CAD/CAM and conventional reconstruction of the mandibular condyle by fibula free flap: a clinical and radiological evaluation.

The aim of this study was to analyse the radiological and clinical outcomes of condylar reconstruction by fibula free flap (FFF), comparing conventional freehand and CAD/CAM techniques. Fifteen patients (nine CAD/CAM, six freehand) who underwent condylar reconstruction with a FFF were reviewed retrospectively regarding pre- and postoperative computed tomography/cone beam computed tomography scans and clinical function. After surgery, all patients were free of temporomandibular joint pain. Mean postoperative mouth opening was 30.80 mm, with no significant difference between the freehand and CAD/CAM groups. In all patients, laterotrusion was decreased to the contralateral side (P = 0.002), with no difference between freehand and CAD/CAM, while the axis of mouth opening deviated to the side of surgery (P < 0.001). All patients showed significant radiological deviation of the fibular neocondyle in the laterocaudal direction (lateral: P = 0.015; caudal: P = 0.001), independent of the technique. In conclusion, reconstruction of the mandibular condyle by FFF provided favourable functional results in terms of mouth opening, reduction of pain, and mandibular excursions. Radiological deviation of the neocondyle and deviation of laterotrusion and mouth opening did not impair clinical function. CAD/CAM planning facilitated surgery, decreased the surgery time, and improved the fit of the neocondyle in the fossa.

Screening for hepatocellular carcinoma among adults with HIV/HBV co-infection in Zambia: a pilot study.

BACKGROUND AND AIMS: Chronic hepatitis B virus (HBV) infection is the main cause of hepatocellular carcinoma (HCC) in sub-Saharan Africa (SSA). An HCC screening initiative was piloted in an established cohort of individuals co-infected with human immunodeficiency virus (HIV) and HBV on antiretroviral therapy (ART) at two outpatient clinics in Lusaka, Zambia. METHODS: All patients underwent abdominal ultrasound (AUS) and transient elastography. RESULTS: Among 279 patients co-infected with HIV/HBV, 165 (59.1%) were men, median age was 34 years [interquartile range (IQR) 28-39 years] and median CD4 count was 246 cells/µL (IQR 112-355 cells/µL) at ART initiation. While 102 (55.7%) individuals had elevated transaminases, 114 (59.7%) had HBV levels >2000 IU/mL and 59 (24.6%) had significant fibrosis. At their first AUS measurement, 75 (26.9%) participants had hepatomegaly and 69 (24.7%) had periportal fibrosis. Five patients had a liver lesion >1 cm, an indication for confirmatory imaging. CONCLUSIONS: In one of the first HCC screening initiatives in SSA, 2% of patients co-infected with HIV/HBV had significant liver lesions, and one-quarter had findings suggestive of schistosomiasis-induced liver damage.

[Digital documentation of complications in visceral surgery: possibilities and evaluation of an instrument for quality management]. / Digitale Komplikationserfassung in der Viszeralchirurgie: Möglichkeiten und Evaluation eines Instrumentes für das Qualitätsmanagement.

Against the background of the growing economization of clinical medicine, in the last decades the topics of risk and complication management have also become more important in surgical disciplines. The standardization and reproducible documentation of outcome and complication data play a key role for valid quality control. In this article a digital system implemented at the surgical clinic of the Charité University Medicine in Berlin is analyzed with respect to its practicability for perioperative and postoperative monitoring of complications within the framework of quality assurance.

Prognostic impact of gross tumor volume during radical radiochemotherapy of locally advanced non-small cell lung cancer-results from the NCT03055715 multicenter cohort study of the Young DEGRO Trial Group.

