A challenging case of carbapenem resistant Klebsiella pneumoniae-related pyogenic liver abscess with capsular polysaccharide hyperproduction: a case report

BACKGROUND

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections are a major public health problem, necessitating the administration of polymyxin E (colistin) as a last-line antibiotic. Meanwhile, the mortality rate associated with colistin-resistant K. pneumoniae infections is seriously increasing. On the other hand, importance of administration of carbapenems in promoting colistin resistance in K. pneumoniae is unknown.

CASE PRESENTATION

We report a case of K. pneumoniae-related pyogenic liver abscess in which susceptible K. pneumoniae transformed into carbapenem- and colistin-resistant K. pneumoniae during treatment with imipenem. The case of pyogenic liver abscess was a 50-year-old man with diabetes and liver transplant who was admitted to Abu Ali Sina Hospital in Shiraz. The K. pneumoniae isolate responsible for community-acquired pyogenic liver abscess was isolated and identified. The K. pneumoniae isolate was sensitive to all tested antibiotics except ampicillin in the antimicrobial susceptibility test and was identified as a non-K1/K2 classical K. pneumoniae (cKp) strain. Multilocus sequence typing (MLST) identified the isolate as sequence type 54 (ST54). Based on the patient's request, he was discharged to continue treatment at another center. After two months, he was readmitted due to fever and progressive constitutional symptoms. During treatment with imipenem, the strain acquired blaOXA-48 and showed resistance to carbapenems and was identified as a multidrug resistant (MDR) strain. The minimum inhibitory concentration (MIC) test for colistin was performed by broth microdilution method and the strain was sensitive to colistin (MIC < 2 µg/mL). Meanwhile, on blood agar, the colonies had a sticky consistency and adhered to the culture medium (sticky mucoviscous colonies). Quantitative real-time PCR and biofilm formation assay revealed that the CRKP strain increased capsule wzi gene expression and produced slime in response to imipenem. Finally, K. pneumoniae-related pyogenic liver abscess with resistance to a wide range of antibiotics, including the last-line antibiotics colistin and tigecycline, led to sepsis and death.

CONCLUSIONS

Based on this information, can we have a theoretical hypothesis that imipenem is a promoter of resistance to carbapenems and colistin in K. pneumoniae? This needs more attention.

The surgery-first approach for orthognathic correction of maxillary deficiency-is it stable? Three-dimensional assessment of CBCT scans and digital dental models

The aim of this study was to determine the skeletal stability of Le Fort I maxillary advancement following the surgery-first approach, by three-dimensional (3D) assessment of cone beam computed tomography (CBCT) scans and digital dental models. CBCT scans of 25 class III patients obtained 1 week preoperatively (T0) and 1 week (T1) and 6 months (T2) postoperatively were superimposed to measure surgical movements (T0-T1) and skeletal relapse (T1-T2). The distorted dentition of the CBCT scans at T1 was replaced with 3D images of the dental models to assess the postoperative occlusion. Surgical movements of the maxilla (mean ± standard deviation values) were 6.79 ± 2.30 mm advancement, 1.28 ± 1.09 mm vertically, and 0.71 ± 0.79 mm mediolaterally. Horizontal rotation (yaw) was 1.56° ± 1.21°, vertical rotation (pitch) 1.86° ± 1.88°, and tilting (roll) 1.63° ± 1.54°. At T2, the posterior relapse was 0.72 ± 0.43 mm (P = 0.001) and relapse in pitch was 1.56° ± 1.42° (P = 0.007). There was no correlation between the size of the surgical movements and the amount of relapse. A weak correlation was noted between the number of teeth in occlusal contact immediately following surgery and relapse of maxillary roll (r = - 0.434, P = 0.030). The stability of maxillary advancement with the surgery-first approach was satisfactory and was not correlated with the quality of the immediate postoperative occlusion.

