Facial esthetics and subjective impairment assessed after maxillomandibular advancement surgery for patients with obstructive sleep apnea.

OBJECTIVE: To assess facial esthetics and quality of life (QoL) as measure of success or failure after maxillomandibular advancement (MMA) surgery for obstructive sleep apnea (OSA). METHODS: Visual analog scales (VAS) on facial esthetics and QoL survey, including EQ-5D3L, Epworth Sleepiness Scale (ESS), and Functional Outcome of Sleep Questionnaire (FOSQ) were collected. Outcomes were analyzed for surgical-success/failure after MMA. RESULTS: Forty-one patients returned completed surveys (response: 66%). Mean VAS on facial esthetics was 57 ± 22 mm preoperative and 51 ± 24 mm postoperative (p = 0.217). When MMA was considered a surgical-failure, VAS was significantly more negative (40 ± 22 mm; p = 0.026). EQ-5D-3L showed an overall mean score of 73.2 ± 15.7, ESS was 6.3 ± 5.4, and FOSQ was 16.0 ± 3.3. CONCLUSION: No significant alteration of facial esthetics were reported after MMA; however, lower QoL was associated with surgical-failure; whereas, in surgical-success, QoL were higher.

Identifying a sublingual triangle as the ideal site for assessment of sublingual microcirculation.

The sublingual mucosa is a commonly used intraoral location for identifying microcirculatory alterations using handheld vital microscopes (HVMs). The anatomic description of the sublingual cave and its related training have not been adequately introduced. The aim of this study was to introduce anatomy guided sublingual microcirculatory assessment. Measurements were acquired from the floor of the mouth using incident dark-field (IDF) imaging before (T0) and after (T1) sublingual cave anatomy instructed training. Instructions consists of examining a specific region of interested identified through observable anatomical structures adjacent and bilaterally to the lingual frenulum which is next to the sublingual papilla. The anatomical location called the sublingual triangle, was identified as stationed between the lingual frenulum, the sublingual fold and ventrally to the tongue. Small, large, and total vessel density datasets (SVD, LVD and TVD respectively) obtained by non-instructed and instructed measurements (NIN (T0) and IM (T1) respectively) were compared. Microvascular structures were analyzed, and the presence of salivary duct-related microcirculation was identified. A total of 72 video clips were used for analysis in which TVD, but not LVD and SVD, was higher in IM compared to NIM (NIM vs. IM, 25 ± 2 vs. 27 ± 3 mm/mm2 (p = 0.044), LVD NIM vs. IM: 7 ± 1 vs. 8 ± 1mm/mm2 (p = 0.092), SVD NIM vs. IM: 18 ± 2 vs. 20 ± 3 mm/mm2 (p = 0.103)). IM resulted in microcirculatory assessments which included morphological properties such as capillaries, venules and arterioles, without salivary duct-associated microcirculation. The sublingual triangle identified in this study showed consistent network-based microcirculation, without interference from microcirculation associated with specialized anatomic structures. These findings suggest that the sublingual triangle, an anatomy guided location, yielded sublingual based measurements that conforms with international guidelines. IM showed higher TVD values, and future studies are needed with larger sample sizes to prove differences in microcirculatory parameters.

Photobiomodulation therapy in management of cancer therapy-induced side effects: WALT position paper 2022.

