Evaluation of soft tissue changes around the nose following subspinal Le Fort â osteotomy.

PURPOSE: This study sought to evaluate the effect of subspinal Le Fort Ⅰ osteotomy (SLFⅠO) and alar base chinch suture (ABCS) in preventing postoperative changes of nasal shape following maxillary movement of advancement-impaction (MAI) or advancement-downward (MAD) by analyzing changes of nasal soft tissue on computed tomography (CT) images. METHODS: Forty-three Japanese patients with dentofacial deformity who underwent orthognathic surgery with SLFⅠO and ABCS were retrospectively examined. Maxillary movement and changes to soft tissues around the nose were analyzed using pre- and postoperative CT. RESULTS: Increased nasal width and alar base width, upturning of the nasal tip and flattening of the nose occurred in both groups, with more prominent changes in MAI. MAD showed horizontal maxillary movement strongly correlated with changes in pronasale and subnasale. Preoperative nasal height correlated negatively with changes to nasal height in both groups, and to nasolabial angle and nasal tip angle in MAD. There were no correlations between the tightness of ABCS during operation and postoperative nasal soft tissue changes including nasal width. CONCLUSION: Postoperative changes to nasal shape following SLFⅠO and ABCS need to be considered with advance movements of the maxilla, regardless of vertical maxillary movement. Postoperative pronasale and subnasale may be estimable from the amount of the maxillary advance movement in MAD. Postoperative changes in nasal shape may be more prominent in cases with low nasal height.

Measurement of Thickness at the Inferior Border of the Mandible Using Computed Tomography Images: A Retrospective Study including 300 Japanese Cases.

Vascularised fibular free flaps are integral to reconstructive surgery for head and neck tumours. We investigated the morphological characteristics of the mandible to improve the incidence of plate-related complications after surgery. Using standard radiological software, thickness measurements of the inferior or posterior margin of the mandible were obtained from computed tomography images of 300 patients at seven sites: (1) mandibular symphysis, (2) midpoint between the mandibular symphysis and mental foramen, (3) mental foramen, (4) midpoint between the mental foramen and antegonial notch, (5) antegonial notch, (6) mandibular angular apex (gonion), and (7) neck lateral border of the dentate cartilage. Relationships between age, sex, height, weight, the number of remaining teeth in the mandible, and the thickness of each mandible were also investigated. Measurement point 1 had the largest median mandibular thickness (11.2 mm), and measurement point 6 had the smallest (5.4 mm). Females had thinner measurements than males at all points, with significant differences at points 1, 2, 3, 4, and 7 (p < 0.001). Age and number of remaining teeth in the mandible did not correlate with mandibular thickness; however, height and weight correlated at all points except point 6. Thickness measurements obtained at the sites provide a practical reference for mandibular reconstruction. Choosing the fixation method based on the measured thickness of the mandible at each site allows for sound plating.

A Sublatissimus Dorsi Abscess Due to Pasteurella multocida Caused by a Cat Scratch.

We encountered a 51-year-old male patient who was not immunocompromised. Thirteen days before his admission, his right forearm was scratched by his pet cat. Swelling, redness, and purulent discharge appeared at the site, but he did not seek medical attention. He developed a high fever and was hospitalized with a diagnosis of septic shock, respiratory failure, and cellulitis on plain computed tomography. After admission, the swelling on his forearm was relieved with empirical antibiotics, but the symptoms spread from his right axilla to his waist. We suspected necrotizing soft tissue infection and made a trial incision in the lateral chest up to the latissimus dorsi, but were unable to prove it. However, an abscess was later found under the muscle layer. Second incisions were made to allow the abscess to drain. The abscess was relatively serous, and no tissue necrosis was observed. The patient's symptoms improved rapidly. In retrospect, the patient probably already had the axillary abscess on admission. It may have been detected at this point if contrast-enhanced computed tomography had been performed, and early axillary drainage may have accelerated the patient's recovery, which could also have prevented the formation of the latissimus dorsi muscle abscess. In conclusion, the Pasteurella multocida infection on the patient's forearm induced a very unusual presentation and caused an abscess to form under the muscle, unlike necrotizing soft tissue infections. Early contrast-enhanced computed tomography may aid earlier and more appropriate diagnosis and treatment in such cases.

