Micro-CT and high-field MRI for studying very early post-mortem human fetal anatomy at 8 weeks of gestation.

OBJECTIVE: This study involved very early post-mortem (PM) examination of human fetal anatomy at 8 weeks of gestation (WG) using whole-body multimodal micro-imaging: micro-CT and high-field MRI (HF-MRI). We discuss the potential place of this imaging in early first-trimester virtual autopsy. METHODS: We performed micro-CT after different contrast-bath protocols including diffusible iodine-based contrast-enhanced (dice) and HF-MRI with a 9.4 T machine with qualitative and quantitative evaluation and obtained histological sections. RESULTS: Nine fetuses were included: the crown-rump length was 10-24 mm and corresponded to 7 and 9 WG according to the Robinson formula. The Carnegie stages were 17-21. Dice micro-CT and HF-MRI presented high signal to noise ratio, >5, according to the Rose criterion, and for allowed anatomical phenotyping in these specimens. Imaging did not alter the histology, allowing immunostaining and pathological examination. CONCLUSION: PM non-destructive whole-body multimodal micro-imaging: dice micro-CT and HF-MRI allows for PM human fetal anatomy study as early as 8 WG. It paves the way to virtual autopsy in the very early first trimester. Obtaining a precision phenotype, even regarding miscarriage products, allows a reverse phenotyping to select variants of interest in genome-wide analysis, offering potential genetic counseling for bereaved parents.

Evaluation of breast skin and tissue stiffness using a non-invasive aspiration device and impact of clinical predictors.

A personalized 3D breast model could present a real benefit for preoperative discussion with patients, surgical planning, and guidance. Breast tissue biomechanical properties have been poorly studied in vivo, although they are important for breast deformation simulation. The main objective of our study was to determine breast skin thickness and breast skin and adipose/fibroglandular tissue stiffness. The secondary objective was to assess clinical predictors of elasticity and thickness: age, smoking status, body mass index, contraception, pregnancies, breastfeeding, menopausal status, history of radiotherapy or breast surgery. Participants were included at the Montpellier University Breast Surgery Department from March to May 2022. Breast skin thickness was measured by ultrasonography, breast skin and adipose/fibroglandular tissue stiffnesses were determined with a VLASTIC non-invasive aspiration device at three different sites (breast segments I-III). Multivariable linear models were used to assess clinical predictors of elasticity and thickness. In this cohort of 196 women, the mean breast skin and adipose/fibroglandular tissue stiffness values were 39 and 3 kPa, respectively. The mean breast skin thickness was 1.83 mm. Only menopausal status was significantly correlated with breast skin thickness and adipose/fibroglandular tissue stiffness. The next step will be to implement these stiffness and thickness values in a biomechanical breast model and to evaluate its capacity to predict breast tissue deformations.

Anatomical variations of interest for posterior nasal nerve cryotherapy in the treatment of chronic rhinitis: A radioanatomic study.

KEY POINTS: An unfavorable insertion of the middle turbinate for cryotherapy was present in 74.2% of cases. Placing cryoprobe 15-30 mm above the nasal floor targets the nerves in 95.8% of cases. Centering the cryoprobe 38 mm behind the inferior turbinate axilla targets the nerves in 94.6% of cases.

Anatomical knowledge retention in Obstetrics and Gynaecology residents and impact of an e-learning tool.

PURPOSE: Anatomical knowledge of medical students and residents is insufficient and further anatomical sciences throughout medical curriculum may be necessary. The first aim of this study was to assess pelvic and perineal anatomical knowledge retention of Obstetrics and Gynaecology (Ob/Gyn) residents. The second was to assess the impact of an e-learning tool on anatomical knowledge. METHODS: A survey was sent by mail to medical students and Ob/Gyn residents. After completion, Ob/Gyn residents were randomised to "e-learning" group or to "Control" group. "E-learning" group had an unlimited access to a tool about female pelvic and perineum anatomy, implemented by iMAIOS society in their online platform. A second assessment of residents' anatomical knowledge was done 2 months after randomisation. RESULTS: Ob/Gyn residents (N = 23) had a significant lower global score than third-year medical students (N = 103) (22.1% (± 10.2) vs 43.8% (± 12.1), p < 0.0001). Two months after randomisation, residents of "control" group demonstrated no significant difference between the two questionnaires (3.6%, p = 0.31), whilst the "e-learning" group demonstrated a significant increase overall (10.6%, p = 0.09). There was no significant difference on the post-intervention questionnaire between control and "e-learning" group (25.4% vs 33% respectively, p = 0.34). CONCLUSION: Knowledge of pelvic and perineal anatomy is poor. This e-learning tool aimed at improving anatomical knowledge retention but is not sufficient. A combination of traditional approaches and innovative solutions should be proposed throughout medical school and residency to maintain anatomical knowledge.

