Impact of COVID-19 epidemic on maxillofacial surgery in Italy

Maxillofacial departments in 23 surgical units in Italy have been increasingly involved in facing the COVID-19 emergency. Elective surgeries have been progressively postponed to free up beds and offer human and material resources to those infected. We compiled an inventory of 32 questions to evaluate the impact of the SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments. The questionnaire focused on three different aspects: the variation of the workload, showing both a reduction of the number of team members (-16% among specialists, -11% among residents) due to reallocation or contamination and a consistent reduction of elective activities (the number of outpatient visits cancelled during the first month of the COVID-19 epidemic was about 10 000 all over Italy), while only tumour surgery and trauma surgery has been widely guaranteed; the screening procedures on patients and physicians (22% of maxillofacial units found infected surgeons, which is 4% of all maxillofacial surgeons); and the availability of Personal Protective Equipment, is only considered to be partial in 48% of Maxillofacial departments.

This emergency has forced those of us in the Italian health system to change the way we work, but only time will prove if these changes have been effective.

Computed tomographic localization of the deepest portion of the femoral trochlear groove in healthy dogs

OBJECTIVE

To validate a computed tomographic (CT) method to measure the femoral trochlear groove depth (FTGD).

STUDY DESIGN

Cadaveric study.

SAMPLE POPULATION

Fifteen dogs, 26 femoral trochleae.

METHODS

Five points were identified from proximal to distal (proximal point [PP], P25, P50, P75, and distal point [DP]) along the trochlea via three-dimensional volume-rendering function on the sagittal plane and measured on multiplanar reconstruction images. Each rater repeated measurements in duplicate, unaware of the identity of the joint. The FTGD was quantitated on the anatomical specimens and statistically compared with CT measurements. Intrarater and interrater agreements were analyzed by using intraclass coefficients. Accuracy was evaluated by using either adjusted R² coefficients (R²  > 80% was considered acceptable) or Student's t test. The ratio of the patellar and the trochlear width and the ratio of the patellar craniocaudal thickness inside the trochlear groove were calculated at three different patellar locations.

RESULTS

Good to excellent intrarater and interrater agreements were observed in four of five trochlear points (P25, P50, P75, and DP), and accuracy was acceptable for these points (R²  > 80%). Computed tomographic measurements differed from the mean anatomical measurements at three of five points (PP, P50, and P75; P < .01), overestimating the FTGD by an overall mean of 0.18 mm (range, 0.02-0.3). P25 and P50 were the deepest points measured.

CONCLUSION

Computed tomography allowed precise measurements of trochlear groove depth except for the most proximal point. The deepest trochlear points were P25 and P50. P25 was the most precise and accurate point measured, while PP was the least consistent.

CLINICAL SIGNIFICANCE

The deepest portion of the trochlea groove may be located between P25 and P50. Evaluation of this CT method in dogs with patellar luxation is recommended.

Thyroid profile during the alternative Sunitinib dosing 2/1 schedule in metastatic renal cell carcinoma

PURPOSE

Hypothyroidism is a common side effect of Sunitinib (SUN) treatment in metastatic renal cell carcinoma (mRCC) patients. We aimed to evaluate thyroid profile during the alternative 2/1 SUN treatment schedule and to assess the predictive value of hypothyroidism in terms of survival.

METHODS

We performed a prospective observational study enrolling 42 consecutive mRCC patients starting first-line alternative SUN dosing 2/1 schedule. Thyroid function was assessed at baseline and during the first three SUN cycles (1 cycle = 6 weeks = 2 ON/1 OFF + 2 ON/1 OFF), and then after 6 and 12 months. Thyroid ultrasound was performed at baseline and after 3, 6, and 12 months.