Outcome measures of the surgery first approach for orthognathic correction of dentofacial deformities

In the surgery-first approach (SFA), orthognathic surgery is performed without the need for presurgical orthodontic treatment. This study was aimed at assessing the treatment durations and occlusal outcomes for a consecutive cohort of patients, with a range of dentofacial deformities, who had completed orthognathic treatment using SFA. The duration of orthognathic treatment was measured. The overall change in occlusion, and the quality of the final occlusion, were evaluated using the patients' study casts. A single, independent, calibrated operator carried out the occlusal scores, using the validated Peer Assessment Rating (PAR) index. This was repeated to test intraoperator reliability. A total of 51 patients completed surgery-first treatment during the study period. The mean (range) age at surgery was 23.3 (15-47) years. The pre-treatment skeletal jaw relationship was Class III in 39 cases, and Class II in 12 cases. The mean (SD) overall treatment duration was 11.7 (5.7) months. The intraexaminer reliability of assessing the occlusion was high. The PAR scores confirmed a significant improvement in the quality of occlusion at the completion of treatment, which compares favourably with previous studies on the conventional orthodontics-first approach. The surgery first approach can be effective at correcting both Class II and Class III malocclusion types with reduced treatment times.

Hospitalization and hospital mortality rates during the first and second waves of the COVID-19 pandemic in Quebec: interrupted time series and decomposition analysis

OBJECTIVES

We investigated hospitalization and hospital mortality rates by cause during the first year of the COVID-19 pandemic in Quebec, Canada.

STUDY DESIGN

Interrupted time series and decomposition analysis.

METHODS

We analyzed hospital mortality during the first (February 25-August 22, 2020) and second waves (August 23, 2020-March 31, 2021), compared with 2019. We identified the cause of death and examined trends using: 1) interrupted time series analysis; 2) log-binomial regression; and 3) decomposition of cause-specific mortality.

RESULTS

Hospitalization rates decreased; however, the proportion of deaths increased from 27.0 per 1000 in 2019 to 35.0 per 1000 in the first wave, for an excess of 8.0 deaths per 1000 admissions. COVID-19 was the cause of a third of excess deaths (2.6 per 1000). Other drivers of excess deaths included respiratory conditions (1.6 deaths per 1000), circulatory disorders (0.6 deaths per 1000), and cancer (0.9 deaths per 1000). COVID-19 was the cause of 58% of excess deaths in the second wave. Interrupted time series regression indicated that the proportion of deaths increased at the outset of the first wave but returned to prepandemic levels before increasing again in the second wave. Compared with 2019, the first wave was associated with 1.31 times (95% confidence interval [CI] 1.28-1.33) and the second wave with 1.17 times (95% CI 1.15-1.19) the risk of death during hospitalization.

CONCLUSIONS

The pandemic was associated with a greater risk of hospital mortality. Excess deaths were driven by COVID-19 but also other causes, including respiratory conditions, circulatory disorders, and cancer.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Reproducibility and reliability of digital occlusal planning for orthognathic surgery

The digital articulation of dental models is gradually replacing the conventional physical approach for occlusal prediction planning. This study was performed to compare the accuracy and reproducibility of free-hand articulation of two groups of digital and physical dental models, 12 Class I (group 1) and 12 Class III (group 2). The models were scanned using an intraoral scanner. The physical and digital models were independently articulated 2 weeks apart by three orthodontists to achieve the maximum inter-digitation, with coincident midlines and a positive overjet and overbite. The occlusal contacts provided by the software color-coded maps were assessed and the differences in the pitch, roll, and yaw were measured. The reproducibility of the achieved occlusion of both the physical and digital articulation was excellent. The z-axis displayed the smallest absolute mean differences of 0.10 ± 0.08 mm and 0.27 ± 0.24 mm in the repeated physical and repeated digital articulations, respectively, both in group 2. The largest discrepancies between the two methods of articulation were in the y-axis (0.76 ± 0.60 mm, P = 0.010) and in roll (1.83° ± 1.72°, P = 0.005). The overall measured differences were< 0.8 mm and< 2°. Despite the steep learning curve, digital occlusal planning is accurate enough for clinical applications.

