Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement

STUDY OBJECTIVES

(1) to investigate if DISE findings are predictive of surgical response for patients undergoing MMA for OSA; and (2) to investigate the predictive value of jaw thrust maneuver during DISE in terms of surgical response to MMA.

METHODS

A retrospective cohort study was conducted on patients with OSA who underwent a baseline polysomnography (PSG) and DISE followed by MMA and a 3-6-months follow-up PSG, between September 1, 2011 and September 30, 2020.

RESULTS

Sixty-four OSA patients (50 males [78.1%]; mean ± SD age = 51.7 ± 9.5 years; mean ± SD AHI = 49.0 ± 20.8 events/hour) were included. Thirty-nine patients were responders, and twenty-five were nonresponders. Adjusting for baseline characteristics and surgical characteristics (e.g., age, baseline AHI, degree of maxillary advancement), patients with complete anteroposterior epiglottic collapse had 0.239 times lower odds for response to MMA (95% confidence interval, 0.059-0.979; P = 0.047). No significant relationship was found between complete concentric velum collapse and MMA response. There was no statistically significant association between effect of jaw thrust maneuver during DISE on upper airway patency and treatment outcome of MMA.

CONCLUSIONS

This study indicates that DISE is a promising tool in order to identify patients who will or will not respond to MMA for treating OSA. Patients with complete anteroposterior epiglottic collapse may be less suitable candidates for MMA.

Pre-operative Limbic System Functional Connectivity Distinguishes Responders From Non-responders to Surgical Treatment for Trigeminal Neuralgia

Background: Trigeminal neuralgia (TN) is a severe facial pain condition often requiring surgical treatment. Unfortunately, even technically successful surgery fails to achieve durable pain relief in many patients. The purpose of this study was to use resting-state functional magnetic resonance imaging (fMRI) to: (1) compare functional connectivity between limbic and accessory sensory networks in TN patients vs. healthy controls; and (2) determine if pre-operative variability in these networks can distinguish responders and non-responders to surgery for TN. Methods: We prospectively recruited 22 medically refractory classic or idiopathic TN patients undergoing surgical treatment over a 3-year period, and 19 age- and sex-matched healthy control subjects. fMRI was acquired within the month prior to surgery for all TN patients and at any time during the study period for controls. Functional connectivity analysis was restricted to six pain-relevant brain regions selected a priori: anterior cingulate cortex (ACC), posterior cingulate cortex, hippocampus, amygdala, thalamus, and insula. Two comparisons were performed: (1) TN vs. controls; and (2) responders vs. non-responders to surgical treatment for TN. Functional connectivity was assessed with a two-sample t-test, using a statistical significance threshold of p < 0.050 with false discovery rate (FDR) correction for multiple comparisons. Results: Pre-operative functional connectivity was increased in TN patients compared to controls between the right insular cortex and both the left thalamus [t ₍₃₉₎ = 3.67, p = 0.0007] and right thalamus [t ₍₃₉₎ = 3.22, p = 0.0026]. TN patients who were non-responders to surgery displayed increased functional connectivity between limbic structures, including between the left and right hippocampus [t ₍₁₈₎ = 2.85, p = 0.0106], and decreased functional connectivity between the ACC and both the left amygdala [t ₍₁₈₎ = 2.94, p = 0.0087] and right hippocampus [t ₍₁₈₎ = 3.20, p = 0.0049]. Across all TN patients, duration of illness was negatively correlated with connectivity between the ACC and left amygdala (r ² = 0.34, p = 0.00437) as well as the ACC and right hippocampus (r ² = 0.21, p = 0.0318). Conclusions: TN patients show significant functional connectivity abnormalities in sensory-salience regions. However, variations in the strength of functional connectivity in limbic networks may explain why some TN patients fail to respond adequately to surgery.

Surgical responses and outcomes of bilateral lateral rectus recession in exotropia with cerebral palsy

PURPOSE

To determine surgical responses and outcomes of bilateral lateral rectus (BLR) recession in exotropes with cerebral palsy (CP) and to compare the results with exotropes without CP.

METHODS

Forty-one exotropes with CP and 82 age- and type (intermittent or constant)-matched exotropes without CP who underwent BLR recession by one surgeon (J-M.H.) were evaluated. Main outcome measures were surgical responses, factors affecting surgical response, success rates, cumulative probabilities of success and recurrence, and drifts of ocular alignment towards exodeviation after surgery (exodrift).

RESULTS

The surgical responses of BLR recession were not significantly different between both groups (p = 0.136). After a mean follow-up period of 2 years, success rates showed no significant difference between the two groups (p = 1.000). The cumulative probabilities of success and recurrence were not significantly different between the two groups (p = 0.770 and 0.754, respectively). The rate of recurrence per person-year during follow-up was 16.7% in patients with CP and 20.2% in patients without CP. The amount of exodrift showed no significant difference between both groups (p = 0.118).

CONCLUSIONS

Exotropes with CP showed a similar surgical response, an amount of exodrift, cumulative success and recurrence rates after BLR recession compared to exotropes without CP.

Using global gene expression to discriminate thin melanomas with poor outcomes

Most melanomas present as thin lesions (≤1.0 mm) with a good prognosis; however, a small percentage of patients with thin lesions experience recurrence or metastasis. The aim of our study was to identify a distinct pattern of gene expression within thin melanomas known to have eventually metastasized to regional lymph nodes or distant sites compared with those that followed the typical course with good response to wide local excision alone. Patients who were disease-free for a minimum of 10 y served as controls (n = 10) to the experimental group who developed metastasis (n = 9). Laser capture microdissection was used to specifically isolate cancer cells from formalin-fixed paraffin-embedded tissue with subsequent gene expression analysis on Affymetrix Human Transcriptome Array 2.0 Arrays. Although gene expression differences were observed between the patients with thin melanoma with poor clinical outcome and those with good clinical outcome, neither the number of genes nor the magnitude of the fold difference was very substantial or significant. Cluster analysis with this subset of genes could definitively separate a subset of the poor responders from the good responders, but there remained a mixed group of tumors that could not be predicted from gene expression alone. Pathway analysis identified cellular processes that were regulated based on the response, including categories commonly associated with melanoma progression. Ultimately, we concluded that there were very few differences between these groups. Future research will be required and investigation of the mutational landscape may be another strategy to uncover genomic changes that drive recurrence and metastasis in thin melanoma.