Evaluation of Alveolar Bone Reconstruction In Clefts With Early Or Late Secondary Bone Grafting: Use Of The 3d Kamperos score.

There is still no consensus on the optimal age for alveolar grafting. In order to decide on the success of this graft, the best known radiographic assessments lacks precision. Kamperos recently proposed a 3D CBCT score that simultaneously assesses alveolar bone height and thickness, as well as the nasal floor level. The aim of this study was to apply this new score and compare it between an early secondary alveolar grafting « ESAG ¼ (4-7 y) and a late secondary alveolar grafting « LSAG ¼ (8-11 y) surgery group. A total of 32 cases of ESAG and 17 of LSAG were analysed. On 3D imaging, the median age of ESAGs was 10 years and 15 years for LSAGs. In the ESAGs, 78% of the permanents canines were not on the arch compared to 18% in the LSAGs. In both groups, the reconstruction of the nasal floor was very adequate but the height and thickness appeared less good in the ESAGs. The final score was higher in LSAG (Chi2, P < 0.005). The analysis of the alveolar bone with the Kamperos score is accurate and relevant but it should preferably be performed in the permanent dentition phase. This is because the area of rhizalysis of the primary teeth and the follicular sac of the erupting permanent teeth influence the presence of effective bone.

A Master Mind Game Code Algorithm Approach to Help Surgical Decision-Making between Retropharyngeal Fat Grafting and Pharyngoplasty for the Treatment of Velopharyngeal Incompetence

Abstract Introduction Velopharyngeal insufficiency (VPI) is a controversial pathology with many surgical options. Objectives To compare pharyngoplasty and retropharyngeal fat grafting and to build a prognostic tool to achieve perfect speech. Methods Retrospective observational cohort study of 114 patients operated for VPI from 1982 to 2019 in a single tertiary center. The instrumental assessment was made using an aerophonoscope and nasofibroscopy. The variables sex, age, genetic syndromes, and type of diagnosis were analyzed with logistic regression model adjusted with propensity score. To generalize results and to build a surgical predictive tool, a marginal analysis concludes the study. Results Among the patients (median [range] age 7 [4-48]), 63 (55.26%) underwent pharyngoplasty and 51 (44.74%) graft. The graft group had no complication, but it had a failure rate of 7.84%. The pharyngoplasty group had no failure, but one patient had postoperative obstructive sleep apnea. The marginal analysis demonstrated that age lower than 7 years, cleft lip and palate, absence of syndrome, and intermittent VPI were important predictive factors of good result regardless of surgical technique. Conclusions Without a statistical demonstration of the superiority of pharyngoplasty over graft, and in the uncertainty of literature background, our perfect-speech patient profile represents an important tool for a postoperative forecast of results in which, like in the Master Mind game, every feature has to be considered not individually but as a pattern of characteristics whose association contributes to the outcome.

A Master Mind Game Code Algorithm Approach to Help Surgical Decision-Making between Retropharyngeal Fat Grafting and Pharyngoplasty for the Treatment of Velopharyngeal Incompetence.

Introduction Velopharyngeal insufficiency (VPI) is a controversial pathology with many surgical options. Objective To compare pharyngoplasty and retropharyngeal fat grafting and to build a prognostic tool to achieve perfect speech. Methods Retrospective observational cohort study of 114 patients operated for VPI from 1982 to 2019 in a single tertiary center. The instrumental assessment was made using an aerophonoscope and nasofibroscopy. The variables sex, age, genetic syndromes, and type of diagnosis were analyzed with logistic regression model adjusted with propensity score. To generalize results and to build a surgical predictive tool, a marginal analysis concludes the study. Results Among the patients (median [range] age 7 [4-48]), 63 (55.26%) underwent pharyngoplasty and 51 (44.74%) graft. The graft group had no complication, but it had a failure rate of 7.84%. The pharyngoplasty group had no failure, but one patient had postoperative obstructive sleep apnea. The marginal analysis demonstrated that age lower than 7 years, cleft lip and palate, absence of syndrome, and intermittent VPI were important predictive factors of good result regardless of surgical technique. Conclusions Without a statistical demonstration of the superiority of pharyngoplasty over graft, and in the uncertainty of literature background, our perfect-speech patient profile represents an important tool for a postoperative forecast of results in which, like in the Master Mind game, every feature has to be considered not individually but as a pattern of characteristics whose association contributes to the outcome.

Hypnosis as an alternative to general anaesthesia for paediatric superficial surgery: a randomised controlled trial.