BACKGROUND: In radical radiochemotherapy (RCT) of inoperable non-small-cell lung cancer (NSCLC) typical prognostic factors include T- and N-stage, while there are still conflicting data on the prognostic relevance of gross tumor volume (GTV) and particularly its changes during RCT. The NCT03055715 study of the Young DEGRO working group of the German Society of Radiation Oncology (DEGRO) evaluated the prognostic impact of GTV and its changes during RCT. METHODS: A total of 21 university centers for radiation oncology from five different European countries (Germany, Switzerland, Spain, Belgium, and Austria) participated in the study which evaluated n = 347 patients with confirmed (biopsy) inoperable NSCLC in UICC stage III A/B who received radical curative-intent RCT between 2010 and 2013. Patient and disease data were collected anonymously via electronic case report forms and entered into the multi-institutional RadPlanBio platform for central data analysis. GTV before RCT (initial planning CT, GTV1) and at 40-50 Gy (re-planning CT for radiation boost, GTV2) was delineated. Absolute GTV before/during RCT and relative GTV changes were correlated with overall survival as the primary endpoint. Hazard ratios (HR) of survival analysis were estimated by means of adjusted Cox regression models. RESULTS: GTV1 was found to have a mean of 154.4 ml (95%CI: 1.5-877) and GTV2 of 106.2 ml (95% CI: 0.5-589.5), resulting in an estimated reduction of 48.2 ml (p < 0.001). Median overall survival (OS) was 18.8 months with a median of 22.1, 20.9, and 12.6 months for patients with high, intermediate, and low GTV before RT. Considering all patients, in one survival model of overall mortality, GTV2 (2.75 (1.12-6.75, p = 0.03) was found to be a stronger survival predictor than GTV1 (1.34 (0.9-2, p > 0.05). In patients with available data on both GTV1 and GTV2, absolute GTV1 before RT was not significantly associated with survival (HR 0-69, 0.32-1.49, p > 0.05) but GTV2 significantly predicted OS in a model adjusted for age, T stage, and chemotherapy, with an HR of 3.7 (1.01-13.53, p = 0.04) per 300 ml. The absolute decrease from GTV1 to GTV2 was correlated to survival, where every decrease by 50 ml reduced the HR by 0.8 (CI 0.64-0.99, p = 0.04). There was no evidence for a survival effect of the relative change between GTV1 and GTV2. CONCLUSION: Our results indicate that independently of T stage, the re-planning GTV during RCT is a significant and superior survival predictor compared to baseline GTV before RT. Patients with a high absolute (rather than relative) change in GTV during RT show a superior survival outcome after RCT.

Value of MRI/CT Image Fusion for Targeting "invisible" Lesions in Stereotactic Microwave Ablation (SMWA) of Malignant Liver Lesions: A Retrospective Analysis.

PURPOSE: To assess the technical feasibility of MRI/CT image fusion and completeness of ablation treatment for primary or metastatic liver lesions invisible on contrast-enhanced CT planning scans and outcome in patients treated with stereotactic microwave ablation (SMWA). MATERIALS AND METHODS: The study was approved by the local ethics committee. Patients who underwent SMWA between January 2015 and December 2018 were retrospectively analyzed. All liver lesions for which MRI/CT fusion was performed due to invisibility on pre-interventional CT planning scans were included and reassessed. The outcome measurement was successful ablation of the lesion at first follow-up imaging. RESULTS: During the study period, 236 patients underwent 312 SMWAs with ablation of 496 lesions. Twenty-four lesions in 15 patients (mean age, 62 years; range, 43-80 years) were included. Following MRI/CT image fusion, all 24 lesions could be sufficiently localized to perform SMWA. The first follow-up imaging showed complete ablation of 22 lesions. Two initially incompletely ablated lesions were hepatocellular carcinomas and were successfully re-ablated afterwards. CONCLUSION: SMWA with MRI/CT image fusion is an accurate and safe treatment option for patients with liver lesions not detectable on contrast-enhanced CT planning scans. MRI/CT image fusion may allow more patients with malignant liver lesions to benefit from local ablation treatment even if their lesions are not visible on CT planning examinations.

Quality of teaching radiation oncology in Germany-where do we stand? : Results from a 2019 survey performed by the working group "young DEGRO" of the German Society of Radiation Oncology.

PURPOSE: Medical students' knowledge of radiation oncology (RO) is of increasing importance with a rising prevalence of malignancies. However, RO teaching in medical schools is heterogeneous and has not been analyzed at a federal level yet. Therefore, the following survey aims to provide a national overview of RO teaching in Germany. METHODS: A questionnaire containing multiple-choice and free-text questions covering the extent and topics of RO teaching was sent to RO departments of all university hospitals in Germany and was answered by the heads of department/main lecturers. RESULTS: 24/35 (68.6%) RO departments returned completed forms. Most faculties employ lectures (91.7%), seminars (87.5%), and practical/bedside training (75.0%), whereas training in radiation biology and medical physics are rare (25% and 33.3%, respectively). Main topics covered are general RO (100%), radiation biology (91.7%), and side effects (87.5%). Regarding RO techniques and concepts, image-guided and intensity-modulated radiotherapy are taught at all faculties, followed by palliative and stereotactic techniques (87.5% each). Notably, all departments offered at least a partial rotation in RO in conjunction with radiology and/or nuclear medicine departments in the last year of medical school, while only 70.8% provided a complete rotation in RO. In addition, 57.1% of the departments have taken measures concerning the upcoming National Competence-Based Learning Objectives Catalogue (NKLM) for medical education. CONCLUSION: RO plays an integral but underrepresented role in clinical medical education in Germany, but faces new challenges in the development of practical and competence-based education, which will require further innovative and interdisciplinary concepts.

