Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India (IndSurg Collaboration)

Context

The COVID-19 pandemic and subsequent lockdowns adversely affected global healthcare services to varying extents. To accommodate its added burden, emergency services were affected along-with elective surgeries.

Aims

To quantify and analyze the trends of essential surgeries and bellwether procedures during the waxing and waning of the pandemic, across various hospitals in India.

Settings and Design

Multi-centric retrospective study.

Methods and Material

A research consortium led by World Health Organization (WHO) Collaboration Center (WHOCC) for Research in Surgical Care Delivery in Low-and Middle-Income countries, India, conducted this study with 5 centers. All surgeries performed during April 2020 (Wave I), November 2020 (Recovery I), and April 2021 (Wave II) were compared with those performed in April 2019 (pre-pandemic period).

Statistical Analysis Used

Microsoft Excel 2019 and SPSS Version 20.

Results

The total number of surgeries reduced by 77% during Wave I, which improved to a 52% reduction in Recovery I compared to the pre-pandemic period. However, surgeries were reduced again during Wave II to 68%, but the reduction was less compared to Wave I. Emergency and essential surgeries were affected along with the elective ones but to a lesser extent.

Conclusions

The present study has quantified the effects of the pandemic on surgical-care delivery across a timeline and documented a reduction in overall surgical volumes during the peaks of the pandemic (Wave I and II) with minimal improvement as the surge of COVID-19 cases declined (Recovery II). The surgical volumes improved during the second wave compared to the first one which may be attributable to better preparedness. Cesarean sections were affected the least.

Histopathologic and immunohistochemical findings of odontogenic jaw cysts treated by decompression technique

Context

Odontogenic cysts are among the most common lesions to affect the oral and maxillofacial region. Cysts are capable of causing significant bony disfigurement, tooth displacement and pathological fractures. Several surgical approaches exist for the management of larger cysts of the jaws. These include enucleation, marsupialization and decompression.

Aims

1. Analysis of histopathologic findings in odontogenic cysts before and after decompression2. Analysis of Ki-67 expression in odontogenic jaw cysts before and after decompression.

Settings and Design

Decompression technique was used for the treatment of 10 cases of odontogenic cysts in the study. Incisional biopsies of cystic lining (pretreatment) and corresponding excisional biopsies (posttreatment) were received for histopathologic and immunohistochemical examination.

Subjects and Methods

Hematoxylin and eosin stain was used for histopathologic findings, and Ki-67 was used for immunohistochemical findings using antibody Ki-67 in fresh tissue samples.

Results

Overall, radicular cysts, dentigerous cysts, and sialo-odontogenic cyst contained fewer Ki-67 ⁺ cells than odontogenic keratocysts. The average scores were found to be 2.2 and 1 for before and after decompression, respectively. A statistically significant difference was observed between the two groups. The two-tailed P value was found to be <0.0001. The confidence interval was found to be 95%.

Conclusions

The proliferative activity evaluated by Ki-67 marker was greater in predecompression epithelial lining compared to postdecompression. Our study infers that proliferative rate of the cystic epithelial lining is significantly diminished after decompression.

Williams–Beuren syndrome: a complete guide for oral healthcare

Introduction: Williams–Beuren syndrome is a rare, congenital, multisystem disorder, resulting from genetic alterations on chromosome 7q11.23. Characteristic features of WBS are the developmental, physical and mental abnormalities associated with it. Typical facial features and a spectrum of tooth disorders are associated with this condition. Cardiac and renal involvement may be so severe that sudden death during oral healthcare procedures is a possibility. Photophobia and hyperacusis further make dental treatment a challenge in these patients. Corpus: Routine dental treatment in the dental office pose a significant risk, depending upon the mental and physical compromise of the patient, thereby making hospital admission a safer approach. A multispeciality approach is necessary to provide effective and safe oral healthcare to such patients. This article provides undergraduates, residents, general dental practitioners, and specialists involved in oral healthcare with a comprehensive overview of the condition with emphasis on its genetic basis, pathology, clinical features, diagnosis, and management of general and oral health. Conclusion: Adequate knowledge regarding the various aspects of Williams–Beuren syndrome allows the oral health care student or specialist to plan and manage oral procedures safely and effectively. Specialist referral and multidisciplinary care may be considered when appropriate.

Dermatomyositis: what the oral healthcare provider must know

Dermatomyositis (DM) is an autoimmune condition characterized by skin rashes and progressive muscle weakness. It is classified under the idiopathic inflammatory myopathies (IIM) and can affect children as well as adults. A heightened incidence of malignancy in adults with DM has laid greater focus on its early diagnosis, treatment, and monitoring. In recent years, a greater understanding of the pathogenesis of the disease, its diagnostic criteria and management has improved the quality of life in affected individuals. The orofacial region presents with many manifestations of the disorder, sometimes even the initial presenting signs. This review presents an update on the disease process, its pathogenesis, diagnostic criteria, orofacial manifestations, medical management and dental considerations for patients with DM. The updated knowledge about DM is crucial for oral health care providers to plan and execute oral health care in a coordinated manner.