Disclaimer: This article is based on recommendations from the 12th WALT Congress, Nice, October 3-6, 2018, and a follow-up review of the existing data and the clinical observations of an international multidisciplinary panel of clinicians and researchers with expertise in the area of supportive care in cancer and/or PBM clinical application and dosimetry. This article is informational in nature. As with all clinical materials, this paper should be used with a clear understanding that continued research and practice could result in new insights and recommendations. The review reflects the collective opinion and, as such, does not necessarily represent the opinion of any individual author. In no event shall the authors be liable for any decision made or action taken in reliance on the proposed protocols. Objective: This position paper reviews the potential prophylactic and therapeutic effects of photobiomodulation (PBM) on side effects of cancer therapy, including chemotherapy (CT), radiation therapy (RT), and hematopoietic stem cell transplantation (HSCT). Background: There is a considerable body of evidence supporting the efficacy of PBM for preventing oral mucositis (OM) in patients undergoing RT for head and neck cancer (HNC), CT, or HSCT. This could enhance patients' quality of life, adherence to the prescribed cancer therapy, and treatment outcomes while reducing the cost of cancer care. Methods: A literature review on PBM effectiveness and dosimetry considerations for managing certain complications of cancer therapy were conducted. A systematic review was conducted when numerous randomized controlled trials were available. Results were presented and discussed at an international consensus meeting at the World Association of photobiomoduLation Therapy (WALT) meeting in 2018 that included world expert oncologists, radiation oncologists, oral oncologists, and oral medicine professionals, physicists, engineers, and oncology researchers. The potential mechanism of action of PBM and evidence of PBM efficacy through reported outcomes for individual indications were assessed. Results: There is a large body of evidence demonstrating the efficacy of PBM for preventing OM in certain cancer patient populations, as recently outlined by the Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). Building on these, the WALT group outlines evidence and prescribed PBM treatment parameters for prophylactic and therapeutic use in supportive care for radiodermatitis, dysphagia, xerostomia, dysgeusia, trismus, mucosal and bone necrosis, lymphedema, hand-foot syndrome, alopecia, oral and dermatologic chronic graft-versus-host disease, voice/speech alterations, peripheral neuropathy, and late fibrosis amongst cancer survivors. Conclusions: There is robust evidence for using PBM to prevent and treat a broad range of complications in cancer care. Specific clinical practice guidelines or evidence-based expert consensus recommendations are provided. These recommendations are aimed at improving the clinical utilization of PBM therapy in supportive cancer care and promoting research in this field. It is anticipated these guidelines will be revised periodically.

Outcome of tubeless percutaneous nephrolithotomy in elder patients: A single-center experience from a developing country.

Background: Percutaneous nephrolithotomy (PCNL) has evolved as a standard procedure to treat large-sized renal stones. A nephrostomy tube is used frequently in this procedure; however, data regarding tubeless PCNL procedures in elder patients is scarce. Aim: The aim of this study was to review the results and outcomes associated with tubeless PCNL procedures in the elderly population. Materials and Methods: A retrospective review of patients aged ≥60 years at our hospital that was treated for renal stones by PCNL procedure. The patients were separated into two groups: Group 1 underwent tubed PCNL procedures and Group 2 received tubeless PCNL procedures. Information regarding variables were recorded in specified pro forma and then processed in Statistical Package for the Social Sciences statistics analyses. Statistical tests were utilized for continuous and categorical variables and a P<0.05 was considered statistically significant. Results: 121 patients with a mean age of 65±5 years were included in the analysis. Mean stone size and body mass index were 3.4±1.5 cm and 26.2±4.3 kg/m2, respectively. Mean operative time was longer in tubed PCNL as compared to the tubeless group. Mean hospital stay was similar among the tubed and tubeless PCNL treated groups. Mean analgesic doses were significantly lower in the tubeless group. The overall stone-free rate was 89/121 patients (74%). Conclusion: Tubeless PCNL can be safely undertaken in geriatric patients and has potential advantages associated with shorter operative times and reduced necessity for analgesia. Relevance for Patients: Tubeless PCNL is considered advantageous as it can reduce post-operative pain and analgesia necessity; shorten hospitalization and lower cost in young patients. However, there is no clear evidence with reference to virtue of tubeless PCNL in the elderly age groups. This study will analyze and review results and outcomes associated with tubeless PCNL in a cohort of elderly patients.

The impact of hyperbaric oxygen therapy on late irradiation injury in oral microcirculation.