BACKGROUND: Reducing perioperative anxiety and controlling pain in children are essential to optimise recovery and outcomes for both children and their parents. By acting on sensory and affective modulation of anxiety and pain, hypnosis is widely used in medical care, especially in anaesthesia. This randomised controlled clinical trial was designed to compare general anaesthesia and intraoperative hypnosis support for perioperative management of children undergoing superficial surgery. METHODS: Children aged 7-16 yr scheduled for day-case superficial surgery were included and randomly assigned to one of the following two groups: general anaesthesia group or hypnosis group. The primary outcome was length of hospital stay. Child and parent anxiety, child pain, and the occurrence of postoperative negative behavioural changes were also evaluated. RESULTS: Sixty children of mean age 10.3 (standard deviation: 2.6) yr were enrolled in the study. Hypnosis was successful in all but one case. The median (25th-75th percentile) length of hospital stay was shorter in the hypnosis group (120 [95-145] vs 240.5 [218-275] min; P<0.001). The general anaesthesia group was associated with a greater incidence of high levels of preoperative anxiety in children (30 vs 11%; P=0.001) and parents (55 vs 30%; P=0.05). Pain scores did not differ between groups. No negative postoperative behavioural changes were reported. CONCLUSIONS: In children aged 7-16 yr, hypnosis appears to be feasible and accepted. The quality of the perioperative experience and the rapid recovery support the use of hypnosis as an effective and safe alternative to general anaesthesia for paediatric superficial surgery. CLINICAL TRIAL REGISTRATION: NCT02505880.

Toward clinical and molecular dissection of frontonasal dysplasia with facial skin polyps: From Pai syndrome to differential diagnosis through a series of 27 patients.

Unique or multiple congenital facial skin polyps are features of several rare syndromes, from the most well-known Pai syndrome (PS), to the less recognized oculoauriculofrontonasal syndrome (OAFNS), encephalocraniocutaneous lipomatosis (ECCL), or Sakoda complex (SC). We set up a research project aiming to identify the molecular bases of PS. We reviewed 27 individuals presenting with a syndromic frontonasal polyp and initially referred for PS. Based on strict clinical classification criteria, we could confirm only nine (33%) typical and two (7%) atypical PS individuals. The remaining ones were either OAFNS (11/27-41%) or presenting with an overlapping syndrome (5/27-19%). Because of the phenotypic overlap between these entities, OAFNS, ECCL, and SC can be either considered as differential diagnosis of PS or part of the same spectrum. Exome and/or genome sequencing from blood DNA in 12 patients and from affected tissue in one patient failed to identify any replication in candidate genes. Taken together, our data suggest that conventional approaches routinely utilized for the identification of molecular etiologies responsible for Mendelian disorders are inconclusive. Future studies on affected tissues and multiomics studies will thus be required in order to address either the contribution of mosaic or noncoding variation in these diseases.

Autologous Fat Grafting in Velopharyngeal Insufficiency Gives Complete and Stable Speech Recovery in Patient Under 7 years.

ABSTRACT: The authorspresent a retrospective observational cohort study of 47 French speaking consecutive patients treated with retropharyngeal wall filling with autologous fat graft from 2006 to 2019 in a single tertiary center, to assess with a long-term follow-up, the best tailored treatment to recovery speech for velopharyngeal insufficiency, and to stress the importance of early treatment with minimally invasive procedure with retropharyngeal wall fat grafting. In preoperative setting, a clinical and instrumental evaluation with aerophonoscope is completed by a palatal closure assessment with nasal endoscopy. All patients were classified according with Borel Maisonny score pre- and post-operatively. Sixty three fat injections were performed. In 4 cases a pharyngeal flap was performed after fat graft for an insufficient speech result. The authors had no complications. Patients with less than 7 years of age obtained a complete recovery of their velopharyngeal incompetence (P = 0.03) compared to older patients. In conclusion, the authors can state that this tailored surgical technique needs a multidisciplinary approach. Many variables can affect postoperative results: fat reabsorption, concurrently performed surgery, pattern of pharyngeal closure, hearing impairment. None of these factors affected our result. Early treatment plays a crucial role to achieve better results. Patients with less of 7 years showed a better result in this functional treatment.

Nasopharyngeal Tube and Functional Treatment in Pierre Robin Sequence: A Tertiary Clinical Experience From 150 Cases.