Translation and Cultural Adaptation of the German Mastocytosis Quality of Life Questionnaire (MC-QoL) into Spanish. / Adaptación transcultural del cuestionario Mastocytosis Quality of Life questionnaire (MC-QoL) del alemán al castellano.

BACKGROUND: Mastocytosis encompasses a spectrum of disorders in which different organs and tissues are affected by the clonal expansion of mast cells. The skin is one of the most frequently affected organs. The clinical manifestations of mastocytosis are linked to the release of proinflammatory mediators, and the impact of this disorder on patient quality of life has been described in various studies. The Mastocytosis Quality of Life Questionnaire (MC-QoL), which was recently developed in Germany and now also exists in English, is an important tool for evaluating the psychosocial impact of this disease. OBJECTIVE: To create a Spanish version of the MC-QoL that was culturally equivalent to the original German questionnaire. MATERIAL AND METHODS: The adaptation process, which involved forward translation, cognitive interviews, and back translation, was conducted in accordance with the principles of good practice for the translation and cultural adaptation of patient-reported measures of the International Society for Pharmacoeconomics and Outcomes Research. The MC-QoL contains 27 items in 4 domains: symptoms, emotions, social life/functioning, and skin. RESULTS: The first version of the Spanish questionnaire, obtained by forward translation from German, was tested in cognitive interviews, after which 3 items were modified to make them easier to understand. The German back translation of the Spanish questionnaire was analyzed by the authors of the original MC-QoL, who modified 1 item they considered to have lost specificity in the adaptation process. The definitive Spanish MC-QoL was then produced following minor modifications agreed on with the German authors. CONCLUSION: We have produced a cultural adaptation of the MC-QoL in Spanish that can be used in routine clinical practice to obtain a more complete picture of the impact of mastocytosis on patient quality of life.

Mast cells are critical for controlling the bacterial burden and the healing of infected wounds.

Skin wound infections are a significant health problem, and antibiotic resistance is on the rise. Mast cells (MCs) have been shown to contribute to host-defense responses in certain bacterial infections, but their role in skin wound superinfection is unknown. We subjected 2 MC-deficient mouse strains to Pseudomonas aeruginosa skin wound infection and found significantly delayed wound closure in infected skin wounds. This delay was associated with impaired bacterial clearance in the absence of MCs. Engraftment of MCs restored both bacterial clearance and wound closure. Bacterial killing was dependent on IL-6 released from MCs, and engraftment with IL-6-deficient MCs failed to control wound infection. Treatment with recombinant IL-6 enhanced bacterial killing and resulted in the control of wound infection and normal wound healing in vivo. Taken together, our results demonstrate a defense mechanism for boosting host innate immune responses, namely effects of MC-derived IL-6 on antimicrobial functions of keratinocytes.

Metallic dental artifact reduction in computed tomography (Smart MAR): Improvement of image quality and diagnostic confidence in patients with suspected head and neck pathology and oral implants.