BACKGROUND: Late side effects of radiotherapy in patients with head and neck cancer (HNCPs) result in decreased tissue vascularity, a compromised healing capacity and spontaneous breakdown of tissue. The aim of this study was to examine the in vivo effect of hyperbaric oxygen therapy (HBOT) on the microcirculation in irradiated oral tissue. METHODS: Using a handheld microscope, the effect of HBOT on oral mucosal microcirculation parameters was measured in 34 previously irradiated HNCPs prior to HBOT and at 4 weeks and 6 months posttreatment. RESULTS: A significant increase in mean buccal vessel density and decrease in buccal vessel diameter was found 6 months after HBOT compared to baseline, 22 ± 11 versus 25 ± 7 cpll/mm2 (p < 0.05) and 20 ± 4 versus 16 ± 5 µm (p < 0.05), respectively. CONCLUSION: Our results indicate that oral microcirculation histopathology associated with irradiation is able to respond to HBOT by redirecting oral microcirculation parameters towards values consistent with healthy tissue.

Comparison of interleukin-21 levels and its correlation with clinical parameters among healthy individuals, chronic periodontitis, and aggressive periodontitis patients.

BACKGROUND: Interleukin-21 (IL-21) has both anti- and pro-inflammatory roles associated with chronic inflammation. It causes tissue destruction by increasing pro-inflammatory cytokines and curbs the activity of certain immune cells that evoke an anti-inflammatory role. OBJECTIVES: The aim of this study was to compare IL-21 levels in gingival crevicular fluid among patients with generalized chronic periodontitis (GCP), aggressive periodontitis, and healthy gingiva (HG) and to correlate IL-21 levels with clinical parameters. METHODS: In this cross-sectional case-control study, 60 subjects were categorized into three groups: HG (n=20), generalized aggressive periodontitis (GAP; n=20), and GCP (n=20). IL-21 was measured using ELISA and results were correlated with clinical parameters including plaque index, gingival index, periodontal probing depth (PPD), and clinical attachment level (CAL). RESULTS: Mean IL-21 levels were 20.0±0.7 in HG, 25.9±0.9 in GCP, and 25.3±1.1 in GAP groups. Significant differences in IL-21 levels were found between HG versus GAP (P<0.05) and HG versus GCP (P<0.05). No statistically significant difference in IL-21 level was found between GCP versus GAP. IL-21 levels positively correlated with PPD (r=0.97) and CAL (r=0.93) in the GAP group and with PPD (r=0.92) and CAL (r=0.96) in the GCP group. CONCLUSION: Although periodontitis pathophysiology involves complex interplay between pro- and anti-inflammatory signaling, data on IL-21 revealed elevated levels in both GCP and GAP. Further longitudinal studies are required to characterize and determine the diagnostic value of IL-21 as a reliable biomarker in periodontal disease. RELEVANCE FOR PATIENTS: Although further longitudinal studies are necessary, IL-21 may serve as a potential inflammatory biomarker in screening for generalized chronic and aggressive periodontitis.

Intraoperative Imaging Techniques to Visualize Hepatic (Micro)Perfusion: An Overview.

The microcirculation plays a crucial role in the distribution of perfusion to organs. Studies have shown that microcirculatory dysfunction is an independent predictor of morbidity and mortality. Hence, assessment of liver perfusion offers valuable information on the (patho)physiological state of the liver. The current review explores techniques in perfusion imaging that can be used intraoperatively. Available modalities include dynamic contrast-enhanced ultrasound, handheld vital microscopes, indocyanine green fluorescence angiography, and laser contrast speckle imaging. Dynamic contrast-enhanced ultrasound relays information on deep tissue perfusion and is a commonly used technique to assess tumor perfusion. Handheld vital microscopes provide direct visualization of the sinusoidal architectural structure of the liver, which is a unique feature of this technique. Intraoperative fluorescence imaging uses indocyanine green, a dye that is administered intravenously to visualize microvascular perfusion when excited using near-infrared light. Laser speckle contrast imaging produces non-contact large surface-based tissue perfusion imaging free from movement- or pressure-related artefacts. In this review, we discuss the intrinsic advantages and disadvantages of these techniques and their clinical and/or scientific applications.

Alveolar Iodine Tampon Packing Reduces Postoperative Morbidity After Third Molar Surgery.

