Occurrence and health risk assessment of organotins in waterworks and the source water of the Three Gorges Reservoir Region, China

Abstract

The occurrence and health risks of organotins (OTs) in the waterworks and source water in the Three Gorges Reservoir Region (TGRR), China were assessed in this study. Water samples were collected at four waterworks (A, B, C, and D) in March and July 2012 to analyze butyltins (BTs) and phenyltins (PTs) using a gas chromatography-mass spectrometry (GC-MS) system. Our results showed that both the waterworks and their nearby water sources were polluted by OTs, with PTs being the most dominant species. Monobutyltin (MBT), monophenyltin (MPT), diphenyltin (DPT), and triphenyltin (TPT) were detected in most of the analyzed water samples. The highest concentrations of OTs in influents, effluents, and source water in March were 52.81, 17.93, and 55.32 ng Sn L⁻¹, respectively. Furthermore, significant seasonal changes in OTs pollution were observed in all samples, showing pollution worse in spring compared with summer. The removal of OTs by the conventional treatment processes was not stable among the waterworks. The removal efficiency of OTs in July reached 100% at plant B, while that at plant C was only 38.8%. The source water and influents shared similar composition profiles, concentrations, and seasonal change of OTs, which indicated that OTs in the waterworks were derived from the source water. A health risk assessment indicated that the presence of OTs in the waterworks would not pose a significant health risk to the population, yet their presence should not be ignored.

Microarray expression profiling and co-expression network analysis of circulating LncRNAs and mRNAs associated with neurotoxicity induced by BPA

Abstract

A growing body of evidence has shown bisphenol A (BPA), an estrogen-like industrial chemical, has adverse effects on the nervous system. In this study, we investigated the transcriptional behavior of long non-coding RNAs (lncRNAs) and mRNAs to provide the information to explore neurotoxic effects induced by BPA. By microarray expression profiling, we discovered 151 differentially expressed lncRNAs and 794 differentially expressed mRNAs in the BPA intervention group compared with the control group. Gene ontology analysis indicated the differentially expressed mRNAs were mainly involved in fundamental metabolic processes and physiological and pathological conditions, such as development, synaptic transmission, homeostasis, injury, and neuroinflammation responses. In the expression network of the BPA-induced group, a great number of nodes and connections were found in comparison to the control-derived network. We identified lncRNAs that were aberrantly expressed in the BPA group, among which, growth arrest specific 5 (GAS5) might participate in the BPA-induced neurotoxicity by regulating Jun, RAS, and other pathways indirectly through these differentially expressed genes. This study provides the first investigation of genome-wide lncRNA expression and correlation between lncRNA and mRNA expression in the BPA-induced neurotoxicity. Our results suggest that the elevated expression of lncRNAs is a major biomarker in the neurotoxicity induced by BPA.

Correction to: The structural changes of pharyngeal airway contributing to snoring after orthognathic surgery in skeletal class III patients

Abstract

The publication of this article [1] unfortunately contained several mistakes.

Novel condylar repositioning method for 3D-printed models

Abstract

Background

Along with the advances in technology of three-dimensional (3D) printer, it became a possible to make more precise patient-specific 3D model in the various fields including oral and maxillofacial surgery. When creating 3D models of the mandible and maxilla, it is easier to make a single unit with a fused temporomandibular joint, though this results in poor operability of the model. However, while models created with a separate mandible and maxilla have operability, it can be difficult to fully restore the position of the condylar after simulation. The purpose of this study is to introduce and asses the novel condylar repositioning method in 3D model preoperational simulation.

Methods

Our novel condylar repositioning method is simple to apply two irregularities in 3D models. Three oral surgeons measured and evaluated one linear distance and two angles in 3D models.

Results

This study included two patients who underwent sagittal split ramus osteotomy (SSRO) and two benign tumor patients who underwent segmental mandibulectomy and immediate reconstruction. For each SSRO case, the mandibular condyles were designed to be convex and the glenoid cavities were designed to be concave. For the benign tumor cases, the margins on the resection side, including the joint portions, were designed to be convex, and the resection margin was designed to be concave. The distance from the mandibular ramus to the tip of the maxillary canine, the angle created by joining the inferior edge of the orbit to the tip of the maxillary canine and the ramus, the angle created by the lines from the base of the mentum to the endpoint of the condyle, and the angle between the most lateral point of the condyle and the most medial point of the condyle were measured before and after simulations. Near-complete matches were observed for all items measured before and after model simulations of surgery in all jaw deformity and reconstruction cases.

Conclusions

We demonstrated that 3D models manufactured using our method can be applied to simulations and fully restore the position of the condyle without the need for special devices.

Lateral alveolar ridge augmentation procedure using subperiosteal tunneling technique: a pilot study

Abstract

Background

In this research article, we evaluate the use of sub-periosteal tunneling (tunnel technique) combined with alloplastic in situ hardening biphasic calcium phosphate (BCP, a compound of β-tricalcium phosphate and hydroxyapatite) bone graft for lateral augmentation of a deficient alveolar ridge.

Methods

A total of 9 patients with deficient mandibular alveolar ridges were included in the present pilot study. Ten lateral ridge augmentation were carried out using the sub-periosteal tunneling technique, including a bilateral procedure in one patient. The increase in ridge width was assessed using CBCT evaluation of the ridge preoperatively and at 4 months postoperatively. Histological assessment of the quality of bone formation was also carried out with bone cores obtained at the implant placement re-entry in one patient.

Results

The mean bucco-lingual ridge width increased in average from 4.17 ± 0.99 mm to 8.56 ± 1.93 mm after lateral bone augmentation with easy-graft CRYSTAL using the tunneling technique. The gain in ridge width was statistically highly significant (p = 0.0019). Histomorphometric assessment of two bone cores obtained at the time of implant placement from one patient revealed 27.6% new bone and an overall mineralized fraction of 72.3% in the grafted area 4 months after the bone grafting was carried out.

Conclusions

Within the limits of this pilot study, it can be concluded that sub-periosteal tunneling technique using in situ hardening biphasic calcium phosphate is a valuable option for lateral ridge augmentation to allow implant placement in deficient alveolar ridges. Further prospective randomized clinical trials will be necessary to assess its performance in comparison to conventional ridge augmentation procedures.

Unklarer Tumor des Oberkiefers

Rekonstruktion der aktinisch geschädigten Unterlippe

Zusammenfassung

Die aktinische Keratose ist eine durch chronische ultraviolette Strahlung verursachte fakultative Präkanzerose. Sie tritt am häufigsten im Kopf-Hals-Bereich auf. Derzeit werden in Deutschland geschätzt etwa 1,7 Mio. Patienten pro Jahr mit einer aktinischen Keratose behandelt. Inzidenz und Prävalenz sind stark steigend. Die Therapie der Wahl ist die vollständige chirurgische Entfernung der Läsion. An der Unterlippe geschieht dies in der Technik des „lip shave" unter Entfernung des gesamten Lippenrots. Zur Rekonstruktion der Unterlippe bietet sich bei dieser Defektsituation entweder eine labiale vestibuläre Mukosaverschiebeplastik aus der Innenseite der Unterlippe oder eine beidseitige Mukosaverschiebeplastik aus dem Planum buccale an. In diesem Beitrag werden beide Techniken dargestellt und diskutiert.

Klassische Methoden der Unterlippenrekonstruktion

Zusammenfassung

Die häufigste Ursache für einen Unterlippendefekt ist die Resektion eines Lippenkarzinoms. Aber auch traumatische oder entzündliche Defekte sind möglich. Ziel der Lippenrekonstruktion muss die Wiederherstellung der Lippenkompetenz bei gleichzeitiger Vermeidung eines Mikrostomas sein. Um dem Chirurgen einen Anhaltspunkt zu geben, welche Rekonstruktionsmethode im Einzelfall am ehesten für einen vorliegenden Defekt geeignet ist, empfiehlt sich eine Einteilung nach der Größe. Defekte von einem Drittel bis zur Hälfte der Unterlippe können primär bzw. durch Dehnungsplastik der Lippenstümpfe verschlossen werden, Defekte zwischen der Hälfte und zwei Drittel werden am ehesten mit einem Abbé‑, Estlander- oder Karapandzic-Lappen gedeckt. Die Bernard-Fries-Plastik ist für noch größere bis vollständige Unterlippendefekte das Mittel der Wahl. Neben der Defektgröße sollte auch die mögliche Beteiligung des Mundwinkels in die Entscheidung für das Rekonstruktionsverfahren miteinbezogen werden.

Unklares Verletzungsmuster nach Sturz eines Jungen

Neues aus der Rechtsprechung

Weibliche Genitalästhetik

Zusammenfassung

Ziel

Die vorliegende Arbeit untersucht die Präferenzen von Männern und Frauen in Bezug auf Ästhetik und Erotik des weiblichen Genitals. Zusätzlich wurden Faktoren wie die Anzahl von Sexualpartnern sowie das Persönlichkeitsmerkmal Offenheit für Erfahrungen hinzugezogen.

Methoden

Die Daten wurden innerhalb einer Online-Befragung erhoben. 202 weibliche und 114 männliche Personen nahmen teil (Durchschnittsalter 29 Jahre). Mittels 40 Abbildungen und eines Fragebogens wurden Ästhetik und Erotik im Erscheinungsbild der Vulva erfragt. Zusätzlich wurde die Skala „Offenheit" des NEO-FFI herangezogen.

Ergebnisse

Es konnten signifikante Unterschiede zwischen beiden Geschlechtern hinsichtlich der Beurteilung des weiblichen Genitals nachgewiesen werden. Insbesondere eine große Klitoris, große Labia minora sowie große Labia majora wurden von Männern positiver als von Frauen bewertet. Symmetrie spielte keine große Rolle. Die Zufriedenheit von Frauen mit dem eigenen Intimbereich zeigte einen signifikanten Zusammenhang mit der Anzahl der Sexualpartner. Bei der Präferenz bezüglich der Intimrasur wurde die Totalrasur am besten bewertet. Es konnte kein Zusammenhang zwischen der Beurteilung einer Vulva mit der Anzahl der Sexualpartner von Männern oder mit Offenheit für Erfahrungen bestätigt werden. Der Artikel beinhaltet Bilder der als am schönsten und der als weniger attraktiv beurteilten weiblichen Geschlechtsorgane. Frauen beurteilten anatomische Abweichungen dieses Körperteils deutlich kritischer als Männer, die aufgrund ihrer biologischen Prägung weibliche Geschlechtsteile insgesamt positiver beurteilten. Bei Frauen stieg die Toleranz für die Variabilität des Geschlechtsorgans mit der Anzahl von Sexualpartnern.

Panorama

Rückblick auf die Jahrestagung der Gesellschaft für Ästhetische Chirurgie Deutschland 2017

Autologe Fettgewebstransplantation

Zusammenfassung

Hintergrund

Das Verfahren des autologen Fetttransfers wurde 1893 erstmals durch den deutschen Chirurgen Gustav Neuber beschrieben. Heutzutage gilt der US-Amerikaner Sydney Coleman als Wiederentdecker der Fettgewebstransplantation, da er diese Methode maßgeblich mit seinem dazu ausgearbeiteten Protokoll prägte. Das Fettgewebe ist wegen seiner volumetrischen und regenerativen Eigenschaften ein anerkannter autologer Filler in der regenerativen plastischen Chirurgie und erfreut sich zunehmender Beliebtheit.

Fragestellung

Neueste Entwicklungen in der autologen Fettgewebstransplantation und deren klinische Anwendung werden zusammengefasst.

Material und Methode

Es wird eine kurze Übersicht über die Bestandteile des Fetttransplantats präsentiert. Im Hauptteil werden die aktuellen Entwicklungen des autologen Fetttransfers dargestellt. Dazu wurden aktuelle Studien analysiert.