RESULTS

Subclinical hypothyroidism developed in 24% of patients during the first cycle; in other 24% in the second cycle and in 14% in the third cycle. The highest TSH values were reached during the second cycle, ON phase (6.58 ± 5.74 μI U/l). We observed a reduction in thyroid size, in echogenicity and in parenchymal perfusion in all patients. Progression-free survival (PFS) tended to be longer in patients with TSH ≥ 5 μI U/ml during the second cycle (p = 0.069). TSH level was an independent risk factor for PFS in men (p = 0.009) but not in women (p = 0.285).

CONCLUSIONS

This is the first study investigating functional and morphological effects on thyroid during the alternative 2/1 SUN schedule in mRCC patients. We detected an early onset of subclinical hypothyroidism, observing the association between TSH ≥ 5 μI U/ml and: (i) longer PFS in men; (ii) progressive decrease of thyroid size in absence of significant changes in autoimmune thyroid profile.

Atypical presentation of acute pancreatitis: a single center case-match analysis of clinical outcomes

OBJECTIVE

Acute pancreatitis (AP) may present an aspecific clinical picture without abdominal symptoms (atypical AP). We compared clinical outcomes between typical and atypical AP.

PATIENTS AND METHODS

Thirty out of 1163 patients (2.6%) presented an atypical AP. Demographic, clinical data, laboratory and radiological findings, management type, length of hospital stay (LOS) and mortality rate were retrospectively reviewed. A case match analysis 2:1 was performed. The final groups comprised 50 typical APs (TAP group) and 25 atypical APs (AAP group).

RESULTS

The AAP patients presented fever (36%), syncope (32%) and dyspnea (16%) as the most frequent symptoms. Laboratory values showed similarity between the two groups. We noted a comparable edematous AP rate in both groups (p=0.36). Ten (20%) TAP and 3 (12%) AAP patients needed ERCP, respectively (p=0.38). Cholecystectomy was similarly performed in both cohorts (p=0.81). One TAP patient underwent a percutaneous drainage and subsequent surgical necrosectomy compared to none in the AAP cohort (p=0.47). LOS and mortality rate were comparable (p=0.76 and 0.3, respectively).

CONCLUSIONS

Similar outcomes have been reached in the two groups. Routine evaluation of the serum amylase values fundamentally contributed to early diagnosis and appropriate treatment.

[Treatment of a hip and patella luxation in a toy dog]

INTRODUCTION

The present case report describes the surgical treatment of a traumatic craniodorsal luxation of the hip and a concomitant medial congenital luxation of the patella (3rd grade) in an 11-year-old Yorkshire Terrier. First the hip luxation was corrected with a cemented hip prosthesis. The femoral stem was inserted in slight anteversion (15°) with respect to the preoperative condition (5°), this contributed contrasting the medial traction of the femoral quadriceps on the patella, improving patellar luxation from 3rd to 2nd grade. However, the persistent patellar luxation and intermittent lameness reduced limb function and made a second intervention necessary. Four weeks after prosthetic surgery, a femoral trocleoplasty and lateral transposition of the tibial crest were performed to definitively re-establish a correct replacement of the patella in the femoral trochlea. No perioperative complications were found. At the final examination the patient did not show any lameness or pain that could be evoked when manipulating the surgically corrected limb. The surgical treatment allowed a restoration of the hip function and the alignment of the extensor mechanism of the femoral quadriceps and ensured a complete return to normal motor activities.

Interlaboratory Trial Validation of an Event-Specific Qualitative Polymerase Chain Reaction-Based Detection Method for Genetically Modified RT73 Rapeseed

The qualitative event-specific polymerase chain reaction detection method of genetically modified (GM) RT73 rapeseed was developed based on the cloned 3 end flanking sequence of RT73 rapeseed integration. The specificity of the method for GM RT73 rapeseed was validated using several different GM rapeseed lines, GM maize lines, GM soybean line, non-GM rapeseed, and other non-GM crops. In this study, the developed method was validated through an interlaboratory study by 12 laboratories from 6 countries. The sensitivity of this method was evaluated using several mixed rapeseed meals with different GM RT73 rapeseed contents from 5.0 to 0.01 prepared by our laboratory. The evaluated results showed that all of the rapeseed endogenous reference high mobility group protein gene (HMG I/Y), figwort mosaic virus 35S (FMV 35S) promoter, and RT73 event-specific fragment could be detected from rapeseed samples at 0.1 (w/w) with a confidence level of more than 95. All results from the 12 laboratories indicated that the developed method could be considered fit for the detection and identification of GM RT73 rapeseed.