PURPOSE: The aim of this study was to assess the efficacy of an iodine tampon after mandibular third molar surgery on oral health-related quality of life (OHRQoL), use of painkillers, postoperative sequelae, and self-care behaviors in the first postoperative week. MATERIALS AND METHODS: This prospective, crossover, randomized controlled study included patients undergoing surgical removal of bilateral symmetrically, horizontally impacted mandibular third molars. The surgical site was randomly allocated to receive an iodine tampon after surgery or wound closure and rinsing with a Monoject syringe (Tyco/Healthcare-Kendall, Mansfield, MA). The primary outcomes measured each day during the first postoperative week were the Oral Health Impact Profile 14 score and postoperative sequelae, including pain, swelling, limited mouth opening, postoperative infection, and alveolar osteitis. The secondary outcome measures were several self-care behaviors. Data were analyzed using repeated-measures analysis of variance and paired-samples t tests. RESULTS: A total of 54 patients (25 men and 29 women; mean age, 25.1 years) were enrolled, with a total of 108 surgically removed impacted mandibular third molars. The use of an iodine tampon resulted in a significantly lower impact on OHRQoL (mean of 21.5 [standard deviation (SD), 9.6] vs 26.5 [SD, 10.6]) on the first postoperative day, which was observable until the seventh postoperative day. In addition, after removal of the impacted third molar, patients with the iodine tampon condition reported less pain (mean of 5.2 [SD, 1.9] vs 6.1 [SD, 2.1] on day 1, lasting throughout the week), less use of painkillers, less limited mouth opening, fewer problems chewing, less swelling, and earlier recovery. CONCLUSIONS: The use of postoperative iodine packing after the removal of impacted mandibular third molars significantly reduces OHRQoL and postoperative sequelae.

Imaging sublingual microcirculatory perfusion in pediatric patients receiving procedural sedation with propofol: A pilot study.

OBJECTIVE: Procedural sedation with propofol is widely used in the pediatric population. A well-known side effect of propofol is a decrease in peripheral vascular resistance resulting in hypotension, but little is known about the effects on microcirculation in humans. We aimed to evaluate the effects of propofol on the sublingual microcirculatory perfusion by continuous video imaging in pediatric patients undergoing procedural sedation. METHODS: Patients admitted to the Pediatric Intensive Care Unit for procedural sedation were recruited. Oral microcirculation was measured employing a continuous monitoring strategy with incident dark-field illumination imaging. Measurements were obtained before and 3 minutes after propofol induction. Total and perfused vessel densities, proportion of perfused vessels, microvascular flow index, blood vessel diameter (Øbv ), and systemic hemodynamics were analyzed. RESULTS: Continuous measurements were achieved in seven patients. Three minutes after propofol induction mean arterial pressure decreased (P = 0.028) and total and perfused vessel densities increased by 12% (P = 0.018) and 16% (P = 0.018), respectively. MFI was unaltered and mean Øbv increased but not significantly. CONCLUSIONS: Propofol induction induces a reduction in mean arterial pressure and a rise in sublingual microvascular perfusion. The observed effects of propofol on the sublingual microcirculation may be due to a decrease in microvascular resistance.

Intraoperative Incident Dark Field Imaging of the Human Peritoneal Microcirculation.

BACKGROUND/AIMS: This study describes the peritoneal microcirculation, compares quantitative parameters and angioarchitecture to the standard of sublingual microcirculatory assessment, and determines the practical feasibility of this method. METHODS: Incident dark field imaging was performed of the peritoneum and sublingually to determine angioarchitecture, total and perfused vessel density (TVD and PVD), the proportion of perfused vessels (PPV), the microvascular flow index (MFI) and image acquisition time. RESULTS: Peritoneal angioarchitecture was characterized by a quadrangular network of longitudinally oriented capillaries, often flanked by fat cells. Differences between peritoneal and sublingual microcirculation were observed with regard to TVD (peritoneum 12 mm/mm2 [95% CI 10-14] vs. sublingual 23 mm/mm2 [95% CI 21-25]; p < 0.0001), PVD (peritoneum 11 mm/mm2 [95% CI 9-13] vs. sublingual 23 mm/mm2 [95% CI 21-25]; p < 0.0001), PPV (peritoneum 88% [95% CI 79-97] vs. sublingual 99% [95% CI 99-100]; p = 0.014), and MFI (peritoneum 3 [IQR 2.3-3.0] vs. sublingual 3 [IQR 3.0-3.0]; p = 0.012). There was no difference in image acquisition time (peritoneum 2: 34 min [95% CI 1: 49-3: 19] vs. sublingual 2: 38 [95% CI 1: 37-3: 32]; p = 0.916). CONCLUSION: The peritoneal microcirculation was characterized by a low capillary density and a distinctive angioarchitecture. The possibility of peri-toneal microcirculatory assessment offers promise for the study of peritoneal (patho-)physiology and (monitoring or detection of) associated diseases.