Ergebnisse

Fett ist ein dynamisches Gewebe, das eine Vielzahl verschiedener Zellen enthält. Hierbei spielen insbesondere die enthaltenen Stammzellen, die „adipose-derived stem cells" (ASC), eine wichtige Rolle. Zudem werden im Fettgewebe Wachstumsfaktoren produziert, wodurch v. a. die Angiogenese gesichert wird. Im Laufe der Zeit wurde das von Coleman entwickelte Protokoll mehrfach modifiziert, und verschiedenste Techniken zur Verbesserung der Fetttransplantation wurden entwickelt.

Schlussfolgerung

Der autologe Fetttransfer hat in der regenerativen, plastischen Chirurgie zunehmend an Bedeutung gewonnen. Aktuell besteht noch kein Konsens zur optimalen Vorgehensweise hinsichtlich des Liposuktions‑, Prozessierungs- und Injektionsverfahren, was jedoch durch kontinuierliche Forschung verbessert wird.

Mitteilungen der GÄCD

Neue Boardstruktur beim Journal für Ästhetische Chirurgie

Patientenvermittlung über Internetportale

Zusammenfassung

Das Internet ist als Medium zur Patienteninformation und -gewinnung unverzichtbar geworden. Fraglich ist, ob die Inanspruchnahme des kostenpflichtigen Angebots einer Patientenvermittlung unter der Nutzung von Internetportalen eine sinnvolle Investition oder eher ein rechtliches Risiko darstellt. Vielfach wird insbesondere plastischen Chirurgen und medizinischen Einrichtungen die Aufnahme in Internetverzeichnisse mit oder ohne Bewertungsmöglichkeit angeboten. Über Kontaktformulare erhalten Patienten die Möglichkeit, direkten Kontakt zum Leistungserbringer aufzunehmen. Eine Vorteilsgewährung für die Zuweisung von Patienten ist standesrechtlich, wettbewerbsrechtlich und sozialrechtlich unzulässig. Dagegen ist die Abführung eines Honorarbruchteils an die Betreiberin einer Preisvergleichsplattform im Internet nicht verboten, wenn sie als Entgelt für die Nutzung des Onlineangebots erfolgt. Neuerdings kann korruptives Zusammenwirken bei der Patientenzuweisung unter Beteiligung zumindest eines Arztes oder eines Angestellten einer medizinischen Einrichtung auch strafrechtlich geahndet werden.

Entschlüsselung der Facial MD Codes

Zusammenfassung

Eine neue Generation des Full-Face-Approach zeichnet sich ab. Seit 2008 hat die Kenntnis über die Anatomie des Gesichtes einen neuen Stellenwert in der minimalästhetischen Medizin eingenommen. Die Entdeckung der Fettkompartimentierung des Gesichtes und die Kenntnis der Alterungsprozesse zusammen mit der Entwicklung einer neuen Fillergeneration, der Vycross® Technologie (Pharm Allergan, Frankfurt a. M., Deutschland) machten eine völlig neue Herangehensweise und Entwicklung des Gesichtes möglich. Zu diesen Neuerungen kommen nun die MD Codes™ nach Dr. Mauricio De Maio hinzu. Der Weg weg von der Nasolabialfalte aus den Jahren 2005 zum Volumenaufbau im Mittelgesicht bis 2013 hin zum 8‑Point-Lift und nun zu „Unlocking the Facial Codes" macht es möglich, rein durch minimalinvasive Methodik ein Gesicht wieder in seine ästhetische Grundstruktur zurückzubringen.

Körperwahrnehmung, Körperideal und Körperzufriedenheit

Zusammenfassung

Länder, in denen gehungert wird, tendieren dazu, füllige Körperproportionen zu präferieren; in Völkern mit einem Überangebot an Nahrung finden sich schlanke Körperideale. In der Studie wurden die Körperideale zwischen Brasilien und Deutschland verglichen. Methode: Es wurden 178 deutsche Frauen (Alter: 21–55 J., M = 24,7 J.) und 93 Brasilianerinnen (21–61 J., M = 27,6 J.) untersucht. Das Körpererleben wurde mithilfe der Skala von Stunkard et al. erfasst, die Zeichnungen einer Frau zwischen anorektisch und adipös in 9 Gewichtsabstufungen zeigt. Ergebnisse: Der Body-Mass-Index (BMI) der deutschen Frauen lag bei M = 19,5 kg/m² ± 1,7 kg/m²; der der brasilianischen Frauen lag durchschnittlich bei M = 20,0 kg/m² ± 2,0 kg/m². Der Mittelwert des Körperideals lag bei der deutschen Stichprobe bei 2,4 ± 0,7. Das entspricht der 2. bis 3. Abbildung der Skala nach Stunkard et al. Der Mittelwert der brasilianischen Stichprobe lag bei 2,5 ± 1,0. Im t‑Test wurde keine signifikante Differenz gefunden. Der Mittelwert der Körperzufriedenheit lag bei den deutschen Teilnehmerinnen bei 0,9 ± 0,8 und bei den brasilianischen Teilnehmerinnen bei 0,6 ± 1,0. Der Vergleich der Mittelwerte ergab eine signifikante Abweichung (p  0,01). Bei der Einschätzung des eigenen Körpers erreichten deutsche Frauen einen Mittelwert von 3,8 ± 1,0; das entspricht tendenziell der 4. Abbildung der Körperwahrnehmungsskala. Die Strichprobe der brasilianischen Frauen erreichte einen Mittelwert von 3,4 ± 1,3. Hier ergab sich ein hochsignifikanter Unterschied (p 0,001). Zusammenfassend lässt sich aus der Studie folgern: 1. Deutsche Frauen zeigen eine signifikant kritischere Selbstwahrnehmung als brasilianische Frauen. 2. Brasilianische Frauen zeigen eine signifikant höher ausgeprägte Körperzufriedenheit. 3. Deutsche Frauen bevorzugen einen signifikant dünneren Körper als brasilianische Frauen. Fazit: Deutsche Frauen sind etwas schlanker als Brasilianerinnen, schätzen sich aber dicker ein.

Kapselfibrose und Off-Label Use des Leukotrieninhibitors Montelukast zu Therapie und Prophylaxe

Zusammenfassung

Es wird ausführlich über den Zusammenhang zwischen Leukotrienexpression und Entstehung der Kapselkontraktur nach Augmentationsplastik unter Verwendung von Silikonendothesen berichtet. Bei physiologischer (moderater) Leukotrienexpression bildet sich eine dünnhäutige Umhüllung der Endothese (Endothesenkapsel) mit einer Stärke von maximal 1,5 mm. Ist aber die Leukotrienexpression pathologisch gesteigert, wird die Kapsel immer dicker und kontrakter. Es resultiert aus dieser quantitativ übertriebenen Inflammations(Fremdkörper)-Reaktion das Krankheitsbild der Kapselkontraktur. Durch Behandlung mit einem Leukotrienrezeptorblocker kann diese pathologische Dynamik gestoppt und damit das Krankheitsbild der Kapselkontraktur verhindert bzw. eingeschränkt werden. Es handelt sich bei dieser Form der Prophylaxe um eine „lokale Immunmodulation". Man beginnt damit am ersten Tag post operationem. Drei Monate lang wird täglich 1 Filmtbl. à 10 mg Montelukast verabreicht. Seit wir dies praktizieren, haben wir keine De-novo-Kapselkontraktur mehr gesehen.

Dieselbe Medikation wird zur Behandlung der Kapselkontraktur empfohlen. Ein anderer Leukotrienrezeptorblocker mit noch besserer Wirkung ist das Zafirlukast (Accolate®). Täglich werden hiervon 2‑mal 20 mg (auch über mindestens 3 Monate) verabreicht. Allerdings ist Accolate® in Deutschland nicht gelistet. Entscheidend für den Therapieerfolg ist, dass mit der Einnahme von Montelukast und auch Accolate® so früh wie möglich, also bei den ersten (klinischen) Anzeichen für Kapselkontraktur, begonnen wird. Bei länger bestehendem Baker-Stadium IV ist die Behandlung effektlos. Für die Verordnung von Montelukast® und Accolate® sind die strikten Bedingungen des Off-Label Use zu beachten.

Haartransplantation

Zusammenfassung

Die Zahl der Haartransplantationen steigt kontinuierlich an, bedingt durch „Prominentenouting" und die im Zusammenhang damit sehr guten und natürlich wirkenden Operationsergebnisse. Ästhetische Resultate erzielte man v. a. durch Einführung mikrochirurgischer Operationstechniken und ständige Weiterentwicklung von Instrumenten und Hilfsmitteln. Neu sind in diesem Zusammenhang die roboterassistierte Entnahme der Haarwurzeln sowie das weitestgehend atraumatische „Punchen" der sog. Follicular Units mit stumpfen, hexagonalen und Hybridbohrsystemen. Eine weitere Verbesserung im Transplantationsprozess ist die Verlängerung der „out-of-body-time" von Haarwurzelzellen durch energiereiche Speicherlösungen und die möglichst atraumatische Transplantation in die Hautempfängerkanälchen mithilfe von Haarwurzelimplantersystemen.

Brustimplantate aus männlicher Sicht

Zusammenfassung

Die vorliegende Arbeit beschäftigt sich mit den Einstellungen von Männern zu Brustimplantaten bei Frauen. Methode: Es wurde ein Fragebogen selbst konzipiert mit 6 Fragen zu persönlichen Angaben und 16 Items zur Einstellung zu Brustimplantaten und zur Partnerschaft. Außerdem wurde die Ausprägung der Persönlichkeitsdimension Extraversion erfasst. Ergebnisse: Die Daten von 81 jungen Männern konnten ausgewertet werden. Die meisten Männer (75 %) haben eine Vorliebe für große Brüste, rund 10 % der befragten Männer fanden große Brüste eher abstoßend. 31–44 % der Männer haben negative Einstellungen zu Brustimplantaten. Nur rund 25 % der Männer finden Brustimplantate angenehm bzw. geschmackvoll, diese Quote wächst aber auf bis zu 40 % hinsichtlich der Attribute „attraktiv" und „erotisch". Beziehungsstatus und Dauer der Partnerlosigkeit haben keinen Einfluss, eher bewerteten Langzeitsingles Brustimplantate negativer als die anderen Gruppen. Die Selbsteinstufung der eigenen Attraktivität wie auch die Persönlichkeitsdimension Introversion/Extraversion des Mannes hatten keinen Einfluss. Insgesamt gibt es bei rund 45 % der Befragten noch deutliche Vorurteile gegen eine künstlich vergrößerte Brust von Frauen.

Octenidindihydrochlorid

Unklare, rötliche Plaque auf der linken Fußsohle

Befragung zur Diagnostik und Therapie bei Patienten mit Lymphödem und Lipödem

Zusammenfassung

Hintergrund und Fragestellung

Die Umsetzung der Leitlinienempfehlungen bezüglich der Diagnose und Therapie des Lipödems und Lymphödems scheint im Alltag Probleme zu bereiten. Daten dazu für die Versorgung in Deutschland sind rar. Ziel war eine Datensammlung zur Diagnostik und Therapie lymphologischer Erkrankungen im ambulanten Setting.

Methoden

Es erfolgte eine monozentrisch, prospektive Befragung von Patienten der lymphologischen ambulanten Sprechstunde mithilfe eines standardisierten Fragebogens zu Diagnostik und Therapie des Lipödems und Lymphödems bei Erstdiagnose.

