What We Learned from Performing the Inverse Malek Procedure to Repair Bilateral Cleft Lips and Palates: A Single-Center Retrospective Study

Background: This study reviews the surgical and functional outcomes of children diagnosed with a bilateral cleft lip and palate and treated by the same surgical team following specific surgical protocols 18 years after surgery and during the follow-up. Methods: Based on a single-center retrospective design, demographic and surgical data were gathered by the authors from international institutions. Most of the data were quantitative in nature, and descriptive statistical and non-parametric tests were employed for analysis. All children born with a bilateral cleft from 1982 to 2002 were considered. Children affected by a syndrome were excluded. Complications and speech results were the main items measured. Results: Thirty patients were selected; 73.3% were treated using the inverse Malek procedure, and 26.7% underwent a modified two-stage procedure. Seventy percent developed an oronasal fistula. An alveolar bone graft was performed in 83%, and 53.3% underwent Le Fort osteotomy. Thirty-six percent required a pharyngeal flap, with good speech results. The median number of times general anesthesia was used among all the interventions considered was 5.5 (4.25-6). Conclusions: This study presents the long-term results of using the inverse Malek procedure to treat children with a bilateral cleft lip and palate. It is shown that this is related to a high risk of developing a fistula, but has good long-term speech results.

Does Fibula Free Flap Harvesting Affect Donor Site of Patients in Facial Reconstructions: A Gait Analysis Study

BACKGROUND

Vascularized fibula free flap (VFFF) remains gold standard for reconstruction of bony defects of the maxilla or mandible. Research and publications in recent years essentially focused on the evolution and improvement of the recipient reconstructed area but very few concerning the donor site morbidity.

PURPOSE

The aim of this study was to analyze walking ability of patients following VFFF operation and to determine if there are long term walking disabilities.

STUDY DESIGN, SETTING, SAMPLE

The retrospective cohort study involved healthy controls and patients who had undergone VFFF between 2012 and 2019 at the oral and maxillo-facial department of the University Hospital in Lausanne, Switzerland. Patients with cardiovascular, pulmonary, neuromuscular or musculoskeletal pathologies that could impair walking were excluded from the study.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Primary predictor is the reconstruction status, VFFF versus healthy patients (controls).

MAIN OUTCOME VARIABLES

Main outcomes were gait parameters. Objective evaluation of walking abilities was assessed using the Gait Up system (Gait Up SA, EPFL Innov'Park-C, Lausanne, Switzerland), which are wearable motion sensors that provides 3D analytics of the gait.

COVARIATES

Covariates implied patient characteristics such as age, sex, time after surgery and subjective evaluation of the gait obtained with two orthopedic validated questionnaires.

RESULTS

This study implied 10 healthy controls and 11 patients who had undergone VFFF. Results showed statistically significant differences in the speed [m/s] (1.3 vs 1.1 for a P value of .001), the stride length [m] (1.4 vs 1.2 for a P value of 0.003), the flat foot phase [%] (55.0 vs 63.3 for a P value of .006) and the pushing phase [%] (34.1 vs 25.1 for a P value of .008).

CONCLUSION AND RELEVANCE

Reconstruction using vascularized autograft in maxillofacial surgery is substantial and well described. Our attention focusing on donor site morbidity has demonstrated subjective and objective long-term alterations. These results will have to be confirmed with gait analysis in a prospective project including preoperative and postoperative analysis of the gait of the patient acting himself as his own control, with a larger scale of patients.

Unilateral Cleft lip and Palate: Long-Term Results of the Malek Technique

To review at 18 years-old the results of surgery and follow-up of children born in our hospital with unilateral cleft lip and palate (uCLP). They were operated at the time by the same surgeon, following the same primary surgical procedure (Malek).

Retrospective cohort study.

Tertiary Children's Hospital.

All children born with uCLP between 1996 and 2001 and operated in our hospital. Syndromic children were excluded.

Results of the primary surgery, ear-nose-throat interventions, maxillo-facial surgery and final phonatory results.

