is the major cause of FN in hematological malignancies at our institute and gram negative organisms are the predominant organisms with E. coli as major isolate while S. aureus represents the most common gram positive organism. Amikacin and cefoperazone/sulbactum appears to be initial antibiotic appropriate to cover most gram negative pathogens while vancomycin to be added for suspected gram positive infections. FN represents a major cause of morbidity and mortality in hematological malignancy patients, high index of suspicion and early empirical antibiotics with supportive care are main interventions to reduce high mortality for these patients. Antibiotics should be modified according to culture sensitive report as soon as possible.

In vitro assays are invaluable for the biochemical characterization of UDP-sugar:undecaprenyl-phosphate sugar-1-phosphate transferases. These assays typically involve the use of a radiolabeled substrate and subsequent extraction of the product, which resides in a lipid environment. Here, we describe the preparation of bacterial membranes containing these enzymes, a standard in vitro transferase assay with solvents containing chloroform and methanol, and two methods to measure product formation: scintillation counting and thin layer chromatography.

Vata is the governing factor in the maintenance of equilibrium in the universe as well as in the body. As age advances, the influence of Vata Dosha progresses, resulting in the process of gradual degeneration of the body. Sandhigatavata (osteoarthritis) is one of the consequences of this process, which is common in the elderly people. This is one of the major causes of chronic disability, affecting the quality of life. Prevalence of osteoarthritis in India is more among menopausal women. This study has been conducted to evaluate the efficacy of Ayurvedic multimodal management in Sandhigatavata and to provide better options to Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). In present clinical trial, 50 patients of Sandhigatavata have been registered and have been given Snehana, Svedana, Mriduvirechana, Matrabasti, and Jalaukavacharana, along with oral medications like Yogaraja Guggulu and Ashvagandha Churna. This multimodal therapy is being used in P.D. Patel Ayurved Hospital, Nadiad, since years, providing good relief to patients with Sandhigatavata. The results have been analyzed statistically by using the Student paired't' test. The therapy showed highly significant (P < 0.001) beneficial effect on the clinical features of Sandhigatavata. On overall effect of therapy, 4% of the patients were relieved completely, while 24% have shown marked improvement, 50% moderate improvement, and 22% mild improvement. Results of follow-up showed that marked improvement decreased, but moderate improvement was steady. Continuing the study on a larger number of patients, with inclusion of more objective parameters to get better conclusions is suggested at the end of the study.

Myelomeningocele is the most common neural tube defect. Repair typically involves deep closure with regional muscle flaps (e.g. latissimus dorsi, gluteus maximus) and skin closure with rotation, bipedicle, or rhomboid flaps. We describe the reconstruction of large myelomeningocele defects using (1) local fascial turnover flaps with or without paraspinous muscle flaps for deep coverage of the dural repair followed by (2) linear, midline skin closure., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)