Comparative evaluation of the effects of bimaxillary and mandibular setback surgery on pharyngeal airway space and hyoid bone position in skeletal class III patients

Background

To compare the effects of bimaxillary surgery ( Maxillary advancement and mandibular setback) and mandibular setback surgery (Bilateral Sagittal Split Osteotomy) on the pharyngeal airway space (PAS) and the hyoid bone position in a skeletal class III patients.

Material and Methods

Thirty four subjects (21 males, 13 females, mean age 26.5 ± 8 years) with skeletal class III pattern (ANB angle of -2° to -6°) were divided into two groups of equal sizes. Group A consisted of 17 individuals who underwent Bilateral Sagittal Split Osteotomy (BSSO)and Group B consisted of 17 individuals who underwent bimaxillary surgery. In both the group, lateral cephalograms were taken, traced and analyzed for the specified parameters at 3 intervals, pre treatment (C1), post surgical (C2), and post orthodontic treatment (C3). Changes in PAS was evaluated at 3 levels i.e, nasopharynx (Upper PAS), oropharynx (Middle PAS) and hypopharynx (Lower PAS). Changes in hyoid bone position were evaluated in anteroposterior and vertical direction at all the 3 intervals.

Results

There was a significant constriction of airway at oropharyngeal and hypo-pharyngeal level at C2 and C3 in both the groups. However, the reduction at the oropharyngeal airway was greater in group A. In group B, there was significant increase in the airway at the level of nasopharynx, Hyoid bone was positioned more posteriorly post-surgery in group A which did not return to its original position post treatment. In group B hyoid bone was positioned postero-inferiorly post surgically which came back to its original position by the end of orthodontic treatment.

Conclusions

Patients undergoing bimaxillary surgery showed a significant increase in the airway at the level of nasopharynx. Hyoid bone returned to its original position by the end of orthodontic treatment in the bimaxillary surgery group. This study suggested that while treating a skeletal class III malocclusion it is advised to perform maxillary advancements along with mandibular setback surgery.

Key words:Bimaxillary surgery, Hyoid bone, Bilateral Sagittal Split Osteotomy, Pharyngeal airway space.

Association of UGT1A6 gene polymorphism with clinical outcome in pediatric epileptic patients on sodium valproate monotherapy

Pediatric epilepsy comprises chronic neurological disorders characterized by recurrent seizures. Sodium valproate is one of the common antiseizure medications used for treatment. Glucuronide conjugation is the major metabolic pathway of sodium valproate, carried out by the enzyme uridine 5'-diphosphate (UDP) glucuronosyl transferase (UGT) whose gene polymorphisms may alter the clinical outcome. The objective of this study was to assess the association between UGT1A6 genetic polymorphism and clinical outcome in terms of efficacy and tolerability in pediatric epileptic patients on sodium valproate monotherapy. Pediatric epileptic patients (n=65) aged 2-18 years receiving sodium valproate monotherapy for the past one month were included. Genetic polymorphism patterns of UGT1A6 (T19G, A541G, A552C) were evaluated by PCR-RFLP. Clinical outcome was seizure control during the 6 months observation period. Tolerability was measured by estimating the hepatic, renal, and other lab parameters. Out of 65 patients, TT (40%), TG (57%), and GG (3%) patterns were observed in UGT1A6 (T19G) gene, AA (51%), AG (40%), and GG (9%) in (A541G) gene, and AA (43%), AC (43%), and CC (14%) in (A552C) gene. No statistical difference in clinical outcome was found for different UGT1A6 genetic polymorphism patterns. We concluded that different patterns of UGT1A6 genetic polymorphism were not associated with the clinical outcome of sodium valproate in terms of efficacy and tolerability. Sodium valproate was well-tolerated among pediatric patients with epilepsy and can be used as an effective antiseizure medication.

35 Comparative Performance of Prediction Model, Non-Expert and Tele-Diagnosis of Common External and Middle Ear Disease Using A Patient Cohort from Cambodia That Included One Hundred and Thirty-Eight Ears

Introduction

Globally 6% of the population suffers from disabling hearing loss and the majority resides in low- and middle-income countries, but diagnosis and treatment are hampered by poor availability of expert diagnosis. We compared the utility of tele-diagnosis, non-expert diagnosis, and prediction model diagnosis as a screening tool for common external and middle ear disorders.