Seventy-nine files of children born with a cleft were reviewed: 34 were taken into consideration for uCLP: 15 right and 19 left. They were operated in two stages, following the inverse Malek procedure. Sixty per cent had a fistula. Eighty-eight percent had grommets. Ninety-seven percent had an alveolar graft at a median age of nine (5-10) and 22% underwent a Le Fort osteotomy. Seven percent were operated for a pharyngeal flap, 29% for a secondary lip surgery at a mean age of 12.8 and 29% for a late rhinoplasty at a mean age of 14.8 years. A median of 5.7 multidisciplinary consultations was realized with a median number of general anesthesia of 7.1 (4-13).

This retrospective study shows that the Malek procedure for children born with uCLP is related to a high risk of fistula but good long-term phonatory results. Twenty percent of children were operated for a Le Fort procedure and one-third for a secondary lip procedure and rhinoplasty.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Cryoneurolysis of alveolar nerves for chronic dental pain: A new technique and a case series

BACKGROUND

Chronic neuropathic dental pain has a poor prognosis with a low chance of significant spontaneous improvement. Local or oral therapies may be efficient, however short in terms of duration with potential side effects. Cryoneurolysis has been described to prevent acute postoperative pain or to treat some chronic pain conditions; however, application to dental orofacial pain has not been reported so far.

CASE SERIES

Following a positive diagnostic block on the corresponding alveolar nerve, neuroablation was performed using a cryoprobe on three patients suffering from persistent pain after a dental extraction and 1 after multiple tooth surgeries. The effect of treatment was assessed using a Pain Numeric Rating Scale (NRS) and determined by changes in medication dosage and quality of life at day 7 and 3 months. Two patients experienced more than 50% of pain relief at 3 months, 2 by 50%. One patient was able to wean off pregabalin medication, one decreased amitriptyline by 50%, and one decreased tapentadol by 50%. No direct complications were reported. All of them mentioned improvement in sleep and quality of life.

CONCLUSION

Cryoneurolysis on alveolar nerves is a safe and easy-to-use technique allowing prolonged neuropathic pain relief after dental surgery.

Cardiac tamponade during venoarterial extracorporeal membrane oxygenation: a case report

BACKGROUND

Cardiac tamponade may present with very different signs and clinical consequences in patients who are supported with venoarterial extracorporeal membrane oxygenation. Failure to recognize cardiac tamponade in this setting can cause failure to wean from venoarterial extracorporeal membrane oxygenation, and even lead to death.

CASE PRESENTATION

We present a 44-year-old Caucasian female in whom cardiac tamponade manifested as venoarterial extracorporeal membrane oxygenation weaning failure. After discovering the contribution of cardiac tamponade, it was possible to wean the patient from venoarterial extracorporeal membrane oxygenation support. No clear signs of cardiac tamponade had existed beforehand.

CONCLUSIONS

The diagnosis of cardiac tamponade can be very challenging in venoarterial extracorporeal membrane oxygenation supported patients due to (patho)physiological particularities related to the parallel blood flow.

Aesthetic results in children with single suture craniosynostosis: proposal for a modified Whitaker classification

OBJECTIVE

Aesthetic assessment after surgery for non-syndromic single suture craniosynostosis (SSC) is crucial. Surgeons' evaluation is generally based on Whitaker classification, while parental impression is generally neglected. The aim of this paper is to compare aesthetic perceptions of parents and surgeons after surgery for SSC, expressed by a 10-item questionnaire that complement Whitaker's classification.

METHODS

The authors submitted a 10-item questionnaire integrating Whitaker's classification in order to evaluate the degree of satisfaction, the detailed aesthetics results and the need for surgical revision, to surgeons and parents of a consecutive series of patients operated for SSC between January 2007 and December 2018. The results were collected blindly.

RESULTS

A total of 70 patients were included in the study. Scaphocephaly and trigonocephaly were the two most frequent craniosynostosis. Parents and surgeons general aesthetics evaluation and average rating for Whitaker's classification were 1.86 vs 1.67 (p = 0.69) and 1.19 vs 1.1 (p = 0.45) respectively. Parents' evaluation for scar perception and alopecia (p < 0.00001), the presence of bony crest (0.002), bony bump (p < 0.00001), or other bone irregularities (p = 0.02) are significantly worse when compared to surgeons' perception.