Patient-Side Appraisal of Late Radiation-Induced Oral Microvascular Changes.

PURPOSE: To determine the clinical feasibility of examining and measuring late irradiation changes in the oral microcirculation of head and neck (HN) cancer patients using the novel CytoCam video microscope system. METHODS AND MATERIALS: In 30 HN cancer patients and 30 age-matched controls, bilateral video images were recorded noninvasively of the oral microcirculation of the buccal mucosa and mandibular gingiva. Tissue perfusion parameters, such as functional capillary density (FCD), buccal blood vessel diameter, and microcirculatory flow index, were analyzed. RESULTS: No difference was observed for mean buccal mucosa FCD in irradiated versus healthy tissue, whereas a lower mean gingival FCD in irradiated versus healthy tissue was observed (34 ± 17 capillaries per millimeter squared [cpll/mm2] vs 68 ± 19 cpll/mm2; P < .001). A significant difference in mean buccal blood vessel diameter of 16 ± 3 µm was measured, compared with 14 ± 1 µm in control buccal mucosa (P < .001). No significant difference in microcirculatory flow index was observed between the 2 groups. CONCLUSIONS: Quantifying oral microcirculatory injury associated with late irradiation effects using the CytoCam was feasible in HN cancer patients. Results indicate that marked differences in tissue-specific microcirculatory measurements of angioarchitecture, diminished capillary density, and extensively dilated blood vessel diameters are associated with late irradiation effects in HN cancer patients.

Natural variation of the zygomaticomaxillary complex symmetry in normal individuals.

OBJECTIVE: The study aim was to investigate variations in the symmetry of the zygomaticomaxillary complex (ZMC) in normal individuals. METHOD: Computed tomography datasets of 200 individuals without facial fractures were analyzed using a validated three-dimensional analysis technique. The absolute average distance (AD) and 90th percentile distance (NPD) were calculated, representing respectively the overall and maximum symmetry between bilateral ZMCs. RESULTS: The mean AD and NPD of the total study group was 0.9 ± 0.3 mm (95% CI 0.3-2.3) and 1.7 ± 0.5 mm (95% CI 0.5-3.9), respectively. The mean AD and NPD in males were 1.0 ± 0.3 mm (95% CI 0.28-2.34) and 1.9 ± 0.5 mm (95% CI 0.5-3.9) versus 0.8 ± 0.3 mm (95% CI 0.4-1.7) and 1.6 ± 0.5 mm (95% CI 0.8-2.9), respectively, for females. A statistically significant difference between male and female was found for both AD and NPD (p < 0.01). The male population <40 years had a mean AD and NPD of 1.0 ± 0.3 mm and 1.8 ± 0.5 mm, which was not statistically significant when compared with males >40 years. CONCLUSION: The naturally occurring anatomic variation in ZMC symmetry described in this study is proposed as a benchmark for evaluating the amount of preoperative displacement and postoperative reduction of ZMC in trauma cases.

Applicability of quantitative optical imaging techniques for intraoperative perfusion diagnostics: a comparison of laser speckle contrast imaging, sidestream dark-field microscopy, and optical coherence tomography.