Sclerosing angiomatoid nodular transformation of the spleen in a child with anemia: a case report and review of the literature

BACKGROUND

Sclerosing angiomatoid nodular transformation of the spleen is a relatively rare benign vascular lesion in both adult and pediatric age groups with unclear etiopathogenesis and variable clinical presentations. Many benign and also malignant splenic masses could mimic sclerosing angiomatoid nodular transformation, both clinically and radiologically. Herein, we report our experience with a case of sclerosing angiomatoid nodular transformation in a 3-year-old girl.

CASE REPORT

A 3-year-old Iranian girl presented with abdominal pain, back pain, and constipation for 2 weeks. She was being followed up by a pediatrician due to her short stature and persistent anemia. Physical examination showed stable vital signs, short stature, pallor, and a puffy face. Laboratory evaluation showed normochromic normocytic anemia with a normal reticulocyte count, ferritin, and hemoglobin electrophoresis. Radiologic assessments revealed a hypoechoic lesion in the spleen with high vascularity, clinically suspected to be lymphoma. She was operated on, and after partial splenectomy, pathologic evaluation of the spleen showed a solitary, well-demarcated, and unencapsulated dark mass. Microscopic examination revealed micronodular appearance composed of irregular-shaped vascular spaces lined by plump endothelial cells and surrounded by concentric collagen fibers, features in keeping with sclerosing angiomatoid nodular transformation. The patient's anemia was resolved after surgery, and no clinical or radiologic deficits were noted during the 10-month follow-up visits.

CONCLUSION

Although sclerosing angiomatoid nodular transformation is exceedingly rare in children, it should be considered a differential diagnosis in pediatric splenic neoplasms with concurrent hematologic manifestations, such as anemia.

Emergence of K1 ST23 and K2 ST65 hypervirulent klebsiella pneumoniae as true pathogens with specific virulence genes in cryptogenic pyogenic liver abscesses Shiraz Iran

Hypervirulent Klebsiella pneumoniae (hvKp) pathotype is emerging worldwide in pyogenic liver abscesses (PLAs). However, the role of virulence factors in pathogenicity remains unclear. On the other hand, the epidemiology of PLAs in Iran is unknown. From July 2020 to April 2022, bacterial species were isolated and identified from the drainage samples of 54 patients with PLAs. K. pneumoniae as the most common pathogen of pyogenic liver abscesses was identified in 20 (37%) of the 54 patients. We analyzed the clinical and microbiological characteristics of K. pneumoniae-related pyogenic liver abscesses. Antibiotic susceptibility testes and string test were performed. 16S rRNA, antibiotic resistance, and virulence genes were determined by polymerase chain reaction amplification. Clonal relatedness of isolates was identified by multilocus sequence typing. Virulence levels were assessed in the Galleria mellonella larval infection model. Four hvKp isolates (K1/K2) were found to be responsible for cryptogenic PLAs, and 16 classical K. pneumoniae isolates (non-K1/K2) were associated with non-cryptogenic PLAs. Three capsular serotype K1 strains belonged to sequence type 23 (ST23) and one K2 strain to ST65. Meanwhile, the non-K1/K2 strains belonged to other STs. ST231 was the most common strain among the classical K. pneumoniae strains. Compared with the non-K1/K2 strains, capsular serotypes K1/K2 strains were less resistant to antibiotics, had positive string test results, and had more virulence genes. In Galleria mellonella, a concentration of 10⁶ colony-forming units of the K1 hvKp strain resulted in 100% death at 24 hours, confirming the higher virulence of the hvKp strain compared with cKp. K. pneumoniae isolates represented that the acquisition of any plasmid or chromosomal virulence genes contributes to pathogenicity and high prevalence in PLAs. Meanwhile, hvKp isolates with a specific genetic background were detected in cryptogenic PLAs.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Exploring the performances of the vibrating barriers for the seismic protection of the Zoser pyramid