A rare case report of craniofacial fibrous dysplasia

Fibrous dysplasia (FD) is a fibro-osseous lesion of the osseous structures of the body. The exact cause is unknown; however, recently, the cause has been reported to be postzygomatic somatic mutation in guanine nucleotide-binding protein, alpha stimulating 1 gene located at chromosome 20q13.2. The three subtypes of FD are monostotic, polyostotic and craniofacial. The term craniofacial FD (CFD) is used to describe FD where the lesions are confined to contiguous bones of the craniofacial skeleton. This report describes the case of CFD of a 20-year-old male patient who had unusual presentation involving right maxilla and frontal bone of the left side of the face. The clinical features, radiological findings and treatment have been discussed.

Comparative evaluation of 2.0 mm locking plate system vs 2.0 mm non-locking plate system for mandibular angle fracture fixation: a prospective randomized study

OBJECTIVE

This prospective randomized study evaluated the efficacy of a 2.0 mm locking plate/screw system compared with a 2.0-mm nonlocking plate/screw system in fixation of 60 isolated non-comminuted mandibular angle fractures.

PATIENTS AND METHODS

Sixty patients were randomly assigned to receive a 2.0 mm locking plate (group A, n = 30) or 2.0 mm non-locking plate (group B, n = 30). All patients were followed up to 6 months postoperatively and evaluated for complications, occlusal stability and overall results of fixation.

RESULTS

Five complications occurred in the locking group and fourteen in the non-locking group with complication rates equalling 17% and 47% respectively. When comparing the overall results according to plates used, the χ² test showed a statistically significant difference between the locking and non-locking plates (p < 0.01). Fewer patients required IMF in group A.

CONCLUSIONS

Mandibular angle fractures treated with 2.0 mm locking plates show greater stability and were associated with fewer complications than with 2.0 mm non-locking plates.

Midline submental intubation might be the preferred alternative to oral and nasal intubation in elective oral and craniomaxillofacial surgery when indicated

PURPOSE

No consensus exists to date regarding the best method of controlling the airway for oral or craniomaxillofacial surgery when orotracheal and nasotracheal intubations are unsuccessful or contraindicated. The most commonly used method of tracheostomy has been associated with a high degree of morbidity. Therefore, the present study was conducted to determine the indications, safety, efficacy, time required, drawbacks, complications, and costs of the midline submental intubation (SMI) approach in elective oral and craniomaxillofacial surgical procedures.

MATERIALS AND METHODS

A retrospective case series study was used to evaluate the surgical, financial, and photographic records of all patients who had undergone oral or craniomaxillofacial operations at Sharda University School of Dental Sciences, Greater Noida, from April 2006 to March 2014. The indications, drawbacks, time required for the procedure, ability to provide a secure airway, intra- and postoperative complications, and additional costs associated with SMI were analyzed.

RESULTS

Of the 2,823 patients treated, the present study included 120 patients (97 men and 23 women, aged 19 to 60 years). The average time required for SMI was 10 ± 2 minutes. No episode of intraoperative oxygen desaturation was noted. One intraoperative complication, an injury to the ventral surface of the tongue, was encountered. Two patients developed infection at the skin incision site. No significant additional cost was incurred with the use of SMI.

CONCLUSIONS

SMI has been successfully used in elective oral and craniomaxillofacial surgical procedures for which oral and nasal intubations were either not indicated or not possible. The advantages include a quick procedure, insignificant complications, the ability to provide a stable airway, and no added costs, making SMI a quick, safe, efficient, and cost-effective alternative in such cases.

Topical review: the enigma of fibromyalgia

Fibromyalgia is a syndrome characterized by chronic widespread pain, stiffness, nonrestorative sleep, fatigue, and comorbid conditions. Recognition of the condition and its associated medications and challenges, along with knowledge of treatment modifications and precautions in drug prescription, can ensure safe and effective delivery of oral health care in fibromyalgia patients. The ever-evolving research into the condition makes it necessary for the oral health care provider to be informed about the current state of the literature and treatment standards regarding the management of fibromyalgia patients. This article reviews the epidemiology, etiology, pathophysiology, and clinical presentation of fibromyalgia, as well as therapeutic advances. Also highlighted are issues that are important to the oral health care provider, including orofacial manifestations and oral health care considerations for patients with fibromyalgia.

Inferior alveolar and mental nerve injuries associated with open reduction and internal fixation of mandibular fractures: a Seven Year retrospective study

PURPOSE

To document adverse neurosensory changes in the inferior alveolar nerve (IAN) and mental nerve (MN) after surgical mandibular fracture treatment and to identify risk factors associated with these changes.

MATERIALS AND METHODS

A retrospective study of patients surgically treated for mandibular fractures. The primary study variable was the postoperative change in IAN/MN neurosensory examination after fracture fixation. Risk factors were categorized as demographic, anatomic, experience of the operator, fracture displacement and number of miniplates placed at each fracture site. Appropriate statistics were computed.