Travelers' vaccines and their adverse events in Nara, Japan.

BACKGROUND: It is important to analyze the types of vaccines in travel clinics to determine the focus points in future practice. METHODS: We retrospectively reviewed the electronic medical records of all patients who visited the travel clinic of Nara Medical University between June 2013 and December 2019 to determine their background and the vaccines administered. The information regarding adverse events of the unapproved vaccines in Japan (Havrix®, Verorab®, Boostrix®, Priorix®, Typhim Vi®, and Mencevax®) was also collected. RESULTS: Of 645 patients, 58.6% were men and the median age was 31 years. Business was the most common travel purpose (34.9%), and Southeast Asia was the most common destination (40.2%). More than 80% of travelers to low- and middle-income countries were vaccinated against hepatitis A, while the rabies vaccination rate was approximately 50%. Typhoid vaccination coverage among travelers to South Asia was approximately 50%. The incidence of adverse events requiring medical consultation, telephonic consultation, or prolonged stay in the examination room was less than 5% for all unapproved vaccines in Japan. CONCLUSION: More patient education is needed to increase the vaccination rate of rabies and typhoid vaccines. Adverse events to unapproved vaccines in Japan were not high and were well-tolerated.

Risk factors for post-extraction bleeding in patients with haemophilia: a retrospective cohort study.

Many guidelines and studies describe haemostatic management protocols for patients with haemophilia, but few have evaluated the risk factors for post-extraction bleeding. This retrospective cohort study was performed to investigate these risks among this group of patients. We used medical records to identify patients with haemophilia who underwent tooth extraction(s) between April 2006 and April 2019 in the Department of Oral and Maxillofacial Surgery at Nara Medical University Hospital, Nara, Japan, and conducted logistic regression analyses to identify risk or protective factors for post-extraction bleeding in procedures involving factor replacement therapy. Post-extraction bleeding was defined as bleeding that could not be stopped by biting down on gauze, and that required medical treatment between 30min and 14 days after the extraction. A total of 151 extractions (84 interventions) in 55 patients fulfilled the inclusion criteria (130 extractions (72 interventions) in 48 patients with haemophilia A, and 21 extractions (12 interventions) in seven patients with haemophilia B). Post-extraction bleeding was observed in nine patients (16.3%), 10 interventions (11.9%), and 12 extractions (7.9%). On average, it occurred six days after the intervention, and on the fifth postoperative day after extractions. Use of mouth splints significantly reduced the risk (odds ratio: 0.13; p=0.01) in patients on factor replacement therapy. We will conduct a prospective study to investigate the optimal type of splint and optimal splint-wearing period.

Oral risk factors associated with medication-related osteonecrosis of the jaw in patients with cancer.

INTRODUCTION: Bone-modifying agents (BMAs) are indispensable to cancer therapy. However, the number of patients with medication-related osteonecrosis of the jaw (MRONJ) is increasing according to the BMA administration. Oral factors predisposing to development of MRONJ are receiving attention, and oral management is recommended for prevention of MRONJ; however, the strategy and criteria have not yet been established. Therefore, we investigated the oral risk factors associated with MRONJ development in this study. MATERIALS AND METHODS: A retrospective study was carried out on 398 cancer patients who had received oncological-dose BMAs between 2007 and 2018; general health factors, demographic, and dental factors were examined along with MRONJ development in all the patients. The cumulative occurrence rate of MRONJ was calculated using a Kaplan-Meier analysis. Clinical factors were analyzed using the Cox regression analysis. RESULTS: MRONJ occurred in 42 of the 398 patients. The cumulative MRONJ incidence rates were 4.5, 12.9, 17.7, and 21.6% at 1, 2, 3, and 4 years, respectively. Age (p = 0.038), male sex (p = 0.002), initiation of dental interventions before BMA administration (p = 0.020), alveolar bone loss involving more than half the root (p < 0.001), and torus mandibularis (p < 0.001) were significantly associated with MRONJ. CONCLUSIONS: Our findings suggest that patients with alveolar bone loss involving more than half the root on panoramic radiographs and torus mandibularis carry a high risk of MRONJ development. Early dental intervention before BMA administration and oral management during the treatment are important for preventing MRONJ.

Does inflammatory dental disease affect the development of medication-related osteonecrosis of the jaw in patients using high-dose bone-modifying agents?