In this paper we aim to investigate the use of the Vibrating Barrier (ViBa) as a potential strategy to mitigate the effects of the seismic action on the Zoser Pyramid. The Vibrating Barrier is a structure buried in the soil that is able to absorb a significant portion of the dynamic energy arising from the ground motion. The working principle exploits the dynamic interaction among vibrating structures resting on a compliant semi-infinite space, namely the structure–soil–structure interaction. A reliable numerical simulation of the Zoser Pyramid and the surrounding soil undergoing stochastic ground motion excitations representing the seismicity in Saqqara is presented. Due to the unique structural form, the ViBa is herein optimized through an ad-hoc procedure to minimize a response strain energy spectral density used as a synthetic performance parameter. Various layouts of the ViBa have been considered and presented in the paper. The efficiency of the ViBa is assessed by numerical simulation of the finite element model of the ViBa-Soil-Pyramid system and by laboratory testing. Results from a pertinent Monte Carlo study show an evident reduction of the stresses in the Pyramid manifesting the feasibility of this novel strategy to protect historic structures from earthquake-induced ground motion. Experimental results on a 1:500 gelatine model of the pyramid and the surrounding area highlighted the efficiency and efficacy of the proposed approach.

Multifocal EBV-associated smooth muscle tumors in a patient with cytomegalovirus infection after liver transplantation: a case report from Shiraz, Iran

Introduction

Immunodeficient patients, including the recipients of solid organs, exhibit an increase in the incidence of neoplasms. Post-transplant smooth muscle tumor (PTSMT) is a distinct and infrequent entity of these groups of neoplasms. Epstein–Barr virus (EBV) is considered to be involved in the etiology of this neoplasm.

Case report

A 28-year-old man who underwent liver transplantation presented with abdominal pain and diarrhea for several months. He had a history of resistant systemic cytomegalovirus (CMV) infection after transplantation. Radiologic evaluation and colonoscopy revealed multiple liver, spleen, lung, and colon lesions. Microscopic assessment of colon and liver lesions using IHC study were in favor of spindle cell proliferation with mild atypia and a mild increase in mitotic rate without any necrosis, with features of smooth muscle tumor. Considering the transplantation history, EBER chromogenic in situ hybridization (CISH) study on paraffin blocks was requested, which demonstrated EBV RNA in tumor cell nuclei, suggesting EBV-associated smooth muscle tumor. In addition, PCR for CMV on paraffin blocks was positive. PCR for EBV and CMV viremia were negative. The dosage of immunosuppressive agents was reduced, and currently, he is being followed, with slow expansion in the size of the lesions.

Conclusion

Although the incidence of post-transplant smooth muscle tumors (PTSMTs) is low, it should be remained in the differential diagnosis in post-transplantation patients, especially dealing with multifocal tumors. As strong stimulant for smooth muscle tumors, close follow-up and screening for EBV and CMV infection and early treatment at the time of diagnosis are recommended to avoid these virus-induced tumors.

The current state of PEEK implant osseointegration and future perspectives: a systematic review

Polyetheretherketone (PEEK) has been considered as an alternative to replace surgical metal implants. Several medical applications, including dental and orthopaedic implants, need confirmed osseointegration before functional loading. The present study aims at providing a comprehensive systematic review of the evidence on PEEK implants' osseointegration. A systematic search was conducted using Cochrane library, MEDLINE (PubMed), Ovid MEDLINE, Web of Science and EMBASE databases. Publications were identified in accordance with specific inclusion and exclusion criteria. Eligibility screening, data extraction and quality assessment were performed. The review protocol was registered in PROSPERO (CRD42018116061). A total of 55 articles were reviewed and 29 of the most relevant that met the inclusion criteria were selected. Heterogeneity was identified among the included studies. Several approaches have been applied to enhance PEEK osseointegration, with most in vivo studies conducted on small-scale animal models but no study evaluating the osseointegration of PEEK under cyclic loading. However, PEEK modifications are demonstrated to enhance osseointegration preclinically. Collectively, the present review shows a shortage of evidence, including a lack of comprehensive assessment of osseointegration, the need for large-animal-model tests, the need to assess the effect of loading on the implants and the lack of randomised controlled clinical trials.