Ergebnisse

Eingeschlossen wurden 72 Patienten (83,3 % Frauen) mit einem im Venenzentrum der Dermatologischen und Gefäßchirurgischen Kliniken diagnostisch gesicherten Lymphödem (n = 26), Lipödem (n = 14) oder Lipolymphödem (n = 32); 44,4 % hatten mehr als 5 Jahre vor Erstdiagnose Beschwerden. Die häufigsten Beschwerden waren Bein- und Fußschwellungen (besonders Lymphödem) und Schweregefühl (besonders Lipödem). In 75 % der Fälle wurde die Erstdiagnose durch einen Facharzt gestellt. Die von den Leitlinien empfohlene lymphologische Basisdiagnostik aus Anamnese (73,6 %) und klinischer Untersuchung (84,7 %) fand mehrheitlich statt. Nach der Erstdiagnose erhielten 46 % der Patienten eine Entstauungsphase von unterschiedlicher Qualität und Intensität; 58,3 % der Patienten erhielten unmittelbar eine Kompressionsstrumpfversorgung. Anleitungen zu Atemübungen (22,2 %), Eigendrainage (6,9 %) oder Muskelübungen (8,3 %) fanden nur bei wenigen Patienten statt.

Diskussion

Es bestehen weiterhin Defizite in der Diagnostik und insbesondere der Therapie lymphologischer Erkrankungen im ambulanten Setting. Fortbildungs- und Schulungsangebote für Ärzte, Physiotherapeuten und Fachhandel sowie aber auch für Patienten sind sinnvoll und notwendig.

Klärung von Begriffen für die Wundbehandlung

Akute Überempfindlichkeitsreaktionen auf monoklonale Antikörper zur zielgerichteten Therapie

Zusammenfassung

Die bei Anwendung von monoklonalen Antikörpern zur zielgerichteten Therapie auftretenden akuten Überempfindlichkeitsreaktionen sind pathophysiologisch heterogen. Auf übergeordneter Ebene können sie in Bezug auf die Pathophysiologie in echte allergische und nichtallergische Reaktionen unterteilt werden. Zu den nichtallergischen akuten Überempfindlichkeitsreaktionen zählen typische infusionsabhängige Reaktionen, die gewöhnlich bereits bei erster Anwendung auftreten und bei Folgeanwendung in ihrer Symptomatik abnehmen. Echte allergische Reaktionen manifestieren sich in der Regel nicht bei erster Anwendung, da eine Sensibilisierungsphase vorausgehen muss. Bei Vorliegen präformierter oder kreuzreagierender Antikörper können Immunglobulin (Ig)E-mediierte Reaktionen aber auch bereits bei erster Anwendung auftreten. Die Therapie akuter Überempfindlichkeitsreaktionen auf monoklonale Antikörper erfolgt in Abhängigkeit des Schweregrades.

Akute Notfälle in der Onkologie

Zusammenfassung

Das Spektrum dermatoonkologischer Notfälle ist vielgestaltig, und diese werden aufgrund der dominierenden Patientenzahlen und neuer therapiebedingter Überlebensraten fortgeschrittener Erkrankungsstadien vorrangig beim malignen Melanom beobachtet. Dermatoonkologische Patienten kommen mit den Symptomen Übelkeit und Emesis, unerwarteten neurologischen Ausfällen, mit gastrointestinalen Problemen bis hin zum akuten Abdomen und akuter Atemnot oder Hämoptysen in die Klinik. Hinzu kommen hämatologisch notfallmäßige Abklärungen und Versorgung von z. B. Anämie und Leukopenie. Neben einer standardmäßigen notfallmedizinischen Versorgung bedürfen die durch Metastasen und/oder Therapien verursachten akuten Probleme vielfach hinsichtlich des operativen, strahlentherapeutischen und medikamentösen Vorgehens einer interdisziplinären Tumorkonferenz, um so unter Berücksichtigung der Gesamtsituation des Patienten das Vorgehen zu optimieren. Der Beitrag befasst sich mit akuten organspezifischen Notfällen, gibt medikamentöse Empfehlungen und Abwägungen für therapeutische Entscheidungen bis hin zur ganzheitlich supportiven Therapie schwersterkrankter onkologischer Patienten. Neben stadienadaptierter Schmerztherapie werden supportiv ergänzende Maßnahmen wie Nahrungsergänzung, Einsatz von Dronabinol bei Inappetenz und antipruriginöse Therapie umrissen. Ziel des Beitrags ist eine kurze und prägnante Darstellung der häufigsten dermatoonkologischen Notfallsituationen unter Verweis auf die jeweilige ausführliche Literatur der zugehörigen Fachgesellschaften und Leitlinien.

Rudolf Happle zum 80. Geburtstag

Physikalische und chemische Notfälle in der Dermatologie

Zusammenfassung

Physikalische und chemische Notfälle ereignen sich häufig durch Haushalts- oder Arbeitsunfälle. Unabhängig vom Fachgebiet und außerhalb von spezialisierten Zentren kann sich ein Mediziner mit der Situation einer Erst- oder Zweitversorgung konfrontiert sehen. Die Identifizierung der jeweiligen Noxe, eine schnelle Beurteilung des Ausmaßes und der Schwere des Gewebeschadens sind essenziell, um eine frühzeitige Verlegung in ein spezialisiertes Verbrennungszentrum einzuleiten. Gewebeschäden des Schweregrades 2b werden in der Regel chirurgisch versorgt. Kleinere und oberflächliche Schäden können konservativ behandelt werden. Auch vermeintlich ungefährliche und frei verkäufliche Arzneimittel können zu schweren Gewebeschäden führen.

Neurophysiologie des atopischen Pruritus

Zusammenfassung

Pruritus ist eines der häufigsten Symptome von entzündlichen Hauterkrankungen und beeinträchtigt signifikant die Lebensqualität. Obwohl die Empfindung und die Reizweiterleitung von Pruritus und Schmerz eng miteinander verflochten sind, stellt der Pruritus eine eigene Sinnesqualität dar, die auf neurophysiologischer Ebene deutlich von der Schmerzempfindung abgegrenzt werden kann. Die pathophysiologischen Grundlagen von chronischem und akutem Pruritus sind bisher noch nicht vollständig verstanden. Neben Histamin ist mittlerweile eine Vielzahl von Neuromediatoren des Pruritus, wie Neurotrophine, Neuropeptide und deren Rezeptoren, bekannt. Bei der atopischen Dermatitis führt die Ausschüttung dieser Mediatoren zur Aktivierung von Immunzellen, wie Mastzellen und eosinophilen Granulozyten, die ihrerseits Neuromediatoren und Zytokine freisetzen und somit zu einer Aktivierung von peripheren Nervenfasern beitragen. Dieser Übersichtsbeitrag stellt die neurophysiologischen Zusammenhänge der Regulation des Pruritus bei atopischer Dermatitis dar.

Mikrobiom, atopisches Ekzem und Blockade der Typ-2-Immunität

Zusammenfassung

Ungefähr 20 % der Kinder und ca. 3 % der Erwachsenen in Deutschland und anderen Industrieländern sind am atopischen Ekzem erkrankt, bei steigender Prävalenz. Die Ätiologie ist immer noch nicht abschließend geklärt, aber eine durch T-Helfer-Zellen vom Typ 2 vermittelte Immunreaktion (Typ-2-Immunität) ist für die Entzündung der Haut dominierend. Bei der Suche nach den zugrunde liegenden Pathogenitätsmechanismen sowie der Entwicklung von verbesserten Präventions- und Therapiemöglichkeiten richtet sich die Aufmerksamkeit zunehmend auch auf den Einfluss der mikrobiellen Besiedlung. Dies wird durch die rasche Entwicklung der Mikrobiomanalyse durch Sequenzierung begünstigt. Eine wachsende Zahl von Studien zeigt Zusammenhänge zwischen Störungen des Hautmikrobioms und dem Auftreten des atopischen Ekzems, und einige weisen auch auf Störungen des Darmmikrobioms hin. Dabei wird insbesondere ein Diversitätsverlust hinsichtlich der Zusammensetzung des Mikrobioms beobachtet.

Pathogenese des atopischen Ekzems

Zusammenfassung

Das atopische Ekzem (AE) zählt in Deutschland zu den häufigsten chronisch-entzündlichen Erkrankungen und ist einer der Hauptgründe, einen Hautarzt aufzusuchen. In den letzten Jahren wuchs das Kenntnis um die zellulären, molekularen und immunologischen Zusammenhänge sowie genetischen Veränderungen rasant. Dies ermöglicht ein besseres Verständnis der Erkrankung. Konsequenterweise befinden sich aktuell innovative zielgerichtete Therapien in klinischer Entwicklung bzw. bereits in der Zulassung. Um aber diese neuen Therapien sinnvoll einsetzen zu können, ist ein noch genaueres Verständnis der Pathogenese wichtig. In Zukunft werden die Stratifizierung von Patienten mit AE und die daraus folgende personalisierte Therapie an Bedeutung gewinnen. In der vorliegenden Übersicht wird der aktuelle Kenntnisstand der komplexen Pathogenese des AE dargestellt.

Panorama Dermatologische Praxis

Externe Therapie des atopischen Ekzems

Zusammenfassung

Das atopische Ekzem (AE) ist eine chronisch-rezidivierend verlaufende, entzündliche Hauterkrankung, die mit starkem Juckreiz und hohem Leidensdruck einhergeht. Aufgrund einer genetisch determinierten Hautbarrierestörung zeigen die betroffenen Patienten eine ausgeprägte Xerosis cutis und eine Tendenz zur mikrobiellen Superinfektionen. Milde und mittelschwere Verlaufsformen der Erkrankung sind häufig; diese können rein äußerlich zumeist erfolgreich behandelt werden. Grundlegend ist das Zusammenspiel zwischen einer Basistherapie mit Anwendung barrierestabilisierender und hautreinigender Externa und einer medikamentösen Therapie mit topischen Glukokortikosteroiden und topischen Kalzineurininhibitoren. Im Fall häufig rezidivierender Ekzeme trotz konsequenter antiinflammatorischer Therapie im Schub stellt das Konzept der proaktiven Therapie eine wichtige Behandlungsoption dar. Grundsätzlich gilt es, die Patienten aktiv in die Behandlungsplanung einzubeziehen und bei der Therapieauswahl individuelle Faktoren wie Patientenalter, Hautzustand, Lokalisation entzündeter Hautareale sowie saisonal-klimatische Faktoren zu berücksichtigen. Neue, vielversprechende Therapieansätze mit topischen Phosphodiesterasehemmern und topischen Januskinaseinhibitoren werden derzeit in klinischen Studien erprobt und könnten das Therapiespektrum der externen Behandlungsoptionen erweitern. Dieser Übersichtsbeitrag erläutert die aktuelle Vorgehensweise und neue Perspektiven der externen Therapie des AE.

Neurodermitis-Erwachsenenschulung nach dem Konzept der „Arbeitsgemeinschaft Neurodermitisschulung für Erwachsene“ (ARNE)

Zusammenfassung

Die atopische Dermatitis (AD) ist eine chronisch entzündliche Hauterkrankung mit einer 1‑Jahres-Prävalenz im Erwachsenenalter von 2–3 %. Zur Verbesserung der ambulanten Versorgungssituation dieser Patienten wurde durch die Arbeitsgemeinschaft Neurodermitisschulung im Erwachsenenalter (ARNE) im Rahmen einer nationalen randomisierten, kontrollierten Multicenterstudie mit Wartekontrollgruppendesign ein Programm zur strukturierten Schulung im ambulanten Setting entwickelt und evaluiert. Die Teilnahme an dieser 12-stündigen, interdisziplinär geleiteten Kleingruppenschulung führte bei den Patienten (n = 168) im Vergleich zur Wartekontrollgruppe (n = 147) 1 Jahr nach Teilnahme an der Schulung zu einer signifikant stärkeren Verbesserung sowohl der Coping-Strategien im Hinblick auf Juckreiz (erfasst anhand des Juckreiz-Kognitions-Fragebogens, p < 0,001) als auch der Lebensqualität (Skindex-29, p < 0,001). Darüber hinaus zeigte sich bei den geschulten Patienten eine vergleichsweise stärkere Verringerung der Krankheitsschwere (SCORAD-Index; p < 0,001). In dieser ersten randomisierten, kontrollierten Studie zur Erwachsenenschulung bei Neurodermitis ließen sich somit signifikante positive Effekte sowohl auf psychosoziale Parameter als auch auf die Krankheitsschwere erzielen.