OBJECTIVES: High-dose bone-modifying agents (BMAs), such as bisphosphonates and denosumab, are essential for the treatment of cancer patients with bone metastases. The incidence of medication-related osteonecrosis of the jaw (MRONJ) is increasing. Inflammatory dental diseases could lead to MRONJ, and hence, they should be managed appropriately. Tooth extractions are commonly advised to prevent dental inflammation; however, the accurate indications for tooth extractions before starting BMA therapy have not been established. Hence, we assessed teeth with inflammatory dental diseases to identify indicators for prophylactic extraction before starting BMA therapy. MATERIALS AND METHODS: We included 745 teeth with inflammatory dental diseases of 212 cancer patients on high-dose BMA therapy. We assessed the relationship between inflammatory dental disease and risk of MRONJ development. Multivariate Cox regression analysis was used for statistical analysis. The cumulative occurrence rate of MRONJ was calculated using the Kaplan-Meier method. RESULTS: MRONJ occurred in 43 of 745 teeth. Teeth characteristics significantly correlated with MRONJ occurrence were mandible (p = 0.009), molar region (p = 0.005), radiopaque changes in bone surrounding the root on orthopantograms obtained at patients' first visits (p < 0.001), and tooth extractions after starting BMA therapy (p < 0.001). CONCLUSIONS: Radiopaque changes in bone surrounding the root are an important radiographic finding that indicates the need for prophylactic tooth extractions before starting BMA therapy. CLINICAL RELEVANCE: Our results suggest that the prophylactic extraction of teeth with radiopaque changes in bone surrounding the root before starting BMA therapy could prevent the onset of MRONJ.

Enumerated sparse extraction of important surgical planning features for mandibular reconstruction.

Because implicit medical knowledge and experience are used to perform medical treatment, such decisions must be clarified when systematizing surgical procedures. We propose an algorithm that extracts low-dimensional features that are important for determining the number of fibular segments in mandibular reconstruction using the enumeration of Lasso solutions (eLasso). To perform the multi-class classification, we extend the eLasso using an importance evaluation criterion that quantifies the contribution of the extracted features. Experiment results show that the extracted 7-dimensional feature set has the same estimation performance as the set using all 49-dimensional features.

Pulmonary involvement of secondary syphilis.

Pulmonary involvement in secondary syphilis is considered a rare occurrence; however, the number of cases has increased in the 2000s. This is likely due to the increased use of computed tomography scans and molecular diagnostic testing. We report a case of an HIV-positive man with pleural chest pain and bilateral subpleural nodules on chest computed tomography. His rapid plasma reagin and Treponema pallidum hemagglutination tests were positive, and the specimen of one of the pulmonary nodules obtained by transthoracic biopsy was positive for the polA gene of Treponema pallidum. Since clinical manifestations of syphilis are highly variable, clinicians should bear in mind that pleural chest pain with bilateral subpleural nodules can be caused by pulmonary syphilis.

Risks of postextraction bleeding after receiving direct oral anticoagulants or warfarin: a retrospective cohort study.

OBJECTIVE: The effect of direct oral anticoagulants (DOACs) on the risk of bleeding after tooth extraction remains unclear. This study aimed to evaluate the incidence of postextraction bleeding among patients who received DOAC and vitamin K antagonists (VKAs), such as warfarin. DESIGN: This study was a retrospective cohort analysis. Incidence rates and propensity score-matched regression models were used to compare the risks of bleeding after tooth extractions involving DOACs and VKAs. SETTING: The study took place in a single university hospital in Japan. PARTICIPANTS: Between April 2013 and April 2015, 543 patients underwent a total of 1196 simple tooth extractions. PRIMARY OUTCOME MEASURE: The primary outcome measure was the occurrence of postextraction bleeding, which was defined as bleeding that could not be stopped by biting down on gauze and required medical treatment between 30 min and 7 days after the extraction. RESULTS: A total of 1196 tooth extractions (634 procedures) in 541 patients fulfilled the study criteria, with 72 extractions (41 procedures) involving DOACs, 100 extractions (50 procedures) involving VKAs and 1024 extractions (543 procedures) involving no anticoagulants. The incidences of postextraction bleeding per tooth for the DOAC, VKA and no anticoagulant extractions were 10.4%, 12.0% and 0.9%, respectively. The incidences of postextraction bleeding per procedure for DOACs, VKAs and no anticoagulants were 9.7%, 10.0% and 1.1%, respectively. In comparison to the VKA extractions, the DOAC extractions did not significantly increase the risk of postextraction bleeding (OR 0.69, 95% CIs 0.24 to 1.97; p=0.49). CONCLUSIONS: The risk of postextraction bleeding was similar for DOAC and VKA extractions.