Prenatal Substance Use Disorders and Dental Caries in Children

Substance use is common in women of reproductive age, but limited data exist on the dental health of their children, including risk of caries. We conducted a longitudinal cohort study of 790,758 infants born between 2006 and 2016 in Quebec, Canada. We identified women with substance use disorders before or during pregnancy. The main outcome measure was hospitalization for dental caries in offspring up to 12 y after birth. We estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for the association of maternal substance use with pediatric dental caries, adjusted for potential confounders. Children exposed to maternal substance use had a higher incidence of hospitalization for dental caries than unexposed children (105.2 vs. 27.0 per 10,000 person-years). Maternal substance use was associated with 1.96 times the risk of childhood dental caries (95% CI, 1.80-2.14), including a greater risk of caries of enamel, dentin, or cementum (HR, 2.00; 95% CI, 1.82-2.19) and dental pulp (HR, 2.36; 95% CI, 2.07-2.70), relative to no substance use. Associations were elevated for alcohol (HR, 2.31; 95% CI, 2.03-2.64) but were also present for cocaine, cannabis, opioids, and other substances. Substance use during pregnancy was more strongly associated with dental caries hospitalization than prepregnancy substance use. Associations were stronger in early childhood. Maternal substance use is associated with the future risk of dental caries hospitalization in children. Targeting substance use early in the lives of women may contribute to dental caries prevention in offspring.

The role of ultrasonography in detecting urinary tract calculi compared to CT scan

Objective

To evaluate the accuracy of ultrasonography (US) in measuring the urinary tract stone using non-contrast computed tomography (NCCT) as the standard reference.

Patients and methods

A total of 184 patients suspected with urolithiasis who had undergone NCCT and US radiologic investigation from 2015 to 2017 were enrolled in this study. The sensitivity, specificity, and stone size measured in US were validated by NCCT. Data of the stone size in US were classified into four groups (0–3.5, 3.6–5, 5.1–10, >10 mm) and then compared with NCCT data.

Results

In 184 patients, NCCT detected 276 (97.2%) stones, while US could identify 213 (75.5%) stones. Overall sensitivity and specificity of US were 75.4% and 16.7%, respectively. Detection rate of mid and distal ureteral stone was lower than that at other locations. The detection rate increased with the stone size. About 73% concordance was obtained for the stone size measured by US and NCCT (Pearson’s correlation coefficient was 0.841). Factors such as the stone size, amount of hydronephrosis, and weight affected the detection rate of the urinary tract stone using US (P<0.001, P=0.02, and P=0.01, respectively).

Conclusion

The stone size obtained by US was almost the same as that detected by NCCT; however, US is a limited imaging modality in detecting urinary tract stone, especially when used by an inexperienced radiologist, and in the case of smaller stone size, increased weight, and low grade of hydronephrosis.

The effect of facial expression on facial symmetry in surgically managed unilateral cleft lip and palate patients (UCLP)

AIM

To evaluate the symmetry of facial expression in surgically managed UCLP patients.

MATERIALS AND METHODS

The study was conducted on 13 four-year-old children. Facial images were captured at rest and at maximum smile using stereophotogrammetry. A generic mesh, which is a mathematical facial mask consisting of a fixed number of indexed vertices, was utilised for the assessment of facial asymmetry. This was quantified by measuring the disparity between the left- and right-hand sides of the face after superimposing the original 3D images on their mirror copies.

RESULTS

Residual asymmetries at rest were identified at the vermillion of the upper lip and at the nares with a deviation of the philtrum towards the scar tissue. Vertical and anteroposterior asymmetries were identified on the cleft side. At maximum smile, the asymmetry increased noticeably at the vermillion of the upper lip and at the alar base. In the mediolateral direction, the philtrum deviated towards the cleft side with a significant increase of the asymmetry scores.

DISCUSSION

Asymmetry of the upper lip has significantly increased at maximum smile as a result of the upward forces of all perioral lifting muscles, which affected the lip directly.

CONCLUSIONS

The innovation of this study is the measurement of facial asymmetry for the objective outcome measure of the surgical repair of UCLP. The philtrum was the main site of residual asymmetry, which indicates the need for refining the primary repair of the cleft lip. Further corrective surgery may be required.