Erratum: Medikamentöse Therapie der Acne inversa

Erratum zu:

Hautarzt 2017

http://ift.tt/2GDVMZW

Sehr geehrte Leserin, sehr geehrter Leser,

im oben genannten Beitrag ist im Abschnitt „Systemische Therapien", „Biologika in der Therapie der Acne inversa" bei der Dosierungsangabe von Adalimumab leider ein Fehler unterlaufen. Der …

Atopisches Ekzem

Aktuelle Aspekte in der Prognose des fortgeschrittenen Melanoms

Zusammenfassung

Die Behandlung des metastasierten malignen Melanoms hat sich in den letzten Jahren rapide verändert: Immuncheckpointinhibitoren und zielgerichtete Therapie haben ihren Weg in die klinische Routine gefunden und die wenig wirksamen Chemotherapien verdrängt. Auch in der adjuvanten Behandlung von Hochrisikopatienten zeigen klinische Studien mit dem Einsatz dieser neuen Therapien Erfolge. Damit hat sich die Prognose von Patienten mit metastasiertem Melanom wesentlich gebessert. Dennoch kommt es häufig zu Rezidiven und Progress der Erkrankung, sodass das fernmetastasierte Melanom nach wie vor mit einer ernsten Prognose einhergeht. Dieser Beitrag soll einen Überblick über aktuelle Therapieverfahren und – soweit absehbar – ihre Bedeutung für den Krankheitsverlauf geben. Zudem sollen Schwerpunkte in der Klassifikation für Melanome, die durch das American Joint Committee of Cancer (AJCC) kürzlich herausgegeben wurden, diskutiert werden, Risikogruppen gewürdigt und ein Ausblick auf neue Therapiestrategien gegeben werden.

Soft-Tissue Anthropometric Norms of Iranians with Proper Occlusion and Inter-Ethnic Norm Comparisons

Abstract

Background

Photographic soft-tissue norms of Iranian race are not reported previously, nor are they compared with other ethnicities. Besides, sex dimorphism is assessed in only very few studies on soft-tissue profile. The aim of this study was to assess the soft-tissue measurements of Iranians with good occlusion and the existing sex dimorphism and to compare the Iranian norms with other ethnicities.

Materials and Methods

Twelve anthropometric variables were measured by a dentist in 100 Iranian subjects with good occlusions. The subjects included 50 males and 50 females. The differences between the two genders, as well as the differences between Iranian norms and the norms in all other ethnicities available in the literature were statistically analyzed using a t test (α = 0.05).

Results

There were significant differences between males and females regarding frontonasal angle (P = 0.0000), mentolabial sulcus (P = 0.0000), vertical height ratio (P = 0.0000), vertical lip–chin ratio (P = 0.0013), nasolabial angle (P = 0.0019), lower vertical height–depth ratio (P = 0.0029), maxillary prognathism (P = 0.0045), and mandibular prognathism (P = 0.0118). The difference in facial convexity was marginally significant (P = 0.0543). Protrusions of both lips and horizontal distance between the lips were not significantly different between sexes (P > 0.2).

Conclusions

Unlike Americans and Brazilians but similar to Koreans, there was considerable sex dimorphism in Iranians. Compared to Iranian men, women might have more convex profiles, more advanced mandibles (unlike all other races studied), more protruded maxillae, lips closer to the middle of nose-chin vertical distance, deeper mentolabial sulci, less protruded noses with higher nose tips, and smaller lower faces.

Nasal Mucosal Cyst a Clinical and Surgical Dilemma

Abstract

A mucous cyst is a lesion which can show a wide range of symptoms but is benign and most of them can even appear several months or even years after nasal surgeries. Size of the displaced epithelial fragment is a crucial factor for the development of the mucous cyst. Complete resection of the mucous cyst is the ideal treatment. Surfing through the literature we came across 18 cases of mucous cyst formation following nasal surgery. Here we describe a mucous cyst which had resulted from a rhinoplasty procedure the patient had undergone earlier in her life.

Single Stage Nipple-Sparing Mastectomy and Reduction Mastopexy in the Ptotic Breast

Purpose. Given the proposed increased risk of nipple-areolar complex (NAC) necrosis, nipple-sparing mastectomy (NSM) is generally not recommended for patients with large or significantly ptotic breasts. NAC preserving strategies in this subgroup include staged or simultaneous NSM and reduction mastopexy. We present a novel approach towards simultaneous NSM and reduction mastopexy in patients with large, ptotic breasts. Methods. Literature pertaining to NSM for women with large, ptotic breasts was reviewed and a surgical approach was designed to allow for simultaneous NSM and reduction mastopexy in such patients. Results. Eight patients underwent bilateral NSM with simultaneous reduction mammaplasty and immediate reconstruction. The majority of breasts demonstrated advanced ptosis (69% grade III, 31% grade II) and the average breast volume excised was 760 grams. In those patients without a history of smoking, NAC necrosis rates were 0%. In those patients with a history of smoking, 83% of breasts experienced NAC necrosis (60% total, 40% partial). One hundred percent of patients who smoked experienced some degree of NAC necrosis. Among breasts with grade II versus grade III ptosis, NAC necrosis rates were roughly equal. Conclusions. Historically, patients with large, ptotic breasts were excluded from NSM due to the proposed increased risk of NAC necrosis. This study demonstrates a safe approach towards NSM and reduction mastopexy using an inferior, wide-based, epithelialized pedicle. While all patients eventually achieved satisfactory results, there was an association between smoking and NAC necrosis. Smoking cessation is paramount to the operation's success.

Soft Tissue Changes Following Combined Anterior Segmental Bimaxillary Orthognathic Procedures

Abstract

Aims & objectives

To analyze the soft tissue response in patients treated by combined anterior segmental bimaxillary procedures.

Methods

A  Prospective, observational and analytical study was carried out for a period of 2 years involving 37 patients with predefined inclusion and exclusion criteria; lateral cephalograms were taken by the same operator on the standardized unit immediately before and 6 months after surgery; hard and soft tissue landmarks were measured in millimeters to both horizontal and vertical reference lines; any differences in distances were recorded as a surgical change; appropriate statistical test was carried; level of significance was p < 0.05.

Results

All patients underwent anterior maxillary osteotomy with 34 anterior mandibular osteotomies, 2 advancement genioplasties and 1 reduction genioplasty. Analysis showed significant angular, horizontal and vertical change. The significant differences in skeletal variables were observed in N–Pg distance, overjet, overbite, U1–NF angle, L1–Mp angle and soft tissue variables like labiomental angle, upper–lower lip protrusion, upper–lower lip length and lower incisor to labrale inferius distance. Nasolabial angle, interlabial gap and upper incisor exposure were extremely significant.

Conclusion

Soft tissue response to surgery is perhaps more predictable after 6 months, so this may be a treatment modality of choice in adult bimaxillary/dentoalveolar protrusion patients who need instant esthetic facial results.

Arthroscopic Management of Synovial Chondromatosis of the Temporomandibular Joint. Case Series and Systematic Review

Abstract

Aim

Synovial chondromatosis (SC) is a benign condition that is characterized by the formation of cartilaginous nodules within the synovial tissue of a joint that may detach and form loose bodies inside the articular space. The purpose of this study is to evaluate the use of surgical arthroscopy for the treatment of SC of the temporomandibular joint (TMJ).

Materials and Methods

A series of six patients treated with arthroscopy (one patient requiring an open arthrotomy due to the size of the loose bodies) in our centre between 1997 and 2016 is presented and results are discussed. A systematic review of the literature of patients with SC treated with arthroscopy or arthroscopy-assisted open arthrotomy is also carried out.

Results

Pain, which was the main symptom in our patients, and maximum mouth opening both improved significantly after surgical treatment. Three of the patients were diagnosed with primary SC, and the other 3 had a previous diagnosis of internal derangement. None of the patients showed signs of relapse during the follow-up period.

Conclusions

Surgical arthroscopy is a minimally invasive procedure that allows the extraction of loose bodies and even partial synovectomy of the affected membrane with good results and without recurrence of the disease. This technique can be useful in cases of SC with loose bodies measuring less than 3 mm or without extra-articular extension.

Ultrasound as an Assessment Method in Predicting Difficult Intubation: A Prospective Clinical Study

Abstract

Objective

Aim of the study is to predict the difficulty in intubation preoperatively using ultrasonography.

Methods

One hundred and thirty-seven patients underwent ultrasound followed by surgery under general anesthesia. A experienced radiologist examined the airway and performed measurements of specific airway parameters: visualization of hyoid bone, visualization of vocal cords through thyroid cartilage, visualization of epiglottis, distance from base of tongue to hyoid bone, distance of hyomental region distance of thyrohyoid region, distance between skin and fat pad thickness to thyroid cartilage, thickness of submental region, distance from epiglottis to skin (above hyoid), and visualization of cricothyroid membrane. After performing ultrasound, patient was presented for surgery. An experienced anesthesiologist who is associated with this study did all the laryngoscopy and intubation.

Results

We were able to visualize all relevant anatomical structures in all the participants using ultrasound. The receiver operating characteristic curve analysis results showed that hyomental is ≤ 1.09 (P value < 0.01) to classify difficult in intubation.

Conclusion

The study shows that ultrasound can reliably image all the airway structures. This study suggests that hyomental distance is a more valid criterion in predicting difficult intubation. Further, case control study is needed for assessing the ease of intubation.

Buccal Fat Pad: A Useful Adjunct Flap in Cleft Palate Repair

Abstract

Aim

The aim of the study is to describe the technique and also the outcome of using buccal fat pad (BFP) as an adjunct flap in cleft palate repair and to report the surgical outcome.

Materials and Methods

All the surgical repairs with BFP were done under general anaesthesia. The use of BFP was indicated in patients who needed a secondary palatal cleft repair, those with wide palatal clefts or patients whose primary palatal cleft repair was complicated intraoperatively by inadvertent tearing of the nasal mucosa. The raw wound surfaces were dressed with Vaseline gauze instilled with Framycetin. All subjects 4 years of age and below had oral toileting with warm saline-soaked gauze after each meal. The other patients had oral toileting with warm saline mouth bath in addition to conventional toothbrushing.

Results

Eight patients were included in this study with an age range of 1–26 years (mean ± SD = 6.1 ± 8.6 years). Three patients presented with wide palatal clefts, another three presented with dehiscence after a primary repair which necessitated a secondary repair, while the remaining two patients had inadvertent iatrogenic tear of the nasal mucosa during the primary surgical repair. For the latter set of patients, repair was completed by the use of BFP as an adjunct at the same surgery. Post-operative evaluation was satisfactory in all cases, with healing of the flaps and complete epithelialization of the BFP in 1 month. All the patients experienced post-operative cheek swelling, signifying the post-operative oedema due to BFP harvest. However, this was usually resolved within 48 h. Healing was satisfactory with full epithelialization, and no complications were observed.

Conclusions

Successful application of BFP as an adjunct flap in palatal cleft closure is demonstrated in these series. It is recommended that cleft surgeons add this technique to their armamentarium in difficult cases, especially in wide palatal cleft repair, secondary palatal cleft repair and in cases of inadvertent tearing of nasal mucosa during primary cleft palate repair.

Comparative Study Between Oral Lorazepam and Diazepam as Sedation in Oral and Maxillofacial Surgery

Abstract

Purpose

The aim of the study was to compare the efficacy of oral lorazepam as night sedation and premedication with diazepam.