Three-dimensional computer-assisted corrective osteotomy with a patient-specific surgical guide for an antebrachial limb deformity in two dogs

INTRODUCTION

We describe patient-specific surgical guide prototyping and surgical treatment of a complex antebrachial deformity in two skeletally mature dogs presented with chronic lameness. Computer-assisted surgery was elected to increase accuracy in the correction of the complex deformity. Radiographs and computed tomography (CT) scans revealed a biplane deformity with valgus, procurvatum and external torsion of the right radius in both cases. The pre-surgical planning started from the quantification of the angular deformity, followed by computer simulated correction and to end up with a rehearsal surgery on 3D printed bone models. During the surgery, the custom-made osteotomy guides closely fitted the bone, allowing for a precise corrective osteotomy, that was stabilized with two locking plates. Postoperative radiographs showed the successful correction of the deformity. Eight and 12 weeks postoperative follow up examinations showed improved lameness, weight-bearing and progression of bone healing in both dogs. Patient-specific surgical guides allowed for a satisfactory correction of the antebrachial deformity. Additional benefits of using customized surgical devices include standardization and reduced surgical time.

Multistate Models: Accurate and Dynamic Methods to Improve Predictions of Thrombotic Risk in Patients with Cancer

Research into cancer-associated thrombosis (CAT) entails managing dynamic data that pose an analytical challenge. Thus, methods that assume proportional hazards to investigate prognosis entail a risk of misinterpreting or overlooking key traits or time-varying effects. We examined the AGAMENON registry, which collects data from 2,129 patients with advanced gastric cancer. An accelerated failure time (AFT) multistate model and flexible competing risks regression were used to scrutinize the time-varying effect of CAT, as well as to estimate how covariates dynamically predict cumulative incidence. The AFT model revealed that thrombosis shortened progression-free survival and overall survival with adjusted time ratios of 0.72 and 0.56, respectively. Nevertheless, its prognostic effect was nonproportional and disappeared over time if the subject managed to survive long enough. CAT that occurred later had a more pronounced prognostic effect. In the flexible competing risks model, multiple covariates were seen to have significant time-varying effects on the cumulative incidence of CAT (Khorana score, secondary thromboprophylaxis, high tumor burden, and cisplatin-containing regimen), whereas other predictors exerted a constant effect (signet ring cells and primary thromboprophylaxis). The model that assumes proportional hazards was incapable of capturing the effect of these covariates and predicted the cumulative incidence in a biased way. This study evinces that flexible and multistate models are a useful and innovative method to describe the dynamic effect of variables associated with CAT and should be more widely used.

Ectopic thoracic thyroid removed by uniportal VATS approach. A case report

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VATS technique is minimally invasive and, moreover, it is characterized by a shorter recovery period, a minor blood loss and a shorter hospital stay.

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We speak of “Ectopic thyroid gland” when a piece of thyroid tissue is placed at a certain distance from the second to fourth tracheal cartilages.

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This case report aims at describing the successful extraction of a massive piece of ectopic thyroid from a young woman’s body, thanks to uniportal VATS.

Introduction

We speak of “Ectopic thyroid gland” when a piece of thyroid tissue is placed at a certain distance from the second to fourth tracheal cartilages.