Patient morbidity and mortality due to hemodynamic complications are a major problem in surgery. Optical techniques can image blood flow in real-time and high-resolution, thereby enabling perfusion monitoring intraoperatively. We tested the feasibility and validity of laser speckle contrast imaging (LSCI), optical coherence tomography (OCT), and sidestream dark-field microscopy (SDF) for perfusion diagnostics in a phantom model using whole blood. Microvessels with diameters of 50, 100, and 400 µm were constructed in a scattering phantom. Perfusion was simulated by pumping heparinized human whole blood at five velocities (0 to 20 mm/s). Vessel diameter and blood flow velocity were assessed with LSCI, OCT, and SDF. Quantification of vessel diameter was feasible with OCT and SDF. LSCI could only visualize the 400-µm vessel, perfusion units scaled nonlinearly with blood velocity. OCT could assess blood flow velocity in terms of inverse OCT speckle decorrelation time. SDF was not feasible to measure blood flow; however, for diluted blood the measurements were linear with the input velocity up to 1 mm/s. LSCI, OCT, and SDF were feasible to visualize blood flow. Validated blood flow velocity measurements intraoperatively in the desired parameter (mL·min-1·g-1) remain challenging.

Analgesic effects of preinjection low-level laser/light therapy (LLLT) before third molar surgery: a double-blind randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the analgesic effects of low-level laser therapy (LLLT) on preinjection sites in patients scheduled for third molar removal. STUDY DESIGN: This double-blind randomized controlled trial included 163 healthy patients undergoing third molar extractions. The study participants were randomly divided into an LLLT and a placebo group. Objective and subjective data sets were obtained from physiologic feedback (heart rate and sweat response) and a questionnaire, respectively. In the LLLT group, each targeted injection site was irradiated twice with 198 mW continuous wave for 30 seconds with a 0.088 cm2 focal spot at an applied energy of 5.94 J and fluence of 67.50 J/cm2. Measurements were recorded from 4 time-points during data acquisition. RESULTS: There was no significant difference between the LLLT and placebo groups in pain experience scores associated with the injected sites for maxillary or mandibular third molar extractions. Mean heart rates before and during injection were lower in the LLLT group than in the placebo group for both maxillary and mandibular regions. No statistically significant differences were observed for any remaining parameters. CONCLUSIONS: The present data indicated that preinjection LLLT did not effectively decrease the pain felt during local anesthetic injections before third molar surgery.

Circulating microaggregates during cardiac surgery precedes postoperative stroke.

Postoperative stroke and encephalopathy are potentially serious complications associated with coronary artery bypass grafting. In this case report a 78-year-old male patient receiving routine elective cardiac surgery presented with microaggregations in the sublingual microcirculation while on cardiopulmonary bypass that was undetected by routine intraoperative anticoagulation assessment. Microaggregates identified using video microscopy on his sublingual microcirculation during the procedure preceded a stroke postoperatively. Postoperative cerebral and carotid artery examination with computed tomography scanning revealed a left watershed cerebral infarct with carotid stenosis. This report presents intraoperative microcirculation-based evidence suggesting that observations of microaggregations, otherwise undetected by conventional anticoagulation assessment techniques, could serve as an early warning in elderly patients at high risk for postoperative cerebrovascular events.

Photobiomodulation therapy in the management of chronic oral graft-versus-host disease.

AIM: Patients treated with allogeneic hematopoietic stem cell transplantation (HSCT) may experience oral complications associated with chronic graft-versus-host disease (cGVHD). These complications may significantly affect quality of life, even many years post-HSCT. Current treatment options for oral cGVHD are limited and often include steroid or other immunomodulatory medications, which may not adequately control the oral condition. A non-immunosuppressive intervention for symptomatic relief in oral cGVHD would thus be a welcome addition to the treatment paradigm. MATERIALS AND METHODS: We report seven cases of oral cGVHD that were treated with photobiomodulation therapy (PBM), previously known as low-level laser therapy (LLLT). Patients underwent at least two PBM treatments per week in addition to local treatment with steroids, and if on systemic therapies, these were either unchanged or dosage was reduced during the period of PBM therapy. Follow-up data is presented for 4 weeks of treatment. RESULTS: Oral pain, sensitivity, and dry mouth improved in most patients. These findings suggest PBM therapy may represent an additional approach for management of oral cGVHD, and suggest that controlled studies should be conducted to confirm the efficacy and safety of PBM therapy in oral cGVHD and to determine optimal PBM therapy protocols.