Methods

A prospective, randomized, and double-blind study was done in 50 healthy patients in each drug group. The impacted third molar impaction was taken as the study model. Study was carried out after giving bioequivalent doses of respective drugs for either side. All the patients were assessed for quality of sleep, sedation, recall of visual stimuli, cooperation shown by patient and recovery postoperatively.

Results

The study concluded that lorazepam showed more advantages than diazepam as well as patient's preference and satisfaction. However, postoperative recovery with lorazepam was longer than diazepam.

Hemangiopericytoma of Gingiva in a 4-Year-Old Child: A Rare Case Report

Abstract

A hemangiopericytoma is a type of soft tissue sarcoma that originates in the pericytes in the walls of capillaries which was characterized in 1942. It is commonly seen in the age group of 5th–6th decades of adults and only 5–10% of cases occur in children with extreme rare occurrence in head and neck region (16%). A rare case of hemangiopericytoma in a 4-year-old female patient is presented here and its clinical, histopathological and immunohistochemically features are discussed. Though surgical resection remains the mainstay, excisional biopsy was primarily performed to reach the final diagnosis. Even in the follow-up phase of 1 year, no recurrence or no metastatic changes were observed.

Screw and Wire Technique for Condylar Fracture Reduction

Abstract

In case of displaced condylar fractures, ideal reduction during open reduction and internal fixation poses a challenge to the surgeon. This article describes a simple technique to aid reduction with the use of a screw and wire during open treatment.

Leech related Aeromonas veronii complex infection after reconstruction with a microvascular forearm flap

Abstract

Medical leeches (Hirudo medicinalis) in plastic and reconstructive surgery are often used for the treatment of vascular failure after microvascular surgery. Leeches are a reservoir for bacteria of the Aeromonas group that help digesting the blood meal. In some cases these bacteria are able to cause severe wound infections that can lead to loss of tissue transplants. We report about a patient with a common microvascular forearm flap after resection of an oral squamous cell carcinoma which got infected by Aeromonas spp. after treatment with medical leeches. Most of these species are resistant for common antibiotic treatment after surgery. This report shows the importance of an early concomitant antibiotic prophylaxis in the treatment of venous congestion with medical leeches.

Chronic Recurrent Temporomandibular Joint Dislocation: A Comparison of Various Surgical Treatment Options, and Demonstration of the Versatility and Efficacy of the Dautrey’s Procedure

Abstract

Introduction

There has been a changing trend of treating temporomandibular joint subluxation, which range from conservative non-surgical measures to various soft and hard tissue surgical procedures aimed at either augmenting or restricting the condylar path.

Aim

This study was aimed at comparing the efficacy of three major surgical treatment modalities: condylar obstruction creation, obstruction removal and anti-translatory procedures. Also, the location, anatomy and morphology of the TMJs pre- and post-surgery were evaluated and compared using radiographs, sagittal and 3-D Computed Tomographic scans.

Materials and Methods

A 6-year study was carried out on seventy-five patients of various age groups. Twenty-five were operated by the Dautrey's procedure, 25 by articular eminectomy alone and the remaining 25 by eminectomy followed by meniscal plication and tethering. The distribution of patients in the three groups was random. Effectiveness of the surgical procedure and incidence of complications including recurrence were carefully compiled and compared between the three groups.

Results and Conclusion

Dautrey's procedure yielded more gratifying and stable results, leading to a successful and permanent correction of chronic recurrent dislocation of the TMJs, with practically nil complications, thus demonstrating it to be an extremely safe, effective and versatile technique, making the joints function normally and securing sufficient volume of mouth opening. There was observed an average increase in articular tubercle height by 3.65 mm and a mean anterior shift of its lowest point by 4.5 mm following the Dautrey's procedure, which were statistically significant findings. The upper age limit to carry out the Dautrey's procedure can be safely taken up to 45 years.

Clinical and MRI Evaluation of Orthodontic Mini-Screws for Disc Repositioning in Internal Derangement of TMJ: A Prospective Study

Abstract

Purpose

The purpose of this study was to assess the efficacy of orthodontic mini-screws as a modified suture anchor for disc repositioning in cases of internal derangement of the temporomandibular joint.

Patients and Methods

A prospective evaluation of ten patients was undertaken for a period of 6 months using this modified approach from Jan 2014 to Jun 2016. Symptomatic patients with clinical and MRI features suggestive of internal derangement of TMJ and willing to undergo surgical repositioning of articular disc to alleviate symptoms of temporomandibular dysfunction were taken up for the study. Post-operatively, functional outcomes were assessed in terms of reduction in pain, joint movement and absence of joint noise and clicking sounds. Post-operative MRI was used to assess the disc position and morphological changes in the disc and arthritic changes in the condyle.

Results

All patients underwent a surgical repositioning of the anteriorly displaced disc by the modified orthodontic suture anchor. Patients were post-surgically followed up at intervals of 1, 3 and 6 months. Immediate complications in terms of pain, restriction of functional motion and transient facial nerve palsy were noted. Late complications include temporal nerve palsy in one case. All patients experienced significant improvement with good functional outcomes and stable repositioning of disc was noticed at the end of 6 months.

Conclusion

The modified disc repositioning using an orthodontic screw via a mini preauricular approach provided a good functional outcome in all patients as assessed over a period of 6 months. However, the long-term functional sequel of the procedure and changes in the articular disc needs to be assessed.

Paradigm shift in theranostics of neuroendocrine tumors: conceptual horizons of nanotechnology in nuclear medicine

Abstract

We present a comprehensive review of Neuroendocrine Tumors (NET) and the current and developing imaging and therapeutic modalities for NET with emphasis on Nuclear Medicine modalities. Subsequently, nanotechnology and its emerging role in cancer management, especially NET, are discussed. The article is both educative and informative. The objective is to provide an insight into the developments made in nuclear medicine and nanotechnology towards management of NET, individually as well as combined together.

Relationship between collateral circulation and myocardial viability of 18 F-FDG PET/CT subtended by chronic total occluded coronary arteries

Abstract

Objective

To analyze the relationship between the collateral flow of coronary chronic total occlusion (CTO) and myocardial viability detected by ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging.

Methods

A prospective analysis of 104 patients diagnosed by coronary angiography. All patients underwent resting myocardial perfusion imaging and PET/CT within 1 week. The collateral circulation was graded with Rentrop classification as no or poor collateral circulation in 16 CTO vessels, moderate collateral circulation in 34 CTO vessels, and good collateral circulation in 69 CTO vessels. Myocardial viability was determined with myocardial perfusion imaging and PET. The patterns were interpreted as mismatch, match and normal perfusion and ¹⁸F-FDG uptake.

Results

There was no significant correlation between the severity and extent of perfusion defect, myocardial viability and collateral circulation grade. The myocardial viability was normal in mild and moderate hypokinetic regions and decreased in severe hypokinetic and akinesis–dyskinesis regions. The presence of collateral circulation was a sensitive (89%) but not a specific (31%) sign of myocardial viability.

Conclusions

In patients with CTO, collateral circulation does not seem to be an effective way for predicting myocardial viability. Further analysis of PET patterns of viable myocardium is needed to guide further revascularization and predict functional improvement and survival benefit.

Automated segmentation and detection of increased uptake regions in bone scintigraphy using SPECT/CT images

Abstract

Purpose

To develop a method for automated detection of highly integrated sites in SPECT images using bone information obtained from CT images in bone scintigraphy.

Methods

Bone regions on CT images were first extracted, and bones were identified by segmenting multiple regions. Next, regions corresponding to the bone regions on SPECT images were extracted based on the bone regions on CT images. Subsequently, increased uptake regions were extracted from the SPECT image using thresholding and three-dimensional labeling. Last, the ratio of increased uptake regions to all bone regions was calculated and expressed as a quantitative index. To verify the efficacy of this method, a basic assessment was performed using phantom and clinical data.

Results

The results of this analytical method using phantoms created by changing the radioactive concentrations indicated that regions of increased uptake were detected regardless of the radioactive concentration. Assessments using clinical data indicated that detection sensitivity for increased uptake regions was 71% and that the correlation between manual measurements and automated measurements was significant (correlation coefficient 0.868).

Conclusion

These results suggested that automated detection of increased uptake regions on SPECT images using bone information obtained from CT images would be possible.

Is 123 I-metaiodobenzylguanidine heart-to-mediastinum ratio dependent on age? From Japanese Society of Nuclear Medicine normal database

Abstract

Background

Heart-to-mediastinum ratios (HMRs) of ¹²³I-metaiodobenzylguanidine (MIBG) have usually been applied to prognostic evaluations of heart failure and Lewy body disease. However, whether these ratios depend on patient age has not yet been clarified using normal databases.

Methods

We analyzed 62 patients (average age 57 ± 19 years, male 45%) derived from a normal database of the Japanese Society of Nuclear Medicine working group. The HMR was calculated from early (15 min) and delayed (3–4 h) anterior planar ¹²³I-MIBG images. All HMRs were standardized to medium-energy general purpose (MEGP) collimator equivalent conditions using conversion coefficients for the collimator types. Washout rates (WR) were also calculated, and we analyzed whether early and late HMR, and WR are associated with age.

Results

Before standardization of HMR to MEGP collimator conditions, HMR and age did not significantly correlate. However, late HMR significantly correlated with age after standardization: late HMR = − 0.0071 × age + 3.69 (r² = 0.078, p = 0.028), indicating that a 14-year increase in age corresponded to a decrease in HMR of 0.1. Whereas the lower limit (2.5% quantile) of late HMR was 2.3 for all patients, it was 2.5 and 2.0 for those aged ≤ 63 and > 63 years, respectively. Early HMR tended to be lower in subjects with the higher age (p = 0.076), whereas WR was not affected by age.

Conclusion

While late HMR was slightly decreased in elderly patients, the lower limit of 2.2–2.3 can still be used to determine both early and late HMR.

The influence of elevated hormone levels on physiologic accumulation of 68 Ga-DOTATOC

Abstract

Objective

PET/CT imaging with ⁶⁸Ga-1,4,7,10-tetraazacyclododecane-N,N′,N″,N‴-tetraacetic acid-D-Phe¹-Tyr³-octreotide (DOTATOC) is useful in patients with neuroendocrine tumors (NETs). Functioning NETs by definition secrete abnormal levels of hormones, causing clinical symptoms. It is known that physiologic accumulation can be seen in some organs, but it remains unknown whether elevated hormone levels can affect the physiologic accumulation pattern of ⁶⁸Ga-DOTATOC. We aimed to investigate the influence of higher hormone levels on physiologic accumulation of ⁶⁸Ga-DOTATOC.

Methods

A total of 167 patients with known or suspected NET lesions were enrolled in this study. The numbers of patients with elevations of ACTH, gastrin, insulin, and no elevation were 10, 25, 7, and 125, respectively. We compared the maximum standardized uptake value (SUVmax) in various organs of each group.

Results

In the group with elevated ACTH levels, SUVmax in the pituitary gland, the uncinate process of the pancreas and adrenal glands was lower than those in the group with no elevation (5.7 ± 1.9 vs. 8.4 ± 3.1, P = 0.015; 4.7 ± 3.5 vs. 6.4 ± 2.8, P = 0.037; 10.8 ± 4.8 vs. 13.9 ± 4.7, P = 0.020, respectively). There were no differences in physiologic uptake of ⁶⁸Ga-DOTATOC in the thyroid gland, the pancreatic body, the liver, the spleen, the bowel, or the kidney.

Conclusions

In NET patients with elevated ACTH levels, physiologic uptake of ⁶⁸Ga-DOTATOC in the pituitary gland, the uncinate process of the pancreas and adrenal glands was significantly decreased. Other organs were unaffected.