Method

We recruited consecutive adult and paediatric patients presenting with ear or hearing symptoms to ENT outpatients at Children’s Surgical Centre, Cambodia. Each participant underwent sequential symptomatic and otoscopic assessment by a non-specialist and an ENT specialist. The non-specialist captured data using a novel automated symptom questionnaire loaded onto a smartphone otoscope. An ENT specialist in the UK subsequently reviewed these data.

Results

138 ears were recruited. The prediction model performed poorly, but absence of otorrhoea was found to reliably exclude a diagnosis of chronic suppurative otitis media (negative predictive value=0.99). Both on-site non-expert and expert tele-diagnosis had high diagnostic specificity (90-99% and 86-99%), but low sensitivity (<43% and 32-100%).

Conclusions

We report the first study to directly compare approaches for non-specialist diagnosis of disorders of the middle/external ear, which shows suboptimal but comparable performance using an automated questionnaire, on site non-expert diagnosis, or remote expert diagnosis

Genome-level insights into the operation of an on-site biological wastewater treatment unit reveal the importance of storage time

On-site wastewater treatment systems are gaining popularity in areas where centralized wastewater treatment is not available. In the current case study a domestic activated sludge system was investigated, where treated effluent was stored in a short-term (1 week turn-over time) and a long-term (over 2-3 months) storage tank and was then used for irrigation. This design provided a unique opportunity to assess the chemical and microbial changes of the effluent upon storage. Long-term storage greatly improved both the chemical quality and the degradation efficiency of most organic micropollutants examined, including petroleum hydrocarbons and the pesticide diethyltoluamide. Taxonomic profile of the core microbiome of the effluent was also influenced upon storage. Relative abundance values of the members of Azoarcus and Thauera genera, which are important in degrading polycyclic aromatic hydrocarbons compounds, clearly indicated the biodegrading activity of these microbes across samples. The abundance of xenobiotics degradation functions correlated with the observed organic micropollutant degradation values indicating efficient microbial decomposition of these contaminants. Functions related to infectious diseases also had the highest abundance in the short-term storage tank corresponding well with the relative abundance of indicator organisms and implying to the significance of storage time in the elimination of pathogens. Based on these results, small, on-site wastewater treatment systems could benefit from long-term storage of wastewater effluent.

High-dose salvage re-irradiation for recurrent/progressive adult diffuse glioma: healing or hurting?

PURPOSE

To report survival outcomes and identify prognostic factors of salvage re-irradiation (re-RT) in recurrent/progressive glioma.

METHODS

Medical records of patients treated with high-dose re-RT as part of multi-modality salvage therapy for recurrence/progression of adult diffuse glioma from 2010 to 2019 were analyzed retrospectively.

RESULTS

A total of 111 patients developing recurrent/progressive high-grade glioma after adequate upfront treatment at initial diagnosis were included. The first course of radiotherapy (RT) had been delivered to a median dose of 59.4 Gy with an inter-quartile range (IQR) of 54-60 Gy. Median time to recurrence/progression was 4.3 years (IQR = 2.3-7.4 years) while the median time to re-RT was 4.8 years (IQR = 3.6-7.9 years). Re-RT was delivered with intensity-modulated radiation therapy (IMRT) using 1.8 Gy/fraction to a median dose of 54 Gy (IQR = 50.4-55.8 Gy) for a cumulative median equivalent dose in 2-Gy fractions (EQD2) of 104.3 Gy (IQR = 102.6-109.4 Gy). At a median follow-up of 14 months after re-RT, the 1-year Kaplan-Meier estimates of post-re-RT progression-free survival (PFS) and overall survival (OS) were 42.8 and 61.8%, respectively. Univariate analysis identified histological grade at recurrence/progression; histological subtype; disease-free interval (DFI) and time interval between both courses of RT; performance status at re-RT; dose at re-RT and cumulative EQD2; isocitrate dehydrogenase (IDH) mutation; and O⁶-methyl-guanine DNA methyl transferase (MGMT) gene promoter methylation as significant prognostic factors. Preserved performance status, longer DFI, prolonged time interval between both courses of RT, and presence of IDH mutation were associated with significantly improved PFS on multi-variate analysis. However, only performance status retained independent prognostic significance for OS on multi-variate analysis. Post-treatment changes were seen in 33 (30%) patients on follow-up imaging, with higher cumulative dose (EQD2 ≥ 104.3 Gy) being associated with increased risk of post-re-RT pseudo-progression.