OBJECTIVES: To describe the initial care practices for children with Pierre Robin sequence (PRS) and analyze the factors predicting the severity of the obstruction breathing disorders. DESIGN: A retrospective single-center study of 150 children with PRS. SETTING: Single tertiary care center, Regional Competence Center for the diagnosis and treatment of PRS. PATIENTS: A total of 150 children with PRS consecutively followed between 1986 and 2017. Group 1 comprises children without specific respiratory management; group 2, children requiring prone positioning to alleviate their respiratory distress symptoms; and group 3, children requiring nasopharyngeal airway tube (NT) or nonconservative surgical treatment. MAIN OUTCOME MEASURES: Evolution and results of the initial treatment of PRS. RESULTS: Forty-two percent (n = 63) were attributed to group 1, 39% (n = 50) to group 2, and 19% (n = 29) to group 3. Preterm birth, birth weight, or associated congenital malformations were not significantly different between the groups. However, the age of exclusive oral feeding was significantly different: 1 day (quartiles: 0-3) for group 1; 11 days (quartiles: 1-28) for group 2; 39 days (quartiles: 19-111) for group 3 (P < .0001). Considering the NT, its use relieves the upper airway obstruction, assessed by a respiratory polygraphy, in 14 children. CONCLUSIONS: Nasopharyngeal airway tube has become our major first-line treatment, avoiding more complex procedures in most of the cases. The achievement of exclusive oral feeding seems to be a good predictor of the severity of respiratory symptoms in PRS.

Dynamic three-dimensional virtual environment to improve learning of anatomical structures.

Increasing number of medical students and limited availability of cadavers have led to a reduction in anatomy teaching through human cadaveric dissection. These changes triggered the emergence of innovative teaching and learning strategies in order to maximize students learning of anatomy. An alternative approach to traditional dissection was presented in an effort to improve content delivery and student satisfaction. The objective of this study is to acquire three-dimensional (3D) anatomical data using structured-light surface scanning to create a dynamic four-dimensional (4D) dissection tool of four regions: neck, male inguinal and femoral areas, female perineum, and brachial plexus. At each dissection step, identified anatomical structures were scanned using a 3D surface scanner (Artec Spider™). Resulting 3D color meshes were overlaid to create a 4D (3D+time) environment. An educational interface was created for neck dissection. Its implementation in the visualization platform allowed 4D virtual dissection by navigating from surface to deep layers and vice versa. A group of 28 second-year medical students and 17 first-year surgery residents completed a satisfaction survey. A majority of medical students (96.4%) and 100% of surgery residents said that they would recommend this tool to their colleagues. According to surgery residents, the main elements of this virtual tool were the realistic high-quality of 3D acquisitions and possibility to focus on each anatomical structure. As for medical students, major elements were the interactivity and entertainment aspect, precision, and accuracy of anatomical structures. This approach proves that innovative solutions to anatomy education can be found to help to maintain critical content and student satisfaction in anatomy curriculum.

Feasibility of Cochlea High-frequency Ultrasound and Microcomputed Tomography Registration for Cochlear Computer-assisted Surgery: A Testbed.

INTRODUCTION: There remains no standard imaging method that allows computer-assisted surgery of the cochlea in real time. However, recent evidence suggests that high-frequency ultrasound (HFUS) could permit real-time visualization of cochlear architecture. Registration with an imaging modality that suffers neither attenuation nor conical deformation could reveal useful anatomical landmarks to surgeons. Our study aimed to address the feasibility of an automated three-dimensional (3D) HFUS/microCT registration, and to evaluate the identification of cochlear structures using 2D/3D HFUS and microCT. METHODS: MicroCT, and 2D/3D 40 MHz US in B-mode were performed on ex vivo guinea pig cochlea. An automatic rigid registration algorithm was applied to segmented 3D images. This automatic registration was then compared to a reference method using manual annotated landmarks placed by two senior otologists. Inter- and intrarater reliabilities were evaluated using intraclass correlation coefficient (ICC) and the mean registration error was calculated. RESULTS: 3D HFUS/microCT automatic registration was successful. Excellent levels of concordance were achieved with regards intra-rater reliability for both raters with micro-CT and US images (ICC ranging from 0.98 to 1, p < 0.001) and with regards inter-rater reliability (ICC ranging from 0.99 to 1, p < 0.001). The mean HFUS/microCT automated RE for both observers was 0.17 ±â€Š0.03 mm [0.10-0.25]. Identification of the basilar membrane, modiolus, scala tympani, and scala vestibuli was possible with 2D/3D HFUS and micro-CT. CONCLUSIONS: HFUS/microCT image registration is feasible. 2D/3D HFUS and microCT allow the visualization of cochlear structures. Many potential clinical applications are conceivable.

Hemangiol in infantile haemangioma: A paediatric post-marketing surveillance drug study.