18 F-FPYBF-2, a new F-18-labelled amyloid imaging PET tracer: first experience in 61 volunteers and 55 patients with dementia

Abstract

Objective

Recently, we developed a benzofuran derivative for the imaging of β-amyloid plaques, 5-(5-(2-(2-(2-¹⁸F-fluoroethoxy)ethoxy)ethoxy)benzofuran-2-yl)-N-methylpyridin-2-amine (¹⁸F-FPYBF-2) (Ono et al., J Med Chem 54:2971–9, 2011). The aim of this study was to assess the feasibility of ¹⁸F-FPYBF-2 as an amyloid imaging PET tracer in a first clinical study with healthy volunteers and patients with various dementia and in comparative dual tracer study using ¹¹C-Pittsburgh Compound B (¹¹C-PiB).

Methods

61 healthy volunteers (age: 53.7 ± 13.1 years old; 19 male and 42 female; age range 24–79) and 55 patients with suspected dementia [Alzheimer's Disease (AD); early AD: n = 19 and moderate stage AD: n = 8, other dementia: n = 9, mild cognitive impairment (MCI): n = 16, cognitively normal: n = 3] for first clinical study underwent static head PET/CT scan using ¹⁸ F⁻ FPYBF-2 at 50–70 min after injection. 13 volunteers and 14 patients also underwent dynamic PET scan at 0–50 min at the same instant. 16 subjects (volunteers: n = 5, patients with dementia: n = 11) (age: 66.3 ± 14.2 years old; 10 males and 6 females) were evaluated for comparative study (50–70 min after injection) using ¹⁸F-FPYBF-2 and ¹¹C-PiB on separate days, respectively. Quantitative analysis of mean cortical uptake was calculated using Mean Cortical Index of SUVR (standardized uptake value ratio) based on the established method for ¹¹C-PiB analysis using cerebellar cortex as control.

Results

Studies with healthy volunteers showed that ¹⁸F-FPYBF-2 uptake was mainly observed in cerebral white matter and that average Mean Cortical Index at 50–70 min was low and stable (1.066 ± 0.069) basically independent from age or gender. In patients with AD, ¹⁸F-FPYBF-2 uptake was observed both in cerebral white and gray matter, and Mean Cortical Index was significantly higher (early AD: 1.288 ± 0.134, moderate AD: 1.342 ± 0.191) than those of volunteers and other dementia (1.018 ± 0.057). In comparative study, the results of ¹⁸F-FPYBF-2 PET/CT were comparable with those of ¹¹C-PiB, and the Mean Cortical Index (¹⁸F-FPYBF-2: 1.173 ± 0.215; ¹¹C-PiB: 1.435 ± 0.474) showed direct proportional relationship with each other (p < 0.0001).

Conclusions

Our first clinical study suggest that ¹⁸F-FPYBF-2 is a useful PET tracer for the evaluation of β-amyloid deposition and that quantitative analysis of Mean Cortical Index of SUVR is a reliable diagnostic tool for the diagnosis of AD.

Open letter to journal editors on: International Consensus Radiochemistry Nomenclature Guidelines

Decision support system for the planning of minimally invasive aortic valve replacement surgery

Abstract

Purpose

Minimally invasive aortic valve replacement (MIAVR) procedures remain more complex and technically challenging compared to conventional full sternotomy surgery. This technique involves a restricted surgical field and a limited workspace, which is, at present, strictly reserved for the most experienced surgeons. The MIAVR clinical outcomes are strongly dependent on the appropriate choice of the thoracic incision. This work presents a decision support system to optimize, through an interactive visualization interface, the exposure of the target structure in a limited field of view.

Methods

Our approach is based on the computation of relevant anatomical measurements from preoperative CT images, and it takes into account the surgical guidelines in order to propose the surgical access that best fits the patient's morphology.

Results

The proposed planning system was applied and tested on 30 datasets from patients affected by severe aortic stenosis for validation purposes. We evaluated the accuracy of the automatic detections and the measurements calculated by the system with those chosen manually by the expert.

Conclusions

In 87% of thirty cases, the surgical strategy proposed by the decision support system was correct. For the remaining cases, the graphical user interface (GUI) allowed the user to manually adjust the anatomical features.

Development of a vibration haptic simulator for shoulder arthroplasty

Abstract

Purpose

Glenoid reaming is a technically challenging step during shoulder arthroplasty that could possibly be learned during simulation training. Creation of a realistic simulation using vibration feedback in this context is innovative. Our study focused on the development and internal validation of a novel glenoid reaming simulator for potential use as a training tool.

Methods

Vibration and force profiles associated with glenoid reaming were quantified during a cadaveric experiment. Subsequently, a simulator was fabricated utilizing a haptic vibration transducer with high- and low-fidelity amplifiers; system calibration was performed matching vibration peak–peak values for both amplifiers. Eight experts performed simulated reaming trials. The experts were asked to identify isolated layer profiles produced by the simulator. Additionally, experts' efficiency to successfully perform a simulated glenoid ream based solely on vibration feedback was recorded.

Results

Cadaveric experimental cartilage reaming produced lower vibrations compared to subchondral and cancellous bones ( \(p\le 0.03\) ). Gain calibration of a lower-fidelity (3.5  \({g}_{\mathrm{pk-pk}}, 0.36\,{g}_{\mathrm{rms}})\) and higher-fidelity (3.4  \({g}_{\mathrm{pk-pk}}, 0.33\,{g}_{\mathrm{rms}})\) amplifier resulted in values similar to the cadaveric experimental benchmark (3.5  \({g}_{\mathrm{pk-pk}}, 0.30\,{g}_{\mathrm{rms}})\) . When identifying random tissue layer samples, experts were correct \(52\pm 9\%\) of the time and success rate varied with tissue type ( \(p=0.003\) ). During simulated reaming, the experts stopped at the targeted subchondral bone with a success rate of \(78\pm 24\%\) . The fidelity of the simulation did not have an effect on accuracy, applied force, or reaming time ( \(p>0.05\) ). However, the applied force tended to increase with trial number ( \(p=0.047\) ).

Conclusions

Development of the glenoid reaming simulator, coupled with expert evaluation furthered our understanding of the role of haptic vibration feedback during glenoid reaming. This study was the first to (1) propose, develop and examine simulated glenoid reaming, and (2) explore the use of haptic vibration feedback in the realm of shoulder arthroplasty.

IMHOTEP: virtual reality framework for surgical applications

Abstract

Purpose

The data which is available to surgeons before, during and after surgery is steadily increasing in quantity as well as diversity. When planning a patient's treatment, this large amount of information can be difficult to interpret. To aid in processing the information, new methods need to be found to present multimodal patient data, ideally combining textual, imagery, temporal and 3D data in a holistic and context-aware system.

Methods

We present an open-source framework which allows handling of patient data in a virtual reality (VR) environment. By using VR technology, the workspace available to the surgeon is maximized and 3D patient data is rendered in stereo, which increases depth perception. The framework organizes the data into workspaces and contains tools which allow users to control, manipulate and enhance the data. Due to the framework's modular design, it can easily be adapted and extended for various clinical applications.

Results

The framework was evaluated by clinical personnel (77 participants). The majority of the group stated that a complex surgical situation is easier to comprehend by using the framework, and that it is very well suited for education. Furthermore, the application to various clinical scenarios—including the simulation of excitation propagation in the human atrium—demonstrated the framework's adaptability. As a feasibility study, the framework was used during the planning phase of the surgical removal of a large central carcinoma from a patient's liver.

Conclusion

The clinical evaluation showed a large potential and high acceptance for the VR environment in a medical context. The various applications confirmed that the framework is easily extended and can be used in real-time simulation as well as for the manipulation of complex anatomical structures.

A hybrid image fusion system for endovascular interventions of peripheral artery disease

Abstract

Purpose

Interventional endovascular treatment has become the first line of management in the treatment of peripheral artery disease (PAD). However, contrast and radiation exposure continue to limit the feasibility of these procedures. This paper presents a novel hybrid image fusion system for endovascular intervention of PAD. We present two different roadmapping methods from intra- and pre-interventional imaging that can be used either simultaneously or independently, constituting the navigation system.

Methods

The navigation system is decomposed into several steps that can be entirely integrated within the procedure workflow without modifying it to benefit from the roadmapping. First, a 2D panorama of the entire peripheral artery system is automatically created based on a sequence of stepping fluoroscopic images acquired during the intra-interventional diagnosis phase. During the interventional phase, the live image can be synchronized on the panorama to form the basis of the image fusion system. Two types of augmented information are then integrated. First, an angiography panorama is proposed to avoid contrast media re-injection. Information exploiting the pre-interventional computed tomography angiography (CTA) is also brought to the surgeon by means of semiautomatic 3D/2D registration on the 2D panorama. Each step of the workflow was independently validated.

Results

Experiments for both the 2D panorama creation and the synchronization processes showed very accurate results (errors of 1.24 and \(2.6 \pm 1.4\)  mm, respectively), similarly to the registration on the 3D CTA (errors of \(1.5 \pm 0.7\)  mm), with minimal user interaction and very low computation time. First results of an on-going clinical study highlighted its major clinical added value on intraoperative parameters.

Conclusion

No image fusion system has been proposed yet for endovascular procedures of PAD in lower extremities. More globally, such a navigation system, combining image fusion from different 2D and 3D image sources, is novel in the field of endovascular procedures.

Automated surgical skill assessment in RMIS training

Abstract

Purpose

Manual feedback in basic robot-assisted minimally invasive surgery (RMIS) training can consume a significant amount of time from expert surgeons' schedule and is prone to subjectivity. In this paper, we explore the usage of different holistic features for automated skill assessment using only robot kinematic data and propose a weighted feature fusion technique for improving score prediction performance. Moreover, we also propose a method for generating 'task highlights' which can give surgeons a more directed feedback regarding which segments had the most effect on the final skill score.

Methods

We perform our experiments on the publicly available JHU-ISI Gesture and Skill Assessment Working Set (JIGSAWS) and evaluate four different types of holistic features from robot kinematic data—sequential motion texture (SMT), discrete Fourier transform (DFT), discrete cosine transform (DCT) and approximate entropy (ApEn). The features are then used for skill classification and exact skill score prediction. Along with using these features individually, we also evaluate the performance using our proposed weighted combination technique. The task highlights are produced using DCT features.

Results

Our results demonstrate that these holistic features outperform all previous Hidden Markov Model (HMM)-based state-of-the-art methods for skill classification on the JIGSAWS dataset. Also, our proposed feature fusion strategy significantly improves performance for skill score predictions achieving up to 0.61 average spearman correlation coefficient. Moreover, we provide an analysis on how the proposed task highlights can relate to different surgical gestures within a task.

Conclusions

Holistic features capturing global information from robot kinematic data can successfully be used for evaluating surgeon skill in basic surgical tasks on the da Vinci robot. Using the framework presented can potentially allow for real-time score feedback in RMIS training and help surgical trainees have more focused training.

High dynamic range ultrasound imaging

Abstract

Purpose

High dynamic range (HDR) imaging is a popular computational photography technique that has found its way into every modern smartphone and camera. In HDR imaging, images acquired at different exposures are combined to increase the luminance range of the final image, thereby extending the limited dynamic range of the camera. Ultrasound imaging suffers from limited dynamic range as well; at higher power levels, the hyperechogenic tissue is overexposed, whereas at lower power levels, hypoechogenic tissue details are not visible. In this work, we apply HDR techniques to ultrasound imaging, where we combine ultrasound images acquired at different power levels to improve the level of detail visible in the final image.

Methods

Ultrasound images of ex vivo and in vivo tissue are acquired at different acoustic power levels and then combined to generate HDR ultrasound (HDR-US) images. The performance of five tone mapping operators is quantitatively evaluated using a similarity metric to determine the most suitable mapping for HDR-US imaging.

Results

The ex vivo and in vivo results demonstrated that HDR-US imaging enables visualizing both hyper- and hypoechogenic tissue at once in a single image. The Durand tone mapping operator preserved the most amount of detail across the dynamic range.