CONCLUSION

This clinical audit reports encouraging survival outcomes and identifies key prognostic factors associated with high-dose salvage re-RT in recurrent/progressive glioma.

P14.50 Clinicopathological spectrum of intracranial germ cell tumors: an Indian tertiary cancer center experience

BACKGROUND

Incidence of intracranial germ cell tumors (ICGCT) in Western literature is low (0.3–0.6 %) as compared to East Asia (3–4 %), & their clinicopathological features are well documented. However, there are scant studies on ICGCT from India.

MATERIAL AND METHODS

Retrospective observational study of all ICGCT histologically diagnosed in our hospital from 2007–2018. Metastasis were excluded. Clinicopathological features were retrieved from hospital’s electronic medical records.

RESULTS

We diagnosed 82 primary ICGCT, forming approx. 0.54 % of all primary brain tumors, & 3.5% of pediatric brain tumors. Age range: 2 months-32 yrs (Median age 14 yrs). M:F ratio: 1.82:1 (53M,29F). Nearly 80% patients were pediatric (<18 yrs), & 8 very young (<3 yrs, 7M1F). Majority were suprasellar & pineal (31/82, 37% each), with one bifocal presentation. Other rarer sites: posterior fossa (4), midbrain (1), corpus callosum (1) & 11 non midline (4 thalamic, 4 frontal, 2 cerebellar, 1 CP angle). Predominant histology was germinoma (G) (51/82, 62%), while non germinomatous (NGGCT) were 31/82 (38%), of which 9 were mixed. Pure teratoma were 11 (9 immature (IT), 2 mature), & 5 pure yolk sac tumor (YST). Interestingly, all very young age group patients (<3 yrs), showed only NGGCT histology (5/8 IT, 3/8 pure YST). In contrast, G histology formed nearly 70% of all patients >3 yrs. Females were associated mainly with G (21/29, 72%). NGGCT were predominantly seen in males (M:F=2.9:1). Also, pure IT (9) were seen only in males. Posterior fossa tumors were all IT (4/4). Spinal tumors were NGGCT (1 mature teratoma, 1 YST). Majority of suprasellar tumors (25/31, 80.6%), other midline locations like corpus callosal, midbrain, & all thalamic tumors were G. However, pineal tumors showed equal distribution of G (15/31) & NGGCT (16/31). Spine screening was positive in 8 patients (6 G, 2 IT)- 7 on MRI and 1 only on CSF cytology. Serum tumor markers were raised in 13/54 cases- 6/34G(17.6%), vs 7/20 NGGCT (35%). CSF tumor markers were raised in 14/34-10/23 G (43.4%), vs 4/11 NGGCT (36.3%). Follow up was available for 37 patients (Duration 3 months-10 yrs, median 2 yrs). On f/u 6/15 (40%) NGGCT showed progression/death, while only 2/32 G relapsed (6.5%). Four deaths in G group were not directly attributable to the tumor.

CONCLUSION

Frequency of ICGCT in our hospital similar to western data rather than Asian, albeit with less striking male preponderance. ICGCT were tumors of 2nd decade & majority occurred in pineal/suprasellar areas. About 2/3rd were pure G on histology, and showed good prognosis. NGGCT were common in infants, males and in posterior fossa. IT were seen exclusively in males and pure YST mainly in males. Although majority of ICGCT are in midline, rarely non midline involvement also occurs, and it’s essential to exclude metastasis before considering primary ICGCT. Expectedly, NGGCT showed poorer prognosis, compared to pure germinomas.

A cadaveric study of variations of external iliac artery and its implication in trauma and radiology

OBJECTIVES

A severe and potentially lethal complication in pelvic injuries is arterial bleeding commonly involving the iliac arteries. Hence, the objective of our study was to systematically document the morphology and variations of the external iliac artery in human cadaveric pelvises.