CONCLUSIONS

Parents seem to be more sensitive to the detection of some aesthetic anomalies and their opinion should not be neglected. The authors propose a modified Whitaker classification based on their results to better stratify the aesthetic outcome after surgery for SSC.

[Temporomandibular joint dysfunctions: evolution in patient care]

Temporomandibular joint dysfunctions are a frequently occurring condition that can have a considerable impact on the quality of life. The treatment modalities vary according to the anatomical involvement and symptomatology of the patient. Conservative and surgical management is still controversial and has evolved significantly in recent decades. The temporomandibular joint prosthesis is one of them. Through improvements in material and case management, the joint prosthesis has gained in popularity and has moved from being a treatment of last resort to being part of standard management.

[Temporomandibular joint disorders: current concepts for conservative management]

The temporomandibular joint is subject to repeated stress. The overloading of the compensation system leads to dysfunction, which manifests itself in the form of muscular and articular damage. Pain, joint noises and limitation of mouth opening are the most frequent reasons for a temporomandibular dysfunction (TMD) consultation. The diagnosis is mainly clinical. The therapeutic concepts are still controversial. The aim of this article is to offer a management strategy based on evidence through the analysis of literature reviews.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

An Intrinsically-Adhesive Family of Injectable and Photo-Curable Hydrogels with Functional Physicochemical Performance for Regenerative Medicine

Attaching hydrogels to soft internal tissues is crucial for the development of various biomedical devices. Tough sticky hydrogel patches present high adhesion, yet with lack of injectability and the need for treatment of contacting surface. On the contrary, injectable and photo-curable hydrogels are highly attractive owing to their ease of use, flexibility of filling any shape, and their minimally invasive character, compared to their conventional preformed counterparts. Despite recent advances in material developments, a hydrogel that exhibits both proper injectability and sufficient intrinsic adhesion is yet to be demonstrated. Herein, a paradigm shift is proposed toward the design of intrinsically adhesive networks for injectable and photo-curable hydrogels. The bioinspired design strategy not only provides strong adhesive contact, but also results in a wide window of physicochemical properties. The adhesive networks are based on a family of polymeric backbones where chains are modified to be intrinsically adhesive to host tissue and simultaneously form a hydrogel network via a hybrid cross-linking mechanism. With this strategy, adhesion is achieved through a controlled synergy between the interfacial chemistry and bulk mechanical properties. The functionalities of the bioadhesives are demonstrated for various applications, such as tissue adhesives, surgical sealants, or injectable scaffolds.

Mucosal Melanoma of the Head and Neck: A Retrospective Review and Current Opinion

Introduction: Head and Neck Mucosal Melanoma (HNMM) is an uncommon malignancy that arises in decreasing order in the nasal cavity, the paranasal sinuses, and the oral cavity. Although radical surgery followed by eventual radiotherapy is acknowledged as the mainstay treatment, patients with advanced stages or multi-focal tumors benefit from new systemic therapies. We wish to share our experience with these treatments and review the current literature. Materials and Methods: We present a case review of every patient treated in our center for an HNMM over the past 10 years, including every patient treated in our center for an HNMM over the past 10 years. We analyzed clinical characteristics, treatment modalities, and outcomes. Results: We included eight patients aged from 62 to 85 years old. We found six MM in the nasal cavity, one in the sphenoidal sinus, and one in the piriform sinus. Six patients underwent endoscopic surgery with negative margins, six underwent radiotherapy with variable modalities. Immunotherapy or targeted therapy was given in cases extensive tumors without the possibility of a surgical treatment or in two patient as an adjuvant treatment after R0 surgery. The three-year overall survival was 50%, and three patients (37.5%) are in remission. Conclusions: HNMM is associated with poor oncologic outcomes regarding the concerned patients of our review, as reported in the literature. New treatments such as immunotherapies or targeted therapies have not significantly changed the prognosis, but they may offer new interesting perspectives. Our small series of cases seems to confirm that surgical resection with negative margins improves overall survival.