Conclusions

Our results strongly suggest that HDR-US imaging can improve the utility of ultrasound in image-based diagnosis and procedure guidance.

Fully automatic detection of renal cysts in abdominal CT scans

Abstract

Purpose

Simple renal cysts are a common benign finding in abdominal CT scans. However, since they may evolve in time, simple cysts need to be reported. With an ever-growing number of slices per CT scan, cysts are easily overlooked by the overloaded radiologist. In this paper, we address the detection of simple renal cysts as an incidental finding in a real clinical setting.

Methods

We propose a fully automatic framework for renal cyst detection, supported by a robust segmentation of the kidneys performed by a fully convolutional neural network. A combined 3D distance map of the kidneys and surrounding fluids provides initial candidates for cysts. Eventually, a second convolutional neural network classifies the candidates as cysts or non-cyst objects.

Results

Performance was evaluated on 52 abdominal CT scans selected at random in a real radiological workflow and containing over 70 cysts annotated by an experienced radiologist. Setting the minimal cyst diameter to 10 mm, the algorithm detected 59/70 cysts (true-positive rate = 84.3%) while producing an average of 1.6 false-positive per case.

Conclusions

The obtained results suggest the proposed framework is a promising approach for the automatic detection of renal cysts as incidental findings of abdominal CT scans.

Retrieval and registration of long-range overlapping frames for scalable mosaicking of in vivo fetoscopy

Abstract

Purpose

The standard clinical treatment of Twin-to-Twin transfusion syndrome consists in the photo-coagulation of undesired anastomoses located on the placenta which are responsible to a blood transfer between the two twins. While being the standard of care procedure, fetoscopy suffers from a limited field-of-view of the placenta resulting in missed anastomoses. To facilitate the task of the clinician, building a global map of the placenta providing a larger overview of the vascular network is highly desired.

Methods

To overcome the challenging visual conditions inherent to in vivo sequences (low contrast, obstructions or presence of artifacts, among others), we propose the following contributions: (1) robust pairwise registration is achieved by aligning the orientation of the image gradients, and (2) difficulties regarding long-range consistency (e.g. due to the presence of outliers) is tackled via a bag-of-word strategy, which identifies overlapping frames of the sequence to be registered regardless of their respective location in time.

Results

In addition to visual difficulties, in vivo sequences are characterised by the intrinsic absence of gold standard. We present mosaics motivating qualitatively our methodological choices and demonstrating their promising aspect. We also demonstrate semi-quantitatively, via visual inspection of registration results, the efficacy of our registration approach in comparison with two standard baselines.

Conclusion

This paper proposes the first approach for the construction of mosaics of placenta in in vivo fetoscopy sequences. Robustness to visual challenges during registration and long-range temporal consistency are proposed, offering first positive results on in vivo data for which standard mosaicking techniques are not applicable.

Trackerless panoramic optoacoustic imaging: a first feasibility evaluation

Abstract

Purpose

Optoacoustic imaging provides high spatial resolution and the possibility to image specific functional parameters in real-time, therefore positioning itself as a promising modality for various applications. However, despite these advantages, the applicability of real-time optoacoustic imaging is generally limited due to a relatively small field of view.

Methods

With this work, we aim at presenting a path towards panoramic optoacoustic tomographic imaging without requiring additional sensors or position trackers. We propose a two-step seamless stitching method for the compounding of multiple datasets acquired with a real-time 3D optoacoustic imaging system within a panoramic scan. The employed workflow is specifically tailored to the image properties and respective challenges.

Results

A comparison of the presented alignment on in-vivo data shows a mean error of \(628 \pm 512\,\upmu \hbox {m}\) compared to ground truth tracking data. The presented compounding scheme integrates the physical resolution of optoacoustic data and hence can provide improved contrast in comparison with other compounding approaches based on addition or averaging.

Conclusion

The proposed method can produce optoacoustic volumes with an enlarged field of view and improved quality compared to current methods in optoacoustic imaging. However, our study also shows challenges for panoramic scans. In this view, we discuss relevant properties, challenges, and opportunities and present an evaluation of the performance of the presented approach with different input data.

Automatic intraoperative estimation of blood flow direction during neurosurgical interventions

Abstract

Purpose

In neurosurgery, reliable information about blood vessel anatomy and flow direction is important to identify, characterize, and avoid damage to the vasculature. Due to ultrasound Doppler angle dependencies and the complexity of the vascular architecture, clinically valuable 3-D flow direction information is currently not available. In this paper, we aim to clinically validate and demonstrate the intraoperative use of a fully automatic method for estimation of 3-D blood flow direction from freehand 2-D Doppler ultrasound.

Methods

A 3-D vessel model is reconstructed from 2-D Doppler ultrasound and used to determine the vessel architecture. The blood flow direction is then estimated automatically using the model in combination with Doppler velocity data. To enable testing and validation during surgery, the method was implemented as part of the open-source navigation system CustusX (www.custusx.org).

Results

Ten patients were included prospectively. Data from four patients were processed postoperatively, and data from six patients were processed intraoperatively. In total, the blood flow direction was estimated for 48 different blood vessels with a success rate of 98%.

Conclusions

In this work, we have shown that the proposed method is suitable for fully automatic estimation of the blood flow direction in intracranial vessels during neurosurgical interventions. The method has the potential to make the understanding of the complex vascular anatomy and flow pattern more intuitive for the surgeon. The method is compatible with intraoperative use, and results can be presented within the limited time frame where they still are of clinical interest.

Reliability and correlation analysis of computed methods to convert conventional 2D radiological hindfoot measurements to a 3D setting using weightbearing CT

Abstract

Purpose

The exact radiographic assessment of the hindfoot alignment remains challenging. This is reflected in the different measurement methods available. Weightbearing CT (WBCT) has been demonstrated to be more accurate in hindfoot measurements. However, current measurements are still performed in 2D. This study wants to assess the use of computed methods to convert the former uniplanar hindfoot measurements obtained after WBCT towards a 3D setting.

Methods

Forty-eight patients, mean age of 39.6 ± 13.2 years, with absence of hindfoot pathology were included. A WBCT was obtained, and images were subsequently segmented and analyzed using computer-aided design operations. In addition to the hindfoot angle (HA), other ankle and hindfoot parameters such as the anatomical tibia axis, talocalcaneal axis (TCA), talocrural angle, tibial inclination (TI), talar tilt, and subtalar vertical angle were determined in 2D and 3D.

Results

The mean \(\hbox {HA}_{2\mathrm{D}}\) was \(0.79^{\circ }\) of valgus ± 3.2 and the \(\hbox {HA}_{\mathrm{3D}}\) was \(8.08^{\circ }\) of valgus ± 6.5. These angles differed significantly from each other with a \(P<0.001\) . The correlation between both showed to be good by \(\hbox {a}\) Pearson correlation coefficient (r) of 0.72 ( \(P < 0.001\) ). The \(\hbox {ICC}_{\mathrm{3D}}\) showed to be excellent when compared to the \(\hbox {ICC}_{\mathrm{2D}}\) , which was good. Similar findings were obtained in other angles. The highest correlation was seen between the \(\hbox {TI}_{\mathrm{2D}}\) and \(\hbox {TI}_{\mathrm{3D}}\) (r = 0.83, \(P < 0.001\) ) and an almost perfect agreement in the \(\hbox {TCA}_\mathrm{3D}\) ( \(\hbox {ICC}_{\mathrm{3D}}=0.99\) ).

Conclusion

This study shows a good and reliable correlation between the \(\hbox {HA}_{\mathrm{2D}}\) and \(\hbox {HA}_{\mathrm{3D}}\) . However, the \(\hbox {HA}_{\mathrm{3D}}\) overcomes the shortcomings of inaccuracy and provides valuable spatial data that could be incorporated during computer-assisted surgery to assess the multiplanar correction of a hindfoot deformity.

Motion-invariant SRT treatment detection from direct M-scan OCT imaging

Abstract

Purpose

Selective retina therapy (SRT) is a laser treatment targeting specific posterior retinal layers. It is focused on inducing damage to the retinal pigment epithelium (RPE), while sparing other retinal tissue compared to traditional photocoagulation. However, the targeted RPE layer is invisible with most imaging modalities and induced SRT lesions cannot be monitored. In this work, imaging scans acquired from an experimental setup that couples the SRT laser beam with an optical coherence tomography (OCT) beam are analyzed in order to evaluate the treatment as they occur.

Methods

We isolated a small part of the time-resolved scan corresponding to the end of the treatment, for which we have microscopic evidence of the SRT outcome. We then use a convolutional neural network to correspond each scan to the treatment result. We explore which aspects of the scan convey more valuable information for a robust therapy evaluation. By only using this adequately small part, we can achieve an online estimation, while being resilient to eye movement.

Results

The available dataset consists of time- resolved OCT scans of 98 ex vivo porcine eyes, treated with different energy levels. The proposed method yields high performance in the task of predicting whether the applied energy was adequate for SRT treatment, by focusing on the immediate OCT signal acquired during treatment time.

Conclusions

We propose a strategy toward online noninvasive SRT treatment assessment, able to provide a satisfying evaluation of a treatment status, that therefore could be used for the planning of the treatment continuation.

A linear stepping endovascular intervention robot with variable stiffness and force sensing

Abstract

Background/purpose

Robotic-assisted endovascular intervention surgery has attracted significant attention and interest in recent years. However, limited designs have focused on the variable stiffness mechanism of the catheter shaft. Flexible catheter needs to be partially switched to a rigid state that can hold its shape against external force to achieve a stable and effective insertion procedure. Furthermore, driving catheter in a similar way with manual procedures has the potential to make full use of the extensive experience from conventional catheter navigation. Besides driving method, force sensing is another significant factor for endovascular intervention.

Methods

This paper presents a variable stiffness catheterization system that can provide stable and accurate endovascular intervention procedure with a linear stepping mechanism that has a similar operation mode to the conventional catheter navigation. A specially designed shape-memory polymer tube with water cooling structure is used to achieve variable stiffness of the catheter. Hence, four FBG sensors are attached to the catheter tip in order to monitor the tip contact force situation with temperature compensation.

Results

Experimental results show that the actuation unit is able to deliver linear and rotational motions. We have shown the feasibility of FBG force sensing to reduce the effect of temperature and detect the tip contact force. The designed catheter can change its stiffness partially, and the stiffness of the catheter can be remarkably increased in rigid state. Hence, in the rigid state, the catheter can hold its shape against a \(1.8 \, \hbox {N} \,\hbox {cm}\) load. The prototype has also been validated with a vascular phantom, demonstrating the potential clinical value of the system.

Conclusion

The proposed system provides important insights into the design of compact robotic-assisted catheter incorporating effective variable stiffness mechanism and real-time force sensing for intraoperative endovascular intervention.

A cable-driven parallel manipulator with force sensing capabilities for high-accuracy tissue endomicroscopy

Abstract

Purpose

Endomicroscopy (EM) provides high resolution, non-invasive histological tissue information and can be used for scanning of large areas of tissue to assess cancerous and pre-cancerous lesions and their margins. However, current robotic solutions do not provide the accuracy and force sensitivity required to perform safe and accurate tissue scanning.

Methods

A new surgical instrument has been developed that uses a cable-driven parallel mechanism (CPDM) to manipulate an EM probe. End-effector forces are determined by measuring the tensions in each cable. As a result, the instrument allows to accurately apply a contact force on a tissue, while at the same time offering high resolution and highly repeatable probe movement.

Results

0.2 and 0.6 N force sensitivities were found for 1 and 2 DoF image acquisition methods, respectively. A back-stepping technique can be used when a higher force sensitivity is required for the acquisition of high quality tissue images. This method was successful in acquiring images on ex vivo liver tissue.