RESULTS

209 patients with 293 fractures were analysed. One hundred twenty fractures (41%) were located between the lingula and mental foramen, and 173 fractures (59%) were located distal to the mental foramen. Two hundred seventeen (41%) were displaced by 5 mm or more. In 38 fractures (13%), the IAN/MN neurosensory status worsened after treatment. In a multivariate model, fracture displacement, operator inexperience and two plate fixation were associated with a statistically significant risk (P ≤ 0.05) for postoperative deterioration of IAN/MN sensation.

CONCLUSION

Fixation with two miniplates, fracture displacement of 5 mm or more and operator inexperience were associated with an increased risk for deterioration of the IAN/MN neurosensory status after treatment of mandibular fractures.

Facial dog attack injuries

The exposed position of the face makes it vulnerable to dog bite injuries. This fact combined with the short stature of children makes them a high-risk group for such attacks. In contrast to wounds inflicted by assaults and accidents, dog bite wounds are deep puncture type wounds compounded by the presence of pathologic bacteria from the saliva of the attacking dog. This, combined with the presence of crushed, devitalized tissue makes these wounds highly susceptible to infection. Key to successful management of such wounds are meticulous cleansing of the wound, careful debridement, primary repair, appropriate antibiotic therapy, and rabies and tetanus immunization where indicated. This review presents an overview of the epidemiology, presentation, management of such emergencies, and the recent advances in the care of such patients.

Prolonged peripheral nerve blockade in patients using lithium carbonate

Peripheral nerve blocks with local anaesthesia are routinely utilized in oral surgical procedures to achieve anaesthesia at the operative site. A number of local tissue factors as well as systemic conditions and medications may alter the onset, depth and duration of peripheral nerve blocks. This article describes two cases of extremely prolonged anaesthesia in patients treated with chronic oral lithium carbonate who had been administered inferior alveolar, lingual, long buccal, greater palatine and posterior superior alveolar nerve blocks with lidocaine with adrenaline for surgical removal of an upper and a lower third molar tooth. A possible relation with systemic lithium therapy and its probable mode of action are explored.

Malignant hyperthermia in the oral and maxillofacial surgery patient: an update

Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle that presents as a hypermetabolic response to potent volatile anesthetic gases, such as halothane, sevoflurane, desflurane, the depolarizing muscle relaxant succinylcholine, and, rarely in humans, to stresses, such as vigorous exercise and heat. The syndrome is likely to be fatal if untreated. Early recognition of the signs of MH provides the clinical diagnostic clues. Diagnostic testing relies on assessing the in vitro contracture response of biopsied muscle to halothane, caffeine, and other drugs. Dantrolene sodium is a specific antagonist of the pathophysiologic changes of MH and should be available wherever general anesthesia is administered. The prevention and treatment of acute episodes of this disorder is of paramount importance to the oral and maxillofacial surgeon. The management of such patients in the oral and maxillofacial surgery setting and the recent advances in the field of MH are presented.

Seminal LDH-C4 isoenzyme and sperm mitochondrial activity: a study in male partners of infertile couples

Lactate dehydrogenase isoenzyme patterns were obtained in the seman of 93 male partners of infertile couples and 28 proven fertile subjects as a control group. Sperm mitochondrial activity index (SMAI) alongwith the conventional seminal parameters was studied for all the subjects excepting the azoospermic and vasectomised males. Only LDH-C4, a germ cell specific isoenzyme activity varied with the variation in sperm density. LDH-C4 activity varied significantly (p<0.001) within and between different groups. Lactate dehydrogenase-C4 activity was absent in 17 azoospermic samples, confirming its germinal epithelial origin, as well as in 8 samples of vasectomised males. In one azoospermic sample, there were many immature germ cells along with surprisingly high LDH-C4 activity suggesting more activity of germinal epithelium associated with high LDH-C4 activity. LDH-C4 activity was reduced significantly in oligozoospermic samples in proportion to sperm density, thus confirming strong correlation (p<0.001) between LDH-C4 and sperm density. There was statistically significant correlation between LDH-C4 and percentage sperm motility as well as between LDH-C4 and Sperm Mitochondrial Activity Index (SMAI) (probability varying from p<0.05 to p<0.01 in different groups), but no such correlation was found between LDH-C4 and sperm morphology. The data confirms LDH-C4 as a germinal epithelial marker. Its relationship with percentage sperm motility is suggestive of definite role of LDH-C4 in evaluation of the spermatozoal quality, similarly its relationship with Sperm Mitochondrial Activity Index (SMAI score) suggest the role of LDH-C4 in metabolism of the spermatocytes and sperms, though further studies are required for clear and detailed understanding of its metabolic role in semen.

Clinical audit: can we improve further?

Clinical audit is an important tool for comparing one's practice against existing standards. The authors have analysed the Junior Doctor's understanding of audit by performing a survey and questionnaire from 146 trainees, SpRs and SHOs from nine hospitals. The study showed that 107 (72.8%) performed audit and among those who performed audit, 52 (48.6%) experienced difficulty in obtaining data. This study highlights the importance of support needed to encourage the junior doctors to participate in audit programmes.