Presentation of case

This case report focuses on a case of a hyperplastic cystic nodule of ectopic thyroid in a 30-year-old woman treated with uniportal video-assisted thoracic surgery (VATS). The patient, was admitted to Emergency Unit for abdominal pain and vomit, underwent a CT which highlighted a mass of significant dimension on the right side of the mediastinum, in contact with close structures. The lesion has been removed with an innovative mini-invasive technique, which is characterized, differently from traditional surgical approaches, by reduced loss of blood and time of hospitalization and, in addiction to that, an aesthetic small-dimensioned scar.

Discussion

VATS technique is minimally invasive and, moreover, it is characterized by a shorter recovery period, a minor blood loss and a shorter hospital stay. VATS has been advocated since 2010 for pulmonary resections, but today it is also performed for mediastinal intervention and a series of reports have demonstrated that it is feasible and safe.

Conclusion

The report aims at pointing out the possibility of undergoing this kind of surgery not only in case of pulmonary mass (on which the previous literature has focused) but also when mediastinum lesions occur, as in our case.

Accuracy of an automated three-dimensional technique for the computation of femoral angles in dogs

AIMS

The purpose of the study was to evaluate the accuracy of a three-dimensional (3D) automated technique (computer-aided design (aCAD)) for the measurement of three canine femoral angles: anatomical lateral distal femoral angle (aLDFA), femoral neck angle (FNA) and femoral torsion angle.

METHODS

Twenty-eight femurs equally divided intotwo groups (normal and abnormal) were obtained from 14 dogs of different conformations (dolicomorphic and chondrodystrophicCT scans and 3D scanner acquisitions were used to create stereolithographic (STL) files , which were run in a CAD platform. Two blinded observers separately performed the measurements using the STL obtained from CT scans (CT aCAD) and 3D scanner (3D aCAD), which was considered the gold standard method. C orrelation coefficients were used to investigate the strength of the relationship between the two measurements.

RESULTS

A ccuracy of the aCAD computation was good, being always above the threshold of R² of greater than 80 per cent for all three angles assessed in both groups. a LDFA and FNA were the most accurate angles (accuracy >90 per cent).

CONCLUSIONS

The proposed 3D aCAD protocol can be considered a reliable technique to assess femoral angle measurements in canine femur. The developed algorithm automatically calculates the femoral angles in 3D, thus considering the subjective intrinsic femur morphology. The main benefit relies on a fast user-independent computation, which avoids user-related measurement variability. The accuracy of 3D details may be helpful for patellar luxation and femoral bone deformity correction, as well as for the design of patient- specific, custom-made hip prosthesis implants.

Translational Research: A Future Strategy for Managing Squamous Cell Carcinoma of the Head and Neck?

BACKGROUND

Squamous Cell Carcinoma of the Head and Neck (SCCHN) are neoplasms arising from the epithelium of the first aero-digestive tract. They are very heterogeneous both clinically and biologically. Classic and well acknowledged risk factors are alcohol and tobacco consumption and other forms of smokeless tobacco assumption, although lately the incidence of Human Papilloma Virus (HPV)-related SCCHN is rapidly increasing. HPV-related tumors are very different from their alcohol and tobacco-associated counterpart, as they show strong chemo and radio sensitivity and thus can often be treated with conservative treatment strategies. Moreover, peculiar biologic features characterize HPV-related tumors, such as wild type TP53, low expression of Epidermal Growth Factor Receptor (EGFR), wild type CCND1 and high expression of P16. In contrast, alcohol and tobacco related SCCHN show opposite features, together with higher number of chromosomal and genetic abnormalities, conferring them chemo and radio resistance.

METHODS

We have performed a narrative review of the PubMed database with the aim to study the mutational landscape of SCCHN.

RESULTS

Several lines of evidence support the existence of at least two genetically different types of SCCHN, one virus-related and the other alcohol and/or tobacco-related, characterized by both clinical and biological opposite features. Virus related SCCHN are very chemo and radiosensitive, so suitable for organ preserving strategy, which in the near future may be induction chemotherapy followed by association of chemotherapy and underpowered radiotherapy. Alcohol and tobacco related SCCHN are themselves strongly heterogeneous and can be divided in different entities on the basis of the "Driver" genetic aberration, responsible for carcinogenesis. The most frequently mutated genes in alcohol and tobacco-related SCCHN are TP53, NOTCH1, CCND1, CDKN2A, EGFR and PI3KCA.