Pediatric cranial osteoblastoma: Technical note of surgical treatment and review of the literature

Osteoblastoma of the skull is a rare entity, and they account only for 2-4% of all the cases of osteoblastoma. We perform a comprehensive review of the pertinent literature on the subject and we report a case of a 3-year-old girl presenting with a 6-month history of a supraorbital mass and exophthalmos due to an osteoblastoma of the frontal and ethmoid bones involving the orbit and anterior skull base. A 3D printed model of the patient's skull was used for the preoperative planning and reconstruction strategy. Total en-bloc resection of the tumor followed by immediate reconstruction was achieved. No recurrence was detected 3 years after the surgery. Gross total resection is strongly advised with skull osteoblastoma, especially in young age, because of the risk of the recurrence and malignant transformation. 3D printing is proven to be a valuable tool to enhance surgical performance by avoiding complications while achieving total resection with accurate reconstruction. Long-term follow-up is important to detect recurrences and improve the management of these young patients.

[Anosmia and COVID-19]

Anosmia associated or not with dysgeusia seems to be a frequent symptom in cases of infection with SARS-CoV-2 responsible for COVID-19. It can be the initial symptom of the disease or remain isolated in pauci-symptomatic patients. Waiting for scientific confirmation and in the context of the current pandemic, it seems essential to consider any patient with a new anosmia as being infected with SARS-CoV-2 until proven otherwise. These patients should therefore isolate themselves and remain alert to the occurrence of other symptoms suggestive of the infection and/or be tested. Topical and systemic corticosteroids and nose washes are contraindicated. The natural course of anosmia seems to be favorable in most cases.

[New features in the management of labio-maxillo-palatal clefts at the CHUV]

The labio-maxillofacial cleft (LMFC) penalizes the child from birth by its aesthetic, functional, psychological and social repercussions. The prognosis is conditioned by a multidisciplinary care that starts from the antenatal period to continue until the end of growth. The treatment is long and complex. This explains the multiplicity of techniques and the variability of schedules according to the teams. The purpose of this article is to describe the protocol of management of the LMFC within the multi-disciplinary team in Lausanne and to emphasize the novelties in both surgical and organizational plan.

[Internal medicine, seen from the mouth]

Many diseases affect the oral cavity. Therefore, the mouth is an organ that internists should observe carefully. Hereafter we present five illustrations of oral semiology that reflect a systemic condition: a strawberry tongue, an ulceration, a labial lesion, a gingival hyperplasia and a gingival hyperpigmentation. Each time, a differential diagnosis is to be considered, potentially allowing the identification of severe diseases.

Composite Double-Network Hydrogels To Improve Adhesion on Biological Surfaces

Despite the development of hydrogels with high mechanical properties, insufficient adhesion between these materials and biological surfaces significantly limits their use in the biomedical field. By controlling toughening processes, we designed a composite double-network hydrogel with ∼90% water content, which creates a dissipative interface and robustly adheres to soft tissues such as cartilage and meniscus. A double-network matrix composed of covalently cross-linked poly(ethylene glycol) dimethacrylate and ionically cross-linked alginate was reinforced with nanofibrillated cellulose. No tissue surface modification was needed to obtain high adhesion properties of the developed hydrogel. Instead, mechanistic principles were used to control interfacial crack propagation. Comparing to commercial tissue adhesives, the integration of the dissipative polymeric network on the soft tissue surfaces allowed a significant increase in the adhesion strength, such as ∼130 kPa for articular cartilage. Our findings highlight the significant role of controlling hydrogel structure and dissipation processes for toughening the interface. This research provides a promising path to the development of highly adhesive hydrogels for tissues repair.

[Sleep apnea : diagnostic and therapeutic modalities in case of failure of the CPAP]

Obstructive sleep apnea (OSA) is a sleep disorder that affects 49 % of men and 23% of women over 40 years old. CPAP is currently the treatment of choice for severe OSAS, but there are mild to moderate cases of OSAS with poor compliance or intolerance to CPAP, for which alternative treatments should be considered. In this article, we present a tool for evaluation of the upper airways, the DISE (Drug-induced sleep endoscopy), the OAM (mandibular advancement device), the bimaxillary advancement osteotomy, the hypoglossal nerve stimulation and the positional treatment.