Automated Planning With Multivariate Shape Descriptors for Fibular Transfer in Mandibular Reconstruction.

OBJECTIVE: This paper introduces methods to automate preoperative planning of fibular segmentation and placement for mandibular reconstruction with fibular flaps. METHODS: Preoperative virtual planning for this type of surgery has been performed by manual adjustment of many parameters, or based upon a single feature of the reconstruction. We propose a novel planning procedure formulated as a nonconvex minimization problem of an objective function using the multilateral shape descriptors. RESULTS: A retrospective study was designed and 120 reconstruction plans were reproduced using computed tomography images with oral surgeons. The proposed automated planning model was quantitatively compared with both the existing model and the surgeons' plans. CONCLUSION: The results show that the developed framework attains stable automated planning that agrees with the surgeons' decisions. SIGNIFICANCE: This method addresses tradeoff problems between symmetric reconstruction and restoration of the native contour of the mandible.

Biomechanical analysis of immediately loaded implants according to the "All-on-Four" concept.

PURPOSE: The purpose of this study was to investigate the biomechanical behavior of immediately loaded implants in an edentulous mandible according to the "All-on-Four" concept. METHODS: A 3D-finite element model of an edentulous mandible was constructed. Four implants were placed between the bilateral mental foramen according to "All-on-Four" concept. A framework made of titanium or acrylic resin between the bilateral first molars was modeled. Immediate loading and a delayed loading protocol were simulated. A vertical load of 200N was applied at the cantilever or on the abutments region of the distal implants, simulating the absence of a cantilever. RESULTS: The peak principal compressive strains in the immediate loading models resulted in 24.0-35.8% and 26.4-39.0% increases compared with the delayed loading models under non-cantilever loading and cantilever loading, respectively. The loading position greatly affected the principal compressive and tensile strain values. The peak principal compressive strains in non-cantilever loading resulted in a 45.3-52.6% reduction compared with those in cantilever loading. The framework material did not influence the peak compressive and tensile strain. The maximum micromotion at the bone-implant interface in the immediate loading models was 7.5-14.4µm. CONCLUSIONS: Mandibular fixed full-arch prostheses without cantilevers may result in a favorable reduction of the peri-implant bone strain during the healing period, compared with cantilevers. The maximum micromotion was within the acceptable limits for uneventful implant osseointegration in the immediate loading models. Framework material did not play an important role in reducing the peri-implant bone strain and micromotion at the bone-implant interface.

Statistical Analysis of Interactive Surgical Planning Using Shape Descriptors in Mandibular Reconstruction with Fibular Segments.

This study was performed to quantitatively analyze medical knowledge of, and experience with, decision-making in preoperative virtual planning of mandibular reconstruction. Three shape descriptors were designed to evaluate local differences between reconstructed mandibles and patients' original mandibles. We targeted an asymmetrical, wide range of cutting areas including the mandibular sidepiece, and defined a unique three-dimensional coordinate system for each mandibular image. The generalized algorithms for computing the shape descriptors were integrated into interactive planning software, where the user can refine the preoperative plan using the spatial map of the local shape distance as a visual guide. A retrospective study was conducted with two oral surgeons and two dental technicians using the developed software. The obtained 120 reconstruction plans show that the participants preferred a moderate shape distance rather than optimization to the smallest. We observed that a visually plausible shape could be obtained when considering specific anatomical features (e.g., mental foramen. mandibular midline). The proposed descriptors can be used to multilaterally evaluate reconstruction plans and systematically learn surgical procedures.

Sparse shape model for fibular transfer planning in mandibular reconstruction.