Assessing the outcome of orthognathic surgery by three-dimensional soft tissue analysis

Studies of orthognathic surgery often focus on pre-surgical versus post-surgical changes in facial shape. In contrast, this study provides an innovative comparison between post-surgical and control shape. Forty orthognathic surgery patients were included, who underwent three different types of surgical correction: Le Fort I maxillary advancement, bilateral sagittal split mandibular advancement, and bimaxillary advancement surgery. Control facial images were captured from volunteers from local communities in Glasgow, with patterns of age, sex, and ethnic background that matched those of the surgical patients. Facial models were fitted and Procrustes registration and principal components analysis used to allow quantitative analysis, including the comparison of group mean shape and mean asymmetry. The primary characteristic of the difference in shape was found to be residual mandibular prognathism in the group of female patients who underwent Le Fort I maxillary advancement. Individual cases were assessed against this type of shape difference, using a quantitative scale to aid clinical audit. Analysis of the combined surgical groups provided strong evidence that surgery reduces asymmetry in some parts of the face such as the upper lip region. No evidence was found that mean asymmetry in post-surgical patients is greater than that in controls.

Assessment of facial asymmetry before and after the surgical repair of cleft lip in unilateral cleft lip and palate cases

This study was performed to assess facial asymmetry in patients with unilateral cleft lip and palate (UCLP) before and after primary lip repair. Three-dimensional facial images of 30 UCLP cases (mean age 3.7±0.8months) captured 1-2days before surgery and 4 months after surgery using stereophotogrammetry were analysed. A generic mesh - a mathematical facial mask consisting of thousands of points (vertices) - was conformed on the three-dimensional images. Average preoperative and postoperative conformed facial meshes were obtained and mirrored by reflecting on the lateral plane. Facial asymmetry was assessed by measuring the distances between the corresponding vertices of the superimposed facial meshes. Asymmetries were further examined in three directions: horizontal, vertical, and anteroposterior. Preoperatively, the philtrum and bridge of the nose were deviated towards the non-cleft side. The maximum vertical asymmetry was at the upper lip. The greatest anteroposterior asymmetry was at the alar base and in the paranasal area. The overall facial asymmetry improved markedly after surgery. Residual anteroposterior asymmetry was noted at the alar base, upper lip, and cheek on the cleft slide. In conclusion, dense correspondence analysis provided an insight into the anatomical reasons for the residual dysmorphology following the surgical repair of cleft lip for future surgical consideration.

The accuracy of three-dimensional prediction of soft tissue changes following the surgical correction of facial asymmetry: An innovative concept

The accuracy of three-dimensional (3D) predictions of soft tissue changes in the surgical correction of facial asymmetry was evaluated in this study. Preoperative (T1) and 6-12-month postoperative (T2) cone beam computed tomography scans of 13 patients were studied. All patients underwent surgical correction of facial asymmetry as part of a multidisciplinary treatment protocol. The magnitude of the surgical movement was measured; virtual surgery was performed on the preoperative scans using Maxilim software. The predicted soft tissue changes were compared to the actual postoperative appearance (T2). Mean (signed) distances and mean (absolute) distances between the predicted and actual 3D surface meshes for each region were calculated. The one-sample t-test was applied to test the alternative hypothesis that the mean absolute distances had a value of <2.0mm. A novel directional analysis was applied to analyse the accuracy of the prediction of soft tissue changes. The results showed that the distances between the predicted and actual postoperative soft tissue changes were less than 2.0mm in all regions. The predicted facial morphology was narrower than the actual surgical changes in the cheek regions. 3D soft tissue prediction using Maxilim software in patients undergoing the correction of facial asymmetry is clinically acceptable.

Neurosensory deficit following mandibular sagittal split osteotomy: A comparative study between positional screws and miniplates fixation

This retrospective study compared the incidence of long-term inferior alveolar nerve injury for positional screws and miniplate fixation of bilateral sagittal split osteotomies carried out in 2 hospitals in Scotland. The study involved a mixture of mandibular setback and advancement surgery. The outcome of neurosensory deficit (NSD) was solely based on subjective assessment by the surgeons and patients' reported alteration in sensation. Numbness, tingling and any alterations in sensation beyond 6 months were considered long-term inferior alveolar nerve injury. This study was conducted on 28 sagittal split osteotomies (group 1) which were fixed with three upper border fixation screws and 36 sagittal split osteotomies (group 2) which were fixed with upper border sliding plate. The reported and documented neurosensory deficits were analysed. The difference in the number of cases of long-term inferior alveolar nerve injury between the 2 methods was 10.3%; the 95% confidence interval for the difference was [-2.94 to 23.5], p = 0.1612. Upper border plate was associated with more long-term NSD but there is insufficient evidence to prove that one method was more superior to the other. The need for a prospective randomized trial was highlighted.