AIM: Infantile haemangioma (IH) is the most common benign tumour in children. Since 2014, propranolol has become the first-choice therapy and currently Hemangiol is the only approved drug for complicated haemangioma. This post-marketing study reports the use of Hemangiol for IH in paediatric practice. METHOD AND RESULTS: From January 2014 to November 2018, 94 children (median age 4 [0; 21] months; 75% female) treated with Hemangiol for proliferative IH were enrolled in the study. The systematic paediatric cardiology consultation never contraindicated beta-blockers. Two Hemangiol initiation protocols were used: a conventional ambulatory 3-week titration phase protocol (n = 76, 80.9%), and a rapid initiation protocol with a 48-hour dose escalation in conventional hospitalization for severe proliferative or ulcerated IH (n = 18, 19.1%). In both protocols, the haemodynamic tolerance was good. The mean maintenance dose of Hemangiol was 2.7 ± 0.8 mg/kg/day, with a median treatment duration of 7 [1.5; 19] months. Adverse events (AEs) have been found in 25 (26,6%) patients, including 8 (8.5%) patients with serious AEs (uncontrolled bronchial hyperreactivity, n = 5; serious hypoglycaemia, n = 3). Some patients had one or more AEs, a total of 24 nonserious AEs was reported in 19 patients (sleep disturbances, n = 9; respiratory disorders, n = 5; digestive disorders, n = 6). No cardiac adverse event was reported. CONCLUSION: This post-marketing surveillance drug study supports the good tolerance of Hemangiol in children with IH. A rapid initiation protocol is of interest when treatment is urgent. The pretherapeutic paediatric cardiology consultation should not be systematic but only indicated for specific patients. CLINICALTRIALS.GOV: NCT04105517.

The Hypoplasic Mandible: What Makes it Different From the Healthy Child?

OBJECTIVE: This study aimed to analyze the morphology of the hypoplasic mandible and its evolution during the growth period to better understand how it differs from the pediatric healthy mandible. METHOD: Three-dimensional mandibular models of hypoplasic and healthy children aged from 39 gestational weeks to 7 years old were analyzed with a morphometric method including data clustering. Morphological distinctions between pathological and healthy mandibles were highlighted. Bilateral and unilateral mandibular hypoplasia were distinguished. RESULTS: The study sample was composed of 31 hypoplasic children and as many sex- and age-matched healthy children. Morphological distinctions between pathological and healthy mandibles were highlighted only from the first year of life. In bilateral hypoplasia, the overall mandibular dimensions were reduced while there was only a ramus asymmetry in unilateral mandibular hypoplasia (mean ± SD of the difference between the Grp03c and Grp03b subgroups: 6.80 ± 6.37 - P value = 1.64e-3 for the height of the left ramus versus 0.18 ± 4.18 - P value = .82 for the height of the right ramus). Supervised classification trees were built to identify the pathology and discriminate unilateral from bilateral mandibular hypoplasia (prediction rates = 81% and 84%, respectively). CONCLUSIONS: Based on a morphometric analysis, we demonstrated that mandibular hypoplasia significantly impacts the mandibular morphology only from the first year of life, with a distinction between bilateral and unilateral hypoplasia.

Solitary Median Maxillary Central Incisor due to Nasal Pyriform Aperture Stenosis in Fetus: The First Prenatal Ultrasound Case Report.

BACKGROUND: The single median incisor is a rare dental abnormality that could be isolated or could be part of many different syndromes or syndromic association with poor prognosis. CASE DESCRIPTION: We report the first prenatal ultrasound description of a 31-year-old patient, gravida 1, para 0, whose male fetus was diagnosed at 25 weeks' gestation with a single median incisor suggestive of nasal pyriform aperture stenosis in Montpellier University Hospital (France). A fetal magnetic resonance imaging (MRI) performed at 30 weeks' gestation retrieved no intracranial midline cerebral anomalies and confirm nasal pyriform aperture stenosis suspicion. Amniocentesis, performed at 31 weeks, found a normal fetal karyotype (46XY) and a normal comparative genomic hybridization (CGH) array. After term vaginal delivery, clinical and radiological examination confirmed the diagnosis of an isolated single median maxillary central incisor linked to nasal pyriform aperture stenosis. CONCLUSION: Prenatal diagnosis of a single median incisor due to nasal pyriform aperture stenosis is feasible and enables close postnatal follow-up. HOW TO CITE THIS ARTICLE: Fuchs F, Chadelle M, Captier G, et al. Solitary Median Maxillary Central Incisor due to Nasal Pyriform Aperture Stenosis in Fetus: The First Prenatal Ultrasound Case Report. Int J Clin Pediatr Dent 2020;13(3):295-298.