Auditory verbal hallucinations in first episode psychosis – an fMRI symptom capture study

Introduction

Neurobiological models of auditory verbal hallucination (AVH) have been advanced by symptom capture functional magnetic resonance imaging (fMRI), where participants self-report hallucinations during scanning. To date, regions implicated are those involved with language, memory and emotion. However, previous studies focus on chronic schizophrenia, thus are limited by factors, such as medication use and illness duration. Studies also lack detailed phenomenological descriptions of AVHs. This study investigated the neural correlates of AVHs in patients with first episode psychosis (FEP) using symptom capture fMRI with a rich description of AVHs. We hypothesised that intrusive AVHs would be associated with dysfunctional salience network activity.

Methods

Sixteen FEP patients with frequent AVH completed four psychometrically validated tools to provide an objective measure of the nature of their AVHs. They then underwent fMRI symptom capture, utilising general linear models analysis to compare activity during AVH to the resting brain.

Results

Symptom capture of AVH was achieved in nine patients who reported intrusive, malevolent and uncontrollable AVHs. Significant activity in the right insula and superior temporal gyrus (cluster size 141 mm3), and the left parahippocampal and lingual gyri (cluster size 121 mm3), P < 0.05 FDR corrected, were recorded during the experience of AVHs.

Conclusions

These results suggest salience network dysfunction (in the right insula) together with memory and language processing area activation in intrusive, malevolent AVHs in FEP. This finding concurs with others from chronic schizophrenia, suggesting these processes are intrinsic to psychosis itself and not related to length of illness or prolonged exposure to antipsychotic medication.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Complete Maxillo-Mandibular Syngnathia in a Newborn with Multiple Congenital Malformations

Syngnathia is an extremely rare condition involving congenital fusion of the maxilla with the mandible. Clinical presentations vary from simple mucosal bands (synechiae) to complete bony fusion (synostosis). Most cases are unilateral incomplete fusions. We report the case of a severely growth-retarded newborn infant with complete synostosis of the mandible with the maxilla and the zygoma associated with cleft palate, choanal atresia, deafness, delayed cerebral white matter development, and genital and limb malformations. Extensive genetic analysis did not reveal any mutations. This association of multiple congenital malformations may represent an entity distinct from previously described syndromes associated with syngnathia.

Affective instability, childhood trauma and major affective disorders

BACKGROUND

Affective instability (AI), childhood trauma, and mental illness are linked, but evidence in affective disorders is limited, despite both AI and childhood trauma being associated with poorer outcomes. Aims were to compare AI levels in bipolar disorder I (BPI) and II (BPII), and major depressive disorder recurrent (MDDR), and to examine the association of AI and childhood trauma within each diagnostic group.

METHODS

AI, measured using the Affective Lability Scale (ALS), was compared between people with DSM-IV BPI (n=923), BPII (n=363) and MDDR (n=207) accounting for confounders and current mood. Regression modelling was used to examine the association between AI and childhood traumas in each diagnostic group.

RESULTS

ALS scores in descending order were BPII, BPI, MDDR, and differences between groups were significant (p<0.05). Within the BPI group any childhood abuse (p=0.021), childhood physical abuse (p=0.003) and the death of a close friend in childhood (p=0.002) were significantly associated with higher ALS score but no association was found between childhood trauma and AI in BPII and MDDR.

LIMITATIONS

The ALS is a self-report scale and is subject to retrospective recall bias.

CONCLUSIONS

AI is an important dimension in bipolar disorder independent of current mood state. There is a strong link between childhood traumatic events and AI levels in BPI and this may be one way in which exposure and disorder are linked. Clinical interventions targeting AI in people who have suffered significant childhood trauma could potentially change the clinical course of bipolar disorder.

Grommets and speech at three and six years in children born with total cleft or cleft palate

OBJECTIVE

Grommets may be considered as the treatment of choice for otitis media with effusion (OME) in children born with a cleft. But the timing and precise indications to use them are not well established. The aim of the study is to compare the results of hearing and speech controls at three and six year-old in children born with total cleft or cleft palate in the presence or not of grommets.

METHODS

This retrospective study concerns non syndromic children born between 1994 and 2006 and operated for a unilateral cleft lip palate (UCLP) or a cleft palate (CP) alone, by one surgeon with the same schedule of operations (Malek procedure). We compared the results of clinical observation, tympanometry, audiometry and nasometry at three and six year-old. The Borel-Maisonny classification was used to evaluate the velar insufficiency. None of the children had preventive grommets. The Fisher Exact Test was used for statistical analysis with p<0.05 considered as significant.