In this paper, we propose an automated preoperative planning method that estimates a plan fitted to the data of a new patient using a planned dataset of previous patients. Although mandibular reconstruction with fibular segments needs preoperative planning for the precise placement of segments, recent interactive planning software cannot secure objectivity of the planning and time-consuming trial-and-error processes are required. The proposed method employs sparse shape modeling; in this modeling, we select a subset of the data from a prepared preoperative planning dataset to make an example or instance of reconstruction via a linear combination of the data. We conduct experiments using the dataset planned by medical doctors and compare the instance estimated by the proposed method to the manual placement by these doctors.

Volumetric fibular transfer planning with shape-based indicators in mandibular reconstruction.

In preoperative planning for mandibular reconstructive surgery, it is necessary to determine the osteotomy lines for fibular shaping and the proper placement of fibular segments in the mandible. Although virtual surgical planning has been utilized in preoperative decision making, current software designs require manual operation and a trial-and-error process to refine the reconstruction plan. We have developed volumetric fibular transfer simulation software that can quickly design a preoperative plan based on direct volume manipulation and quantitative comparison with the patient's original mandible. We propose three quantitative shape indicators-volume ratio, contour error, and maximum projection-for symmetrical lesions of the mandible, and have implemented a parallel computation algorithm for the semiautomatic placement of fibular segments. Using this virtual planning software, we conducted a retrospective study of the computed tomography data from nine patients. We found that combining direct volume manipulation with real-time local search of placement improved the applicability of the planning system to optimize mandibular reconstruction.

[18F]fluoro-2-deoxyglucose-positron emission tomography for the assessment of histopathological response after preoperative chemoradiotherapy in advanced oral squamous cell carcinoma.

BACKGROUND: [(18)F]fluoro-2-deoxyglucose-positron emission tomography (FDG-PET) is widely used to evaluate tumor metabolic activity. The aim of this study was to evaluate the usefulness of FDG-PET in assessing the histopathological response to preoperative concurrent chemoradiotherapy (CRT) in patients with oral squamous cell carcinoma (OSCC). METHODS: Forty-five patients with resectable advanced OSCC who had received preoperative CRT followed by tumor ablative surgery between January 2004 and December 2011 were included in the study. All patients underwent FDG-PET before and after preoperative CRT. The maximum standardized uptake value (SUVmax) before (pre-SUV) and after preoperative CRT (post-SUV) and the SUVmax reduction rate (ΔSUV %) were used to evaluate the response to preoperative CRT. Correlations among SUVmax, histopathological response, and expression of cancer antigen Ki-67 and hypoxia-inducible factor-1α (HIF-1α) were analyzed. RESULTS: Preoperative CRT significantly reduced intratumoral FDG uptake (P < 0.001). The pre-SUV and post-SUV were significantly lower in patients with a pathological complete response (pCR) than in those with a non-pCR (pre-SUV P = 0.037; post-SUV P = 0.001). ΔSUV % was higher in patients with pCR than in those with non-pCR (P = 0.029). The pre-SUV was significantly correlated with Ki-67 and HIF-1α expression in pretreatment biopsy specimens (Ki-67 P = 0.046, R = 0.292; HIF-1α P = 0.007, R = 0.385). The expression of both Ki-67 and HIF-1α was significantly lower in patients with pCR than in those with non-pCR (Ki-67 P < 0.001; HIF-1α P < 0.001). CONCLUSIONS: Low pre-SUV and post-SUV and high ΔSUV % may predict a good histopathological response to preoperative CRT. Ki-67 and HIF-1α expression in pretreatment biopsy specimens were predictors of histopathological response to preoperative CRT.

Volumetric surgical planning system for fibular transfer in mandibular reconstruction.

This presentation introduces a new software design for virtual preoperative planning for free fibular transfer in mandibular reconstructive surgery. Direct volume resection and manipulation of superimposed fibular segments allow interactive editing of the surgical plan without the need for a surface modeling process. We also introduce three shape indicators: volume ratio, contour error and maximum projection for evaluating the reconstruction plan from geometrical aspects. The indicators significantly quantify the difference between 2-segment and 3-segment cases, and suggest optimization of preoperative planning while satisfying appropriate placement margins for fibular segments.

An autopsy case of pulmonary fissure induced by zygomycosis.