CONCLUSIONS

Virus-related SCCHN can be managed with chemo-radiotherapy. Alcohol and tobacco-related tumors should be further characterized on the basis of their "Driver Mutations" in order to select effective targeted therapies.

Nab-paclitaxel plus gemcitabine versus FOLFIRINOX in the first-line chemotherapy for patients with advanced pancreatic ductal adenocarcinoma: A national cohort (Comunica-TTD working group)

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Background: Advanced pancreatic ductal adenocarcinoma (PDAC) is a highly lethal disease with a five-year overall survival (OS) of less than 5%. Folfirinox and Nab-Paclitaxel plus Gemcitabine (NabPacGem) are the most active treatments in the first-line (1L). The decision to use Folfirinox or NabPacGem is a matter of debate. Methods: A retrospective cohort of advanced PDAC patients treated from January 2011 to May 2018 in four Spanish institutions was analyzed. The principal objective was to compare OS among patients receiving Folfirinox versus NabPacGem in 1L. Progression-free survival (PFS) was a secondary objective. Results: Characteristics of 251 patients included: median age 66.6 years; male 54.4%; stage IV at diagnosis 66.7%; ECOG 0/1/2 18/70/12%; treated with Folfirinox 18.3% and NabPacGem 81.7%. Patients treated with Folfirinox versus NabPacGem were younger (median age 58.3 vs. 67.9; p<0.001) and had lower ECOG (0/1/2 of 46/54/0% vs. 13/71/16%; p<0.001). Univariate analysis: median PFS 5.8 months (95%CI, 4.3 – 7.3) for Folfirinox and 4.2 months (95%CI, 3.7 – 5.2) for NabPacGem, HR=1.53 (95%CI, 1.1 – 2.1; p=0.012); median OS 12.7 months (95%CI, 8.4 – 14.3) for Folfirinox and 7.6 months (95%CI, 5.8 – 8.8) for NabPacGem, HR=1.38 (95%CI, 0.96 – 1.98; p=0.081). Multivariate Cox analysis (including type of treatment, ECOG and age) showed that ECOG was the only variable associated with PFS and OS (Table). Conclusions: In our study, advanced PDAC patients treated with Folfirinox were younger and had a better performance status than those treated with NabPacGem. We found no differences in survival between both treatments when adjusting by ECOG and age.[Table: see text]

Trifluridine/tipiracil (FTD/TPI) in patients (pts) aged ≥65 years with metastatic gastric/gastroesophageal junction cancer (mGC/mGEJC): Subgroup analysis from TAGS

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Background: 60% of newly diagnosed GC pts are > 65 y of age, a proportion that is increasing. The global phase 3 study TAGS (NCT02500043) demonstrated the efficacy and safety of FTD/TPI in previously treated pts with mGC/mGEJC. Here we report results in the pt subgroup aged ≥65 in TAGS. Methods: Pts with mGC/mGEJC treated with ≥2 prior chemotherapy regimens were randomized (2:1) to receive FTD/TPI (35 mg/m2 BID on days 1–5 and 8–12 of each 28-day cycle) or placebo, plus best supportive care. A preplanned efficacy/safety analysis was performed in pts aged ≥65 y. Results: Of 507 randomized pts, 228 (45%) were aged ≥65 y (range 65–89). The pt subset aged ≥65 y was similar to the overall population, except for a higher incidence of moderate renal impairment in the elderly subgroup (31% vs 17%). For pts aged ≥65 y, baseline characteristics were generally balanced across the treatment groups, although more pts treated with FTD/TPI than with placebo had ECOG PS 1 (69% vs 59%). FTD/TPI had an efficacy benefit in pts aged ≥65 y, and the FTD/TPI safety profile was similar in this subgroup vs the overall population (table). Treatment-related deaths (one in each treatment group) did not occur in pts aged ≥65 y. No drug-related deaths associated with cardiotoxicity were reported in pts aged ≥65 y. Although dose modifications were used more often in this subgroup, there was no increase in discontinuations vs the overall population. Conclusions: FTD/TPI was safe and effective in pts aged ≥65 y, who had a higher incidence of moderate renal impairment vs the overall population. Clinical trial information: NCT02500043. [Table: see text]