State-of-the-art three-dimensional analysis of soft tissue changes following Le Fort I maxillary advancement

We describe the comprehensive 3-dimensional analysis of facial changes after Le Fort I osteotomy and introduce a new tool for anthropometric analysis of the face. We studied the cone-beam computed tomograms of 33 patients taken one month before and 6-12 months after Le Fort I maxillary advancement with or without posterior vertical impaction. Use of a generic facial mesh for dense correspondence analysis of changes in the soft tissue showed a mean (SD) anteroposterior advancement of the maxilla of 5.9 (1.7) mm, and mean (SD) minimal anterior and posterior vertical maxillary impaction of 0.1 (1.7) mm and 0.6 (1.45) mm, respectively. It also showed distinctive forward and marked lateral expansion around the upper lip and nose, and pronounced upward movement of the alar curvature and columella. The nose was widened and the nostrils advanced. There was minimal forward change at the base of the nose (subnasale and alar base) but a noticeable upward movement at the nasal tip. Changes at the cheeks were minimal. Analysis showed widening of the midface and upper lip which, to our knowledge, has not been reported before. The nostrils were compressed and widened, and the lower lip shortened. Changes at the chin and lower lip were secondary to the limited maxillary impaction.

Efficacy of three-dimensional visualization in mobile apps for patient education regarding orthognathic surgery

'Sur-face' is an interactive mobile app illustrating different orthognathic surgeries and their potential complications. This study aimed to evaluate the efficacy of Sur-face by comparing two methods of delivering patient information on orthognathic surgeries and their related potential complications: a mobile app with interactive three-dimensional (3D) animations and a voice recording containing verbal instructions only. For each method, the participants' acquired knowledge was assessed using a custom-designed questionnaire. Participants in the 'app' group performed significantly better (P<0.0034) than those in the 'voice' group and retained more knowledge, suggesting that interactive visualizations play a key role in improving understanding of the orthognathic surgical procedure and its associated complications. This study emphasizes the impact of 3D visualizations in delivering information regarding orthognathic surgery and highlights the advantage of delivering validated patient information through mobile apps.

[Landmark-based statistical procrustes analysis in the examination of breast shape and symmetry]

AIM

The aim of this presentation is the explanation of a mathematical analysis of a landmark-based procrustes calculation. The various components of breast symmetry and their impact on breast reconstruction have been examined.

METHOD

In an objective breast shape analysis asymmetries are quantified as a measure of the difference between a 3D landmark configuration of a breast and its mirror image. 10 landmarks, 4 on each side and 2 for a definition of the midline were defined. For each landmark the 3D coordinates were calculated statistically with the help of the software Programme R. Over a midline from the jugulum to the manubrium sterni, a mirror image of the breast was constructed. The data for the breast to be reconstructed and the non-operated breast from 44 patients were investigated. The statistical differences of the Procrustes analysis were used for an asymmetry score and the proportions of the individual components were calculated. These included size, location and orientation of the breast as well as the individual inherent morphological surface form data of the breast.

RESULTS

All 44 patients exhibited breast asymmetries and the mean asymmetry score amounted to 0.52. A calculation of the proportions of the individual components making up the asymmetry score revealed that morphological surface data made the largest contribution to the asymmetry score, closely followed by location, i. e., positioning of the breast on the thoracic wall. In contrast, the size of the breast and its orientation were of lesser relevance.

CONCLUSION

When considering breast symmetry in plastic surgery, the form plays a more important role than the size as objectively calculated by the statistical procrustes analysis. Almost equally important as the form is the positioning of the breast on the thoracic wall which contributes significantly more to total breast symmetry than axial displacements.