RESULTS

Seventy-seven patients were analyzed in both groups. Abnormal hearing status was statistically more frequent in children with UCLP compared to children with CP, at three and six years (respectively, 80-64%, p<0.03 and 78-60%, p<0.02), with the use of grommets at six years in 43% of cases in both groups. Improvement of hearing status between three and six year-old was present in 5% of children with UCLP and 9% with CP, without the use of grommets.

CONCLUSION

The use of grommets between three and six year-old was not associated to any improvement of hearing status or speech results children with UCLP or with CP, with a low risk of tympanosclerosis. These results favor the use of grommets before the age of three, taking into account the risk of long term tympanosclerosis.

Are open mandibular fractures still an emergency?

INTRODUCTION

Early surgical management is often advocated for fractures of the tooth-bearing portion of the mandible. A 6-hour delay has been mentioned for the fixation of these fractures. Our aim was to bring this paradigm into question.

METHODS

All patients referred to our department from September 2012 to May 2014 for fractures of the tooth-bearing portion of the mandible were retrospectively included. For each patient, age, gender, aetiology of the fracture, and characteristics of the fractures were recorded. Tobacco and/or alcohol addictions, diabetes and mandibular dental condition were taken into account. We also noticed the preoperative delay and the occurrence of complications such as: haematoma, infection, wound dehiscence, osteosynthesis failure and pseudarthrosis.

RESULTS

Among the 47 patients referred, 36 were treated with a delay of more than 6 hours (76.6%). In 88.8% of the cases, the reason for this delay was unavoidable. The mean delay time from trauma to surgery was 52 hours (range: 7-312). Forty-nine percent of the patients had comorbidities. Complications occurred in 6 patients leading to an overall complication rate of 16.67%. A statistically significant higher complication rate was observed among smokers (P=0.006). No statistical relationship was found between the delay and the occurrence of complications (P=0.994). This study suggests that fractures of the tooth-bearing portion of the mandible should no longer be considered as an emergency that must be treated within a 6-hour delay.

Failure to deactivate medial prefrontal cortex in people at high risk for psychosis

Impaired working memory is a core feature of schizophrenia and is linked with altered engagement the lateral prefrontal cortex. Although altered PFC activation has been reported in people with increased risk of psychosis, at present it is not clear if this neurofunctional alteration differs between familial and clinical risk states and/or increases in line with the level of psychosis risk. We addressed this issue by using functional MRI and a working memory paradigm to study familial and clinical high-risk groups. We recruited 17 subjects at ultra-high-risk (UHR) for psychosis, 10 non-affected siblings of patients with schizophrenia (familial high risk [FHR]) and 15 healthy controls. Subjects were scanned while performing the N-back working memory task. There was a relationship between the level of task-related deactivation in the medial PFC and precuneus and the level of psychosis risk, with deactivation weakest in the UHR group, greatest in healthy controls, and at an intermediate level in the FHR group. In the high-risk groups, activation in the precuneus was associated with the level of negative symptoms. These data suggest that increased vulnerability to psychosis is associated with a failure to deactivate in the medial PFC and precuneus during a working memory task, and appears to be most evident in subjects at clinical, as opposed to familial high risk.

First Report of Kudzu (Pueraria montana) Infections by Tobacco ringspot virus in Mississippi