Management of recurrent nasopharyngeal carcinoma: current perspectives

Nasopharyngeal carcinoma is a rare disease in Western countries. Nevertheless, its incidence in China, Singapore, and other Eastern countries reaches 20 cases per 100,000 people. Being an extremely chemo- and radiosensitive disease, upfront treatment often consists in the association of intensity-modulated radiation therapy and concurrent cisplatin. Unfortunately, about 20% of the patients suffer from a radioresistant disease which recurs after upfront therapy. For these patients, mainly available therapeutic options consist in systemic therapy, in particular poly-chemotherapy. In those showing a single locoregional recurrence, chemotherapy is not considered to be the preferred approach and other different strategies may be employed. Re-irradiation and surgery are strategies that are always used more often, albeit related to high risk of morbidity. Immunotherapy and targeted therapy, such as heavy ions-based re-irradiations, are experimental but very intriguing options.

Supercutaneous Plating for the Treatment of Traumatic Injuries of the Appendicular Skeleton in Dogs

Objectives The purpose of this study was to report the clinical outcomes of traumatic appendicular bone injuries treated with supercutaneous plating.

Methods We conducted a retrospective case series of medical records following fracture fixation using locking implants with a supercutaneous plating technique. Inclusion criteria comprised a complete clinical and radiographical follow-up until implant removal. Patient history and signalment as well as fracture configuration were recorded.

Results Five appendicular long bone fractures (3 radii, 2 tibiae) were included in the study and they were all treated using conical coupling locking plates. The patient mean age was 2.3 years (range: 0.3–5.8 years) and the mean body weight 16.5 kg (range: 3–27 kg).

One major (implant failure) and minor complications (delayed bone union and iatrogenic recurvatum deformity) were detected. The removal of the plates was quick and did not require general anaesthesia. All five fractures treated healed and patients were sound at final follow-up. Neither discomfort nor pain were noticed during the postoperative patient management.

Clinical Significance The advantages related to the minimally invasive approach and implant removal could make the supercutaneous plating (SCP) an alternative to the traditional external skeletal fixation.

Further clinical investigations are required before definitive treatment recommendations using this technique can be made. In consideration of some of the complications detected, the use of fluoroscopy is recommended to support the surgeon at the beginning of their SCP learning curve.

Unresolved Gamma-Ray Sky through its Angular Power Spectrum

The gamma-ray sky has been observed with unprecedented accuracy in the last decade by the Fermi -large area telescope (LAT), allowing us to resolve and understand the high-energy Universe. The nature of the remaining unresolved emission [unresolved gamma-ray background (UGRB)] below the LAT source detection threshold can be uncovered by characterizing the amplitude and angular scale of the UGRB fluctuation field. This Letter presents a measurement of the UGRB autocorrelation angular power spectrum based on eight years of Fermi-LAT Pass 8 data products. The analysis is designed to be robust against contamination from resolved sources and noise systematics. The sensitivity to subthreshold sources is greatly enhanced with respect to previous measurements. We find evidence (with ∼3.7σ significance) that the scenario in which two classes of sources contribute to the UGRB signal is favored over a single class. A double power law with exponential cutoff can explain the anisotropy energy spectrum well, with photon indices of the two populations being 2.55±0.23 and 1.86±0.15.