Conclusion

The proposed approach offers high force sensitivity and precise control, which is essential for robotic EM. The technical benefits of the current system can also be used for other surgical robotic applications, including safe autonomous control, haptic feedback and palpation.

Convolution neural networks for real-time needle detection and localization in 2D ultrasound

Abstract

Purpose

We propose a framework for automatic and accurate detection of steeply inserted needles in 2D ultrasound data using convolution neural networks. We demonstrate its application in needle trajectory estimation and tip localization.

Methods

Our approach consists of a unified network, comprising a fully convolutional network (FCN) and a fast region-based convolutional neural network (R-CNN). The FCN proposes candidate regions, which are then fed to a fast R-CNN for finer needle detection. We leverage a transfer learning paradigm, where the network weights are initialized by training with non-medical images, and fine-tuned with ex vivo ultrasound scans collected during insertion of a 17G epidural needle into freshly excised porcine and bovine tissue at depth settings up to 9 cm and \(40^{\circ }\) – \(75^{\circ }\) insertion angles. Needle detection results are used to accurately estimate needle trajectory from intensity invariant needle features and perform needle tip localization from an intensity search along the needle trajectory.

Results

Our needle detection model was trained and validated on 2500 ex vivo ultrasound scans. The detection system has a frame rate of 25 fps on a GPU and achieves 99.6% precision, 99.78% recall rate and an \({F}_{1}\) score of 0.99. Validation for needle localization was performed on 400 scans collected using a different imaging platform, over a bovine/porcine lumbosacral spine phantom. Shaft localization error of \(0.82^{\circ }\pm 0.4^{\circ }\) , tip localization error of \(0.23\pm 0.05\) mm, and a total processing time of 0.58 s were achieved.

Conclusion

The proposed method is fully automatic and provides robust needle localization results in challenging scanning conditions. The accurate and robust results coupled with real-time detection and sub-second total processing make the proposed method promising in applications for needle detection and localization during challenging minimally invasive ultrasound-guided procedures.

Planning nonlinear access paths for temporal bone surgery

Abstract

Purpose

Interventions at the otobasis operate in the narrow region of the temporal bone where several highly sensitive organs define obstacles with minimal clearance for surgical instruments. Nonlinear trajectories for potential minimally invasive interventions can provide larger distances to risk structures and optimized orientations of surgical instruments, thus improving clinical outcomes when compared to existing linear approaches. In this paper, we present fast and accurate planning methods for such nonlinear access paths.

Methods

We define a specific motion planning problem in \(\mathrm{SE}(3)=\mathbb {R}^3\times \mathrm{SO(3)}\)  with notable constraints in computation time and goal pose that reflect the requirements of temporal bone surgery. We then present \(\kappa \) -RRT-Connect: two suitable motion planners based on bidirectional Rapidly exploring Random Tree (RRT) to solve this problem efficiently.

Results

The benefits of \(\kappa \) -RRT-Connect are demonstrated on real CT data of patients. Their general performance is shown on a large set of realistic synthetic anatomies. We also show that these new algorithms outperform state-of-the-art methods based on circular arcs or Bézier–Splines when applied to this specific problem.

Conclusion

With this work, we demonstrate that preoperative and intra-operative planning of nonlinear access paths is possible for minimally invasive surgeries at the otobasis.

Surgical skills: Can learning curves be computed from recordings of surgical activities?

Abstract

Purpose

Surgery is one of the riskiest and most important medical acts that are performed today. The need to improve patient outcomes and surgeon training, and to reduce the costs of surgery, has motivated the equipment of operating rooms with sensors that record surgical interventions. The richness and complexity of the data that are collected call for new methods to support computer-assisted surgery. The aim of this paper is to support the monitoring of junior surgeons learning their surgical skill sets.

Methods

Our method is fully automatic and takes as input a series of surgical interventions each represented by a low-level recording of all activities performed by the surgeon during the intervention (e.g., cut the skin with a scalpel). Our method produces a curve describing the process of standardization of the behavior of junior surgeons. Given the fact that junior surgeons receive constant feedback from senior surgeons during surgery, these curves can be directly interpreted as learning curves.

Results

Our method is assessed using the behavior of a junior surgeon in anterior cervical discectomy and fusion surgery over his first three years after residency. They revealed the ability of the method to accurately represent the surgical skill evolution. We also showed that the learning curves can be computed by phases allowing a finer evaluation of the skill progression.

Conclusion

Preliminary results suggest that our approach constitutes a useful addition to surgical training monitoring.

In vitro assessment of the accuracy of digital impressions prepared using a single system for full-arch restorations on implants

Abstract

Purpose

This study describes a method for measuring the accuracy of the virtual impression.

Methods

In vitro measurements according to a metrological approach were based on (1) use of an opto-mechanical coordinate measuring machine to acquire 3D points from a master model, (2) the mathematical reconstruction of regular geometric features (planes, cylinders, points) from 3D points or an STL file, and (3) consistent definition and evaluation of position and distance errors describing scanning inaccuracies. Two expert and two inexpert operators each made five impressions. The 3D position error, with its relevant X, Y, and Z components, the mean 3D position error of each scanbody, and the intra-scanbody distance error were measured using the analysis of variance and the Sheffe's test for multiple comparison.

Results

Statistically significant differences in the accuracy of the impression were observed among the operators for each scanbody, despite the good reliability (Cronbach's \(\alpha \) = 0.897). The mean 3D position error of the digital impression was between 0.041 ± 0.023 mm and 0.082 ± 0.030 mm.

Conclusions

Within the limitations of this in vitro study, which was performed using a single commercial system for preparing digital impressions and one test configuration, the data showed that the digital impressions had a level of accuracy comparable to that reported in other studies, and which was acceptable for clinical and technological applications. The distance between the individual positions (#36 to #46) of the scanbody influenced the magnitude of the error. The position error generated by the intraoral scanner was dependent on the length of the arch scanned. Operator skill and experience may influence the accuracy of the impression.

Use the force: deformation correction in robotic 3D ultrasound

Abstract

Purpose

Ultrasound acquisitions are typically affected by deformations due to the pressure applied onto the contact surface. While a certain amount of pressure is necessary to ensure good acoustic coupling and visibility of the anatomy under examination, the caused deformations hinder accurate localization and geometric analysis of anatomical structures. These complications have even greater impact in case of 3D ultrasound scans as they limit the correct reconstruction of acquired volumes.

Methods

In this work, we propose a method to estimate and correct the induced deformation based solely on the tracked ultrasound images and information about the applied force. This is achieved by modeling estimated displacement fields of individual image sequences using the measured force information. By representing the computed displacement fields using a graph-based approach, we are able to recover a deformation-less 3D volume.

Results

Validation is performed on 30 in vivo human datasets acquired using a robotic ultrasound framework. Compared to ground truth, the presented deformation correction shows errors of \(3.39 \, \pm \, 1.86\,\hbox {mm}\) for an applied force of 5 N at a penetration depth of 55 mm.

Conclusion

The proposed technique allows for the correction of deformations induced by the transducer pressure in entire 3D ultrasound volumes. Our technique does not require biomechanical models, patient-specific assumptions or information about the tissue properties; it can be employed based on the information from readily available robotic ultrasound platforms.

Correction to: Nonlinear deformation of tractography in ultrasound-guided low-grade gliomas resection

Abstract

The author would like to include grant number of NSERC Discovery grant in the acknowledgement section of the original article.

Cutaneous posttransplantation lymphoma: clinical features and survival outcomes

The Effect of Psoriatic Arthritis on Ixekizumab Clinical Outcomes in Moderate-to-Severe Psoriasis Patients: A Post Hoc Analysis

Demographics and Outcomes of Microcystic Adnexal Carcinoma

Hair wax for preservation of eyebrows during laser tattoo removal

Ustekinumab treatment is associated with decreased systemic and vascular inflammation in patients with moderate to severe psoriasis: Feasibility study using 18F-fluorodeoxyglucose positron emission tomography-computed tomography

Psoriasis may be associated with metabolic syndrome and an increased risk of cardiovascular disease.; Patients with psoriasis had increased hepatic, splenic, and arterial inflammation, which decreased with ustekinumab therapy.; Ustekinumab treatment was significantly associated with decreased systemic and vascular inflammation related to metabolic syndrome and cardiovascular disease among patients with psoriasis.

Mycoplasma pneumoniae-related erythema multiforme: clinical and histological features. A single center series of 33 cases compared to 100 cases induced by other causes

Clinical aspects of Mycoplasma pneumoniae-related erythema multiforme (MP-EM) have been poorly described, MP-EM has a distinctive presentation compared with non-MP EM with diffuse atypical targets, and severe and extensive mucositis. Histology is similar to toxic epidermal necrolysis. Mucosal involvement management is essential in MP-EM to prevent possible sequelae.

The Timing and Distribution of Non-Scalp Hair Loss in Patients with Lichen Planopilaris and Frontal Fibrosing Alopecia: A Survey-Based Study

Acute effects of PM 2.5 on lung function parameters in schoolchildren in Nanjing, China: a panel study

Abstract

The association between exposure to ambient particulate matter (PM) and reduced lung function parameters has been reported in many works. However, few studies have been conducted in developing countries with high levels of air pollution like China, and little attention has been paid to the acute effects of short-term exposure to air pollution on lung function. The study design consisted of a panel comprising 86 children from the same school in Nanjing, China. Four measurements of lung function were performed. A mixed-effects regression model with study participant as a random effect was used to investigate the relationship between PM_2.5 and lung function. An increase in the current day, 1-day and 2-day moving average PM_2.5 concentration was associated with decreases in lung function indicators. The greatest effect of PM_2.5 on lung function was detected at 1-day moving average PM_2.5 exposure. An increase of 10 μg/m³ in the 1-day moving average PM_2.5 concentration was associated with a 23.22 mL decrease (95% CI: 13.19, 33.25) in Forced Vital Capacity (FVC), a 18.93 mL decrease (95% CI: 9.34, 28.52) in 1-s Forced Expiratory Volume (FEV₁), a 29.38 mL/s decrease (95% CI: -0.40, 59.15) in Peak Expiratory Flow (PEF), and a 27.21 mL/s decrease (95% CI: 8.38, 46.04) in forced expiratory flow 25–75% (FEF_25–75%). The effects of PM_2.5 on lung function had significant lag effects. After an air pollution event, the health effects last for several days and we still need to pay attention to health protection.

Heavy metal accumulation by Corchorus olitorius L. irrigated with wastewater

Abstract

Many agricultural soils in Egypt irrigated with untreated wastewater. Herein, we investigated the effect of untreated industrial wastewater irrigation on the soil and fodder plant Corchorus olittorius (Jew mallow). It also aimed to assess its effect on the growth measurements as well as analyses of soils, irrigation waters, and plants for heavy metal and nutrient concentrations. Significant differences between irrigation waters and soil irrigated with fresh and wastewater were recognized. Wastewater irrigation leads to remarkable reduction in the growth parameters and reduced its vegetative biomass. The concentration of Pb, Cd, Cr, Cu, Fe, and Zn were high significant and above phytotoxic concentrations in leaves (edible part) and roots of wastewater-irrigated plant. The present study indicated that Jew mallow plant tends to phytostabilize (Cd, Ni, and Mn) in its root and had the ability to translocate (Pb, Cu, Cr, Fe, and Zn) to its leaves. Higher concentrations of Cd, Cu, Cr, Pb, Fe, Mn, Ni, and Zn in the roots than leaves indicate that the roots are hyper-accumulators for Pb, Cr, Cu, Fe, and Zn more than the leaves. The research study recommended that there is a need to protect the soil from contamination through regular monitoring and not to cultivate Jew mallow in wastewater-irrigated soil and that it had a high capacity to accumulate heavy metals in its edible part and causes several harmful health effects for consumers.