MATERIALS AND METHODS

Study was conducted on 48 pelvic halves which were obtained by making mid-line saw cuts through formalin embalmed adult human male cadaveric pelvises. The external iliac artery was cleaned, its length and diameter were measured using a scale. Following parameters were noted: variations of the external iliac artery in terms of its location, course, termination, relations with other vessels and variations in its branching pattern.

RESULTS

Variations related to the morphology and branching pattern of the external iliac artery was observed in 20 hemipelvises (42%). Nine (19%) hemipelvises showed morphological variations of the artery (looped, tortuous, curved, twisted or 'S' shaped). Variations in the branching pattern of the artery were seen in 6 (13%) hemipelvises and the artery was superficial or medial to the external iliac vein in 5 (10%) hemipelvises. Mean length of the artery was 10cm on the right and 9.9cm on the left side of the pelvis. Its mean diameter was 0.94mm on the right and 0.99mm on left side.

CONCLUSION

Diagnostic and interventional radiologic procedures on the pelvic arteries are becoming more frequent, and hence in here, we have performed the morphological study of the external iliac artery is necessary to guide interventional procedures.

Prenatal diagnosis and implications of microphthalmia and anophthalmia with a review of current ultrasound guidelines: two case reports

BACKGROUND

Microphthalmia and anophthalmia are rare congenital fetal abnormalities. The combined incidence is estimated at 1 in 10,000 births. These two conditions arise from complex and incompletely understood genetic and/or environmental causes. Prenatal diagnosis is neither frequent nor easy and relies on precise, high-quality ultrasonography. Current antenatal ultrasound protocols for imaging of the fetal eye are inconsistent and inadequate to screen for the spectrum of ocular malformations, and there are no clear guidelines on detection of these rare abnormalities. Our study of two cases highlights the importance of early detection, and we review current practice and suggest a definitive fetal imaging protocol.

CASE PRESENTATION

We present two antenatal cases, one each of microphthalmia and anophthalmia, both diagnosed at the morphology scan at our tertiary fetal medicine unit. In both cases, the parents (a 36-year-old woman of Mauritanian ethnicity and a non-consanguineous partner of Nepalese descent, and a 31-year-old Caucasian woman and non-consanguineous Caucasian partner) elected to terminate their pregnancies and made unremarkable recoveries. Subsequent fetal autopsy confirmed the ultrasound scan findings.

CONCLUSIONS

We recommend that antenatal ultrasound guidelines are updated to specify use of a curvilinear transducer (2-9 MHz) to image both orbits in the axial and coronal planes, aided by use of a transvaginal probe when the transabdominal approach is inadequate to generate these images. When applicable, three-dimensional reverse-face imaging should be obtained to aid the diagnosis. The presence, absence, or non-visualization of lenses and hyaloid arteries should be documented in reports and these cases referred for a tertiary-level ultrasound scan and fetal medicine review. Imaging of the orbits should occur from 12 weeks' gestation. Magnetic resonance imaging and amniocentesis with chromosome microarray testing may provide additional genetic and structural information that may affect the overall morbidity associated with a diagnosis of microphthalmia or anophthalmia.

Descendens vagohypoglossi: rare variant of the superior root of ansa cervicalis

Knowledge of variants in the formation and position of the ansa cervicalis is important in head and neck surgery, specifically in reconstructions of the tongue that use the infrahyoid muscles, and in the anastomosis of the ansa cervicalis to the recurrent laryngeal nerve when the laryngeal muscles have been paralysed. We describe a rare variant of the superior root of the ansa cervicalis, which had a contribution from the vagus and hypoglossal nerves. The inferior root was formed by the C2 and C3 ventral rami, but it passed medial to the internal jugular vein before it joined the superior root to form the loop.

A new approach to exfoliative cytology: A comparative cytomorphometric study

CONTEXT

Early detection of oral premalignancy and malignancy using simple screening aids play a promising role in curbing the disease.

AIM

The primary aim of this study is to evaluate and the secondary aim of this study is to compare the cytomorphometry and cellular atypia in keratinocytes obtained from oral rinse and conventional exfoliative cytology in normal oral mucosa and clinically diagnosed oral leukoplakia.