Virus-like symptoms were observed in several kudzu patches in Mississippi during a survey of viruses infecting soybean carried out in late summer/fall of 2013 as a part of a project funded by the Mississippi Soybean Promotion Board. Symptomatology consisted of chlorotic mottle and ringspots, vein-associated feathering, necrosis, and leaf deformation, which were often observed in combination on the same plant. In order to identify the virus(es) involved in the disease, young leaves from a symptomatic kudzu sample collected in Kemper County were crushed in 10 volumes of 0.1 M phosphate buffer (pH 7.2) and mechanically inoculated onto celite-dusted leaves of two soybean varieties (Asgrow AG4605 and AG4730), each represented by 10 plants. Sap from an asymptomatic kudzu sample from Oktibbeha County was used as a control. Both varieties reacted by systemic mottle, stunting, and apical leaf necrosis approximately 2 weeks after inoculation, while no symptoms could be observed in controls. Partially purified preparations from both symptomatic soybean cultivars exhibited the presence of putative intact and empty spherical virus particles ~30 nm in diameter. ELISA tests with antisera to several soybean viruses were performed on the original kudzu sample and inoculated AG4605 and AG4730 soybean plants. These tests revealed the presence of Tobacco ringspot virus (TRSV) in all symptomatic samples. In order to better understand the incidence of this virus in kudzu in Mississippi, a total of 127 samples from 28 counties were collected during October 2013 and tested using ELISA. A total of 11 samples collected in 8 different counties were positive for TRSV. To further confirm these results, one step RT-PCR test was performed on total nucleic extracts from all ELISA-positive and four negative kudzu samples using TRSV-specific primers (3). A specific PCR product of 766 bp was present in all ELISA-positive samples and positive controls, whereas no visible bands were present in negative samples. PCR products generated from samples, collected in Kemper, Tippah, and Jefferson Davis counties, were cloned and custom sequenced. Pair-wise comparisons indicated conserved nucleotide (95 to 98%) and amino acid (98 to 99%) contents among sequenced products. Kudzu isolates from Mississippi shared 91 to 96% and 98 to 99% conserved nucleotides and amino acids, with TRSV sequences currently available in the NCBI/GenBank database. This is the first report of TRSV infection of kudzu in Mississippi. The possible implications to the soybean industry are yet to be determined since kudzu occupies approximately 202,000 ha in Mississippi and TRSV has historically been reported associated with bud blight in soybean (1). Nonetheless, results of our study, along with the recent report from Louisiana (2), strongly suggest that kudzu, due to its widespread distribution in the region, may represent a major reservoir of TRSV in the southeastern United States. References: (1) G. L. Hartman et al. Compendium of Soybean Diseases. American Phytopathological Society, St. Paul, MN, 1999. (2) Khankhum et al. Plant Dis. 97:561, 2013. (3) S. Sabanadzovic et al. Plant Dis. 94:126, 2010.

Are we really mapping psychosis risk? Neuroanatomical signature of affective disorders in subjects at ultra high risk

BACKGROUND

The majority of people at ultra high risk (UHR) of psychosis also present with co-morbid affective disorders such as depression or anxiety. The neuroanatomical and clinical impact of UHR co-morbidity is unknown.

METHOD

We investigated group differences in grey matter volume using baseline magnetic resonance images from 121 participants in four groups: UHR with depressive or anxiety co-morbidity; UHR alone; major depressive disorder; and healthy controls. The impact of grey matter volume on baseline and longitudinal clinical/functional data was assessed with regression analyses.

RESULTS

The UHR-co-morbidity group had lower grey matter volume in the anterior cingulate cortex than the UHR-alone group, with an intermediate effect between controls and patients with major depressive disorder. In the UHR-co-morbidity group, baseline anterior cingulate volume was negatively correlated with baseline suicidality/self-harm and obsessive-compulsive disorder symptoms.

CONCLUSIONS

Co-morbid depression and anxiety disorders contributed distinctive grey matter volume reductions of the anterior cingulate cortex in people at UHR of psychosis. These volumetric deficits were correlated with baseline measures of depression and anxiety, suggesting that co-morbid depressive and anxiety diagnoses should be carefully considered in future clinical and imaging studies of the psychosis high-risk state.

[3D planning in maxillofacial surgery]

The development of new technologies such as three-dimensional (3D) planning has changed the everyday practice in maxillofacial surgery. Rapid prototyping associated with the 3D planning has also enabled the creation of patient specific surgical tools, such as cutting guides. As with all new technologies, uses, practicalities, cost effectiveness and especially benefits for the patients have to be carefully evaluated. In this paper, several examples of 3D planning that have been used in our institution are presented. The advantages such as the accuracy of the reconstructive surgery and decreased operating time, as well as the difficulties have also been addressed.