[Obstructive sleep apnea syndrome in the elderly]

Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a common disease in the general population. However, original works on the SAHS in the elderly are few and their results are discordant. Studies show an increased prevalence of OSAHS with age, and despite this high prevalence, it remains under-diagnosed due to lack of knowledge of geriatric features of this disease and the frequency of comorbidities that may worsen as a result of nocturnal breathing problems but can also mask the symptoms necessary for positive diagnosis. The functional symptoms are dominated by neurological signs such as daytime hypersomnia and cognitive impairment often reported by those around the patient. The treatment is based mainly on continuous positive airway pressure which tolerance in elderly patients suffering from sleep apnea is similar to that of younger patients. Mandibular implants can be discussed depending on the severity of the condition. Surgical treatment is not indicated because of the increased frequency of complications.

[Determinants of quality of life in chronic obstructive pulmonary disease]

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is considered as a systemic disease with pulmonary starting point. The use of spirometry alone is certainly not the best way to reflect the impact of disease on quality of life for patients.

PATIENTS AND METHODS

Prospective study concerning 70 patients treated for COPD. Quality of life was assessed using the French version of the Saint-George questionnaire.

RESULTS

Our population was predominantly male (97%) with a mean age of 63 years. All patients were smokers with an average of 46 pack-years. The total score of the Saint-Georges respiratory questionnaire was 50.7%. The mean scores of different fields were 68% for the field activities, 49% for impact and 26% for the item of symptoms. The multidimensional BODE index was correlated with the quality of life and its various fields were more powerfully than the forced expiratory volume per second, the number of exacerbations, the six-minute walking test and dyspnea score.

CONCLUSION

It is important to integrate the multidimensional classification indices in assessing the severity of the disease because only these indices can reflect the systemic aspect of the disease.

[Pseudotumor phenotype of sarcoidosis: about two cases]

INTRODUCTION

Sarcoidosis is a multisystem benign granulomatous disease of unknown etiology. It can sometimes cause diagnostic confusion by presenting in the form of a pseudotumor, thus constituting a trap for the unwary.

COMMENTS

The authors report two cases of pseudotumor sarcoidosis. In the first, the pseudotumor occurred in the context of multisystem disease in a 48-year-old man. The response to treatment with systemic corticosteroids was complicated by the development of disseminated tuberculosis, which was rapidly fatal. The second case, by contrast, was about a 58-year-old woman and the disease was self-limiting, resolving spontaneously in less than 3 months.

CONCLUSION

Through these two cases, the authors focus on the particularities of the pseudotumor manifestation of pulmonary sarcoidosis. The diagnosis is often difficult. The mismatch between the clinical picture and the extent of radiological lesions should, however, suggest the diagnosis. Histological evidence is needed to eliminate other etiologies including malignant tumors. The condition usually resolves either spontaneously or after treatment with systemic corticosteroids. However, relapses are possible, including on discontinuation of corticosteroid therapy.

The accuracy of three-dimensional prediction planning for the surgical correction of facial deformities using Maxilim

The motivation for orthognathic surgery is to improve facial appearance and quality of life. This study aimed to validate a three-dimensional (3D) orthognathic planning programme (Maxilim) for predicting soft tissue changes following Le Fort I advancements. Cone beam computed tomography (CBCT) scans were taken before surgery (T(1)) and at 6-12 months after surgery (T(2)) for 13 patients. For each patient the 3D hard tissue changes between T(1) and T(2) were determined by CBCT superimposition on the cranial vault. Using Maxilim, each patient's skeletal movements were used to generate a 3D soft tissue prediction. The actual soft tissue mesh at T(2) was compared to the predicted mesh. The face was divided into areas: nose, right and left nares, right and left paranasal regions, upper and lower lip, and chin. The absolute distance between meshes for each region was calculated. A one-sample t-test showed the distances between the meshes for all of the areas were within 3 mm (P<0.05), except for the upper lip which was greater than 3 mm (P=0.577). Using Maxilim, 3D soft tissue predictions for Le Fort I advancements were clinically satisfactory in the regions assessed, but associated with marked errors around the region of the upper lip.