MATERIALS AND METHODS

The study comprised of 55 clinically diagnosed cases of leukoplakia and 55 age and sex matched normal controls. Smears were prepared using oral rinse technique followed by the conventional exfoliative cytology. Papanicoloau stained smears were evaluated for atypia and subjected to image analysis. Based on the presence of atypia they were further divided into three groups (Group 1-cases with atypia, Group 2-without atypia and Group 3-normal controls) and analyzed. Statistical analysis used one-way analysis of variance followed by Tukey Honestly Significant Difference test for intergroup analysis and unpaired students t-test to compare the two methods.

RESULTS

Smears prepared with both methods demonstrated atypia in 18 cases. The cellular diameter and cellular area (CA) were progressively increased from Group 1 through Groups 2 and 3 in both the smears. Nuclear diameter and nuclear area and nuclear cytoplasmic ratio progressively decreased from Group 1 through Groups 2 and 3. Both the methods showed no significant differences among the cellular parameters except in normal controls.

CONCLUSION

Cytomorphometric analysis of keratinocytes obtained with oral rinse method and wooden spatula can serve as a useful screening aid to detect oral leukoplakia. Oral rinse method being more convenient results in smears of better quality.

Pharmacogenetic Association Between Glutamatergic Genes and Sri Treatment Response in Obsessive Compulsive Disorder

Introduction

Pharmacogenetic studies in obsessive-compulsive disorder (OCD) primarily focussing on serotonergic and dopaminergic polymorphisms, provided inconsistent findings. There is recent evidence for glutamatergic abnormalities in OCD.

Aims

Examine the association glutamatergic genes with serotonin reuptake inhibitor (SRI) response in OCD.

Objectives

To study pharmacogenetic association between SLC1A1 and GRIN2B polymorphisms with SRI response in OCD.

Methods

DSM-IV OCD patients were recruited from a specialty OCD clinic and evaluated using the Yale-Brown obsessive compulsive scale (YBOCS), Mini International Neuropsychiatric Interview (MINI) plus, Clinical Global Impression scale (CGI). They were subsequently reassessed with YBOCS and CGI. To study extreme phenotypes, we included only full responders (> 35% YBOCS improvement and CGI-I score of 1 or 2) to any SRI (n = 191) and non-responders (< 25% YBOCS improvement and CGI-I score ≥ 4) to adequate trial of at least two SRIs (n = 84). Partial responders were excluded. Genotyping was performed using an ABI9700 PCR machine.

Results

Genotype frequencies did not deviate significantly from the values predicted by the Hardy-Weinberg equation. Case-control association analyses revealed no significant association between genotype/allele frequencies with SRI response.

Conclusion

Our data does not show any association between polymorphisms in glutamatergic genes and SRI response in OCD though such associations have been found in other studies. More SNP's in the same gene could be responsible for the pharmacogenetic associations. More homogenous sample considering symptom dimensions and other phenotypic variables may be needed. It may be critical to go beyond “usual suspect” candidate gene research. In this regard, a novel approach to identify SRI response biomarkers is the use of cellular models.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Correlation of vermilion symmetry to alveolar cleft defect in unilateral cleft lip repair

Asymmetry is a major problem in repaired unilateral cleft lip (UCL). One of the important manifestations of this is the asymmetry of the vermilion. The aim of this study was to correlate the severity of the asymmetry in the vermilion to the size of the alveolar defect. Twenty patients aged between 6 and 18 months with complete unilateral cleft lip, alveolus, and palate were included. An impression of each patient's alveolus at the time of cheiloplasty was taken using silicon rubber base material, and a study cast was prepared. The width of the cleft alveolus was measured on these casts using a transparent grid. Frontal photographs were taken at 6 months postoperative and vermilion symmetry was measured as the ratio between the cleft and non-cleft sides. The results obtained in this study showed a direct correlation between the size of the alveolar defect and the vermilion symmetry in repaired UCL. The wider the cleft alveolus and greater the antero-posterior discrepancy, the greater is the vermilion asymmetry. The asymmetry of the vermilion in UCL after repair is directly dependent on the size of the alveolar defect. The alveolar discrepancy causes 'in-rolling' of the vermilion on the cleft side and affects the vermilion symmetry.