Measuring zygomaticomaxillary complex symmetry three-dimensionally with the use of mirroring and surface based matching techniques.

OBJECTIVE: The study aim was to validate a new method for measuring zygomaticomaxillary complex (ZMC) symmetry, which can be helpful in analyzing ZMC fractures. METHODS: Three-dimensional virtual hard-tissue models were reconstructed from computed tomography (CT) datasets of 26 healthy individuals. Models were mirrored and superimposed. Absolute average distance (AD) and 90th percentile distance (NPD) were used to measure overall and maximal symmetry. The Intraclass Correlation Coefficient (ICC) was calculated to measure interobserver consistency. In order to determine whether this technique is applicable in ZMC fracture cases, 10 CT datasets of individuals with a unilateral ZMC fracture were analyzed. RESULTS: For the unaffected group the mean AD was 0.84 ± 0.29 mm (95% CI 0.72-0.96) and the mean NPD was 1.58 ± 0.43 mm (95% CI 1.41-1.76). The ICC was 0.97 (0.94-0.98 as 95% CI), indicating almost perfect interobserver agreement. In the affected group the mean AD was 2.97 ± 1.76 mm (95% CI 1.71-4.23) and the mean NPD was 6.12 ± 3.42 mm (95% CI 3.67-8.57). The affected group showed near-perfect interobserver agreement with an ICC of 0.996 (0.983-0.999 as 95% CI). CONCLUSIONS: The method presented is an accurate instrument for evaluation of ZMC symmetry, which can be helpful for advanced diagnostics and treatment evaluation.

Laser speckle contrast imaging identifies ischemic areas on gastric tube reconstructions following esophagectomy.

Gastric tube reconstruction (GTR) is a high-risk surgical procedure with substantial perioperative morbidity. Compromised arterial blood supply and venous congestion are believed to be the main etiologic factors associated with early and late anastomotic complications. Identifying low blood perfusion areas may provide information on the risks of future anastomotic leakage and could be essential for improving surgical techniques. The aim of this study was to generate a method for gastric microvascular perfusion analysis using laser speckle contrast imaging (LSCI) and to test the hypothesis that LSCI is able to identify ischemic regions on GTRs.Patients requiring elective laparoscopy-assisted GTR participated in this single-center observational investigation. A method for intraoperative evaluation of blood perfusion and postoperative analysis was generated and validated for reproducibility. Laser speckle measurements were performed at 3 different time pointes, baseline (devascularized) stomach (T0), after GTR (T1), and GTR at 20° reverse Trendelenburg (T2).Blood perfusion analysis inter-rater reliability was high, with intraclass correlation coefficients for each time point approximating 1 (P < 0.0001). Baseline (T0) and GTR (T1) mean blood perfusion profiles were highest at the base of the stomach and then progressively declined towards significant ischemia at the most cranial point or anastomotic tip (P < 0.01). After GTR, a statistically significant improvement in mean blood perfusion was observed in the cranial gastric regions of interest (P < 0.05). A generalized significant decrease in mean blood perfusion was observed across all GTR regions of interest during 20° reverse Trendelenburg (P < 0.05).It was feasible to implement LSCI intraoperatively to produce blood perfusion assessments on intact and reconstructed whole stomachs. The analytical design presented in this study resulted in good reproducibility of gastric perfusion measurements between different investigators. LSCI provides spatial and temporal information on the location of adequate tissue perfusion and may thus be an important aid in optimizing surgical and anesthesiological procedures for strategically selecting anastomotic site in patients undergoing esophagectomy with GTR.

Low level laser therapy/photobiomodulation in the management of side effects of chemoradiation therapy in head and neck cancer: part 1: mechanisms of action, dosimetric, and safety considerations.