PURPOSE: We determined whether the Smart MAR metal artifact reduction tool - a three-stage, projection-based, post processing algorithm - improves subjective and objective image quality and diagnostic confidence in patients with dental artifacts and suspected head and neck pathology compared to standard adaptive statistical iterative reconstructions (ASIR V) alone. METHOD: The study included 100 consecutive patients with nonremovable oral implants or dental fillings and suspected oropharyngeal cancer or abscess. CT raw data of a single-source multislice CT scanner were postprocessed using ASIR V alone and with additional Smart MAR reconstruction. Image quality of baseline ASIR V and Smart MAR-based reconstruction series was compared both quantitatively (5 regions of interest, ROIs) and qualitatively (two independent raters). RESULTS: Additional Smart MAR reconstruction significantly seems to improve both attenuation and noise adjacent to implants and in more distant areas (all p < 0.001) compared to standard ASIR V reconstructions alone. Signal-to-noise ratio (SNR; p = 0.001) and contrast-to-noise ratio were improved significantly (CNR; p = 0.001). Smart MAR improved visualization of tumor/abscess (detected in 36 of 100 patients, 36%) and representative oropharyngeal tissue (p < 0.001). In 8 of 36 patients (22%), tumor was only detected in Smart MAR series. Mean total DLP was 506.8mGy*cm; average CTDIvol was 5.5 mGy. CONCLUSIONS: The supplementary use of the Smart MAR post-processing tool seems to significantly improve both subjective and objective image quality as well as diagnostic confidence and lesion detection in CT of the head and neck. In 22% of cases, the tumor was detected only in Smart MAR reconstructed images.

Spectral CT and its specific values in the staging of patients with non-small cell lung cancer: technical possibilities and clinical impact.

AIM: To investigate how spectral computed tomography (SCT) values impact the staging of non-small cell lung cancer (NSCLC) patients. MATERIALS AND METHODS: One hundred and thirteen patients with confirmed NSCLC were included in a prospective cohort study. All patients underwent single-phase contrast-enhanced SCT (using the fast tube voltage switching technique, 80-140 kV). SCT values (iodine content [IC], spectral slope pitch, and radiodensity increase) of malignant tissue (primary and metastases) and lymph nodes (LNs) were measured. Adrenal masses were evaluated in a virtual non-contrast series (VNS). If pulmonary embolism was present, pulmonary perfusion was analysed as an additional finding. RESULTS: Fifty-two untreated primary NSCLC lesions were evaluable. Lung adenocarcinoma had significantly higher normalised IC (NIC: 19.37) than squamous cell carcinoma (NIC: 12.03; p=0.035). Pulmonary metastases were not significantly different from benign lung nodules. A total of 126 LNs were analysed and histologically proven metastatic LNs (2.08 mg/ml) had significantly lower IC than benign LNs (2.58 mg/ml; p=0.023). Among 34 adrenal masses, VNS identified adenomas with high sensitivity (91%) and specificity (100%). In two patients, a perfusion defect due to pulmonary embolism was detected in the iodine images. CONCLUSION: SCT may contribute to the differentiation of histological NSCLC subtypes and improve the identification of LN metastases. VNS differentiates adrenal adenoma from metastasis. In case of pulmonary embolism, iodine imaging can visualise associated pulmonary perfusion defects.

Association of CCL2 with systemic inflammation in Schnitzler syndrome.

BACKGROUND: Schnitzler syndrome (SchS) is a rare autoinflammatory disease characterized by urticarial exanthema, bone and joint alterations, fever and monoclonal gammopathy, which manifest mostly in the second half of life. It involves overactivation of the interleukin (IL)-1 system, but the exact pathophysiological pathways remain largely unknown. OBJECTIVES: To identify and characterize the pathogenetic players in SchS. METHODS: Blood parameters were quantified in patients with SchS compared with healthy controls and patients with psoriasis and hidradenitis suppurativa using enzyme-linked immunosorbent assay (ELISA). CCL2 expression in cultured primary cells was analysed by quantitative reverse-transcriptase polymerase chain reaction and ELISA. RESULTS: CCL2, a chemoattractant for monocytic and further mononuclear immune cells, was found to be significantly elevated in patients with SchS. CCL2 levels showed a positive association with global disease activity, especially with bone pain, but not disease duration, gammopathy, neutrophilia or skin disease. In vitro stimulation assays demonstrated a strong CCL2 production capacity of mononuclear immune cells and fibroblasts, but not epithelial or endothelial cells. Among a range of inflammatory mediators, only IL-1ß (immune cells, fibroblasts) and tumour necrosis factor (TNF)-α (fibroblasts) were important CCL2 inducers. TNF-α, but not IL-17, strengthened the CCL2-inducing effect of IL-1ß in fibroblasts. Accordingly, CCL2 levels positively correlated with both TNF-α and IL-1ß serum levels in patients with SchS. Therapeutic IL-1ß blockade decreased CCL2 blood levels in these patients as early as 1 week after the initiation of treatment. CONCLUSIONS: CCL2 may be an important component of the pathogenetic cascade leading to bone alterations, and a suitable marker of disease activity in patients with SchS.