For immunodeficient patients, fungi are life-threatening pathogens. In this paper, we present an autopsy case of combined zygomycosis and aspergillosis. A female in her 70s on chronic hemodialysis was admitted to a hospital suffering bloody sputum, dyspnea, and fever, probably due to perinuclear anti-neutrophil cytoplasmic antibody-related vasculitis. Antibiotics were administered and immunosuppressive therapy was started, resulting in an improvement in her condition. Pneumonia later developed, followed by pulmonary bleeding and intractable pneumothorax from which she ultimately died. On autopsy, the upper lobe of the left lung was found to have hemorrhagic necrosis and showed a large longitudinal fissure. Microscopically, Zygomycota were observed in both the lungs and heart, while Aspergillus was found in the middle lobe of the right lung. Zygomycosis, which usually has a poor prognosis, is assumed to have induced hemorrhagic infarction of the lungs, inducing pulmonary bleeding and necrosis, despite the use of lipid formulations of amphotericin B, which are effective medicines against Zygomycota.

Neuroprotective effects of granulocyte colony-stimulating factor on ischemia-reperfusion injury of the retina.

PURPOSE: It has been reported that granulocyte colony-stimulating factor (G-CSF) provides neuroprotection in models in which neuronal cell death is induced. This research was designed to investigate the effects of G-CSF on neurodegeneration of the inner retinal layer in a rat model of ischemic reperfusion (I/R) injury. MATERIALS AND METHODS: Retinal ischemia was induced by increasing the intraocular pressure to 110 mm Hg for 45 min in the left eyes of the rats. A sham operation was carried out on the right eyes. G-CSF (100 µg/kg/day in 0.3 ml saline) or the same volume of saline was intraperitoneally injected just before the operation and continued for 4 consecutive days (a total of 5 consecutive days). Morphological examinations, including the terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, were performed 7 days after I/R induction. The expression of phosphorylated AKT in the retina was examined by Western blot analysis and immunohistochemistry. RESULTS: Cell loss in the ganglion cell layer was more significantly reduced in the I/R-induced eyes of the G-CSF-injected rats than in the I/R-induced eyes of the saline-injected rats (20.3 vs. 6.6%). The inner retinal thickness ratios, such as the inner plexiform layer to the inner limiting membrane/outer nuclear layer and the inner nuclear layer/outer nuclear layer, were significantly better preserved in the I/R-induced eyes of the G-CSF-injected rats than in the I/R-induced eyes of the saline-injected rats. TUNEL assays showed fewer apoptotic cells in the retinal sections of the I/R-induced eyes of the G-CSF-injected rats. The phosphorylation of AKT (p-AKT/AKT) was upregulated in the retinas of the I/R-induced eyes of the G-CSF-injected rats. CONCLUSION: Our results demonstrated that systemic injection of G-CSF can protect retinal ganglion cells and inner retinal layers from I/R injury. The effects could be associated with the activation of AKT.

Measurement of urinary 8-oxo-7,8-dihydro-2-deoxyguanosine in a novel point-of-care testing device to assess oxidative stress in children.

BACKGROUND: 8-oxo-7,8-dihydro-2-deoxyguanosine (8-oxodG), also known as 8-hydroxy-2'-deoxyguanosine (8-OHdG), is an oxidatively damaged nucleobases of DNA and is excreted into urine. Therefore, its urinary level is used as a sensitive marker for oxidative stress (OS). Although it can be measured by enzyme-linked immunosorbent assay (ELISA), its application to clinical pediatrics remains limited. Recently, a novel automatic analyzer (model no. ICR-001: Techno Medica Co., Ltd., Japan) has been developed for point-of-care testing (POCT) to measure urinary 8-oxodG. We verified the reliability of the value of urinary 8-oxodG measured by this novel analyzer and to set the age-related reference intervals. METHOD: We obtained random urine samples from 100 healthy Japanese adults and 157 healthy Japanese children aged 0-15years. Urinary 8-oxodG was determined using two methods: competitive immunochromatography using a novel automatic analyzer (ICR-001) and another was ELISA. RESULTS: Both urinary 8-oxodG and urinary creatinine measured by ICR-001 correlated well with those measured by ELISA (r(s)=0.945, p<0.0001) and an enzymatic method (r(s)=0.988, p<0.0001). Age-related reference for 8-oxodG corrected by creatinine were highest in the youngest subjects and decreased until adolescence, consistent with published data by ELISA. CONCLUSION: A new automatic analyzer that measures urinary 8-oxodG can be used as a POCT for the assessment of OS levels in children.