PURPOSE: There is a large body of evidence supporting the efficacy of low level laser therapy (LLLT), more recently termed photobiomodulation (PBM), for the management of oral mucositis (OM) in patients undergoing radiotherapy for head and neck cancer (HNC). Recent advances in PBM technology, together with a better understanding of mechanisms involved, may expand the applications for PBM in the management of other complications associated with HNC treatment. This article (part 1) describes PBM mechanisms of action, dosimetry, and safety aspects and, in doing so, provides a basis for a companion paper (part 2) which describes the potential breadth of potential applications of PBM in the management of side-effects of (chemo)radiation therapy in patients being treated for HNC and proposes PBM parameters. METHODS: This study is a narrative non-systematic review. RESULTS: We review PBM mechanisms of action and dosimetric considerations. Virtually, all conditions modulated by PBM (e.g., ulceration, inflammation, lymphedema, pain, fibrosis, neurological and muscular injury) are thought to be involved in the pathogenesis of (chemo)radiation therapy-induced complications in patients treated for HNC. The impact of PBM on tumor behavior and tumor response to treatment has been insufficiently studied. In vitro studies assessing the effect of PBM on tumor cells report conflicting results, perhaps attributable to inconsistencies of PBM power and dose. Nonetheless, the biological bases for the broad clinical activities ascribed to PBM have also been noted to be similar to those activities and pathways associated with negative tumor behaviors and impeded response to treatment. While there are no anecdotal descriptions of poor tumor outcomes in patients treated with PBM, confirming its neutrality with respect to cancer responsiveness is a critical priority. CONCLUSION: Based on its therapeutic effects, PBM may have utility in a broad range of oral, oropharyngeal, facial, and neck complications of HNC treatment. Although evidence suggests that PBM using LLLT is safe in HNC patients, more research is imperative and vigilance remains warranted to detect any potential adverse effects of PBM on cancer treatment outcomes and survival.

Low-level laser therapy/photobiomodulation in the management of side effects of chemoradiation therapy in head and neck cancer: part 2: proposed applications and treatment protocols.

PURPOSE: There is a large body of evidence supporting the efficacy of low-level laser therapy (LLLT), more recently termed photobiomodulation (PBM) for the management of oral mucositis (OM) in patients undergoing radiotherapy for head and neck cancer (HNC). Recent advances in PBM technology, together with a better understanding of mechanisms involved and dosimetric parameters may lead to the management of a broader range of complications associated with HNC treatment. This could enhance patient adherence to cancer therapy, and improve quality of life and treatment outcomes. The mechanisms of action, dosimetric, and safety considerations for PBM have been reviewed in part 1. Part 2 discusses the head and neck treatment side effects for which PBM may prove to be effective. In addition, PBM parameters for each of these complications are suggested and future research directions are discussed. METHODS: Narrative review and presentation of PBM parameters are based on current evidence and expert opinion. RESULTS: PBM may have potential applications in the management of a broad range of side effects of (chemo)radiation therapy (CRT) in patients being treated for HNC. For OM management, optimal PBM parameters identified were as follows: wavelength, typically between 633 and 685 nm or 780-830 nm; energy density, laser or light-emitting diode (LED) output between 10 and 150 mW; dose, 2-3 J (J/cm(2)), and no more than 6 J/cm(2) on the tissue surface treated; treatment schedule, two to three times a week up to daily; emission type, pulsed (<100 Hz); and route of delivery, intraorally and/or transcutaneously. To facilitate further studies, we propose potentially effective PBM parameters for prophylactic and therapeutic use in supportive care for dermatitis, dysphagia, dry mouth, dysgeusia, trismus, necrosis, lymphedema, and voice/speech alterations. CONCLUSION: PBM may have a role in supportive care for a broad range of complications associated with the treatment of HNC with CRT. The suggested PBM irradiation and dosimetric parameters, which are potentially effective for these complications, are intended to provide guidance for well-designed future studies. It is imperative that such studies include elucidating the effects of PBM on oncology treatment outcomes.