How is affective instability defined and measured? A systematic review

BACKGROUND

Affective instability (AI) is poorly defined but considered clinically important. The aim of this study was to examine definitions and measures of AI employed in clinical populations.

METHOD

This study was a systematic review using the PRISMA guidelines. MEDLINE, Embase, PsycINFO, PsycArticles and Web of Science databases were searched. Also five journals were hand searched. Primary empirical studies involving randomized controlled trials (RCTs), non-RCTs, controlled before and after, and observational investigations were included. Studies were selected, data extracted and quality appraised. A narrative synthesis was completed.

RESULTS

A total of 11 443 abstracts were screened and 37 studies selected for final analysis on the basis that they provided a definition and measure of AI. Numbers of definitions for each of the terms employed in included studies were: AI (n = 7), affective lability (n = 6), affective dysregulation (n = 1), emotional dysregulation (n = 4), emotion regulation (n = 2), emotional lability (n = 1), mood instability (n = 2), mood lability (n = 1) and mood swings (n = 1); however, these concepts showed considerable overlap in features. A total of 24 distinct measures were identified that could be categorized as primarily measuring one of four facets of AI (oscillation, intensity, ability to regulate and affect change triggered by environment) or as measuring general emotional regulation.

CONCLUSIONS

A clearer definition of AI is required. We propose AI be defined as 'rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences'. No single measure comprehensively assesses AI and a combination of current measures is required for assessment. A new short measure of AI that is reliable and validated against external criteria is needed.

[Skin cancers infiltrating the skull base]

Squamous cell and basocellular carcinoma of the face have an excellent prognosis. Nevertherless, a small proportion therefore of these cancers differs by a much more aggressive behavior, caracterised by a tendency to infiltrate the deep facial soft tissues and facial bones. The invasion of the craniofacial skeleton and the intracranial structures follows the embryonic fusion lines or the facial sensitive or motor nerves, sometimes years after the initial treatment. The development of craniofacial surgery, reconstruction techniques and conformational radiotherapy allows us now to offer curative guided treatments, for these advanced staged tumors with a remaining limited prognosis. A therapeutic benefit implies a rigorous selection of these patients.

Conceptual issues in psychiatric neuroimaging: an update

AIM

In this paper, we provide an update on the conceptual issues of psychiatric neuroimaging, especially in the light of the current reductive claims of the eliminative physicalism.

ARGUMENT

our argument is developed on three stages. The first is to highlight the crucial importance of phenomenological psychopathology and person-centered approach, which remains underestimated; the second is to bring forward the view that functional neuroimaging is relevant to the area of 'translation' in the mind-brain debate. The third point is to present a critical analysis of the shortcomings in structural and functional neuroimaging from methodological and epistemological perspectives.

CONCLUSION

a novel paradigm for translational cross-validation among neuroscience, psychopathology and clinical psychology is presented.

[Complex fronto-orbital reconstruction with a PEEK prosthesis and skin expansion: about a case]

INTRODUCTION

Reconstructions of the fronto-orbital area remain a challenge to the reconstructive surgeon, due to the functional and esthetic impact.

OBSERVATION

The authors present a case of a complex fronto-orbital reconstruction with a PEEK (PolyEtherEtherKetone) implant, associated with a skin expansion.

DISCUSSION

With a follow-up of over three years, the cosmetic result is excellent. The authors believe that this technique is reliable, fast with long-term good results.

Abstract 3558: In vitro and in vivo profiling of class I and class II ATP-competitive c-Met kinase inhibitors defines potential c-Met-specific sensitivity biomarkers

c-Met is a receptor tyrosine kinase with oncogenic potential for which several small molecule inhibitors are currently being tested in clinical trials. There are suggestions in the literature that c-Met inhibitors could have anti-tumor effects under a variety of contexts, including in tumors in which the MET gene is amplified, contains a gain-of-function mutation or in tumors with receptor overexpression. We have developed ATP-competitive c-Met inhibitors that possess different selectivity profiles and fall into two categories. Class I molecules are highly selective for c-Met while class II molecules are multi-kinase inhibitors. These molecules were profiled in vitro and in vivo to identify biomarkers of c-Met dependence. We show that both classes of molecules inhibited c-Met kinase activity in vitro and in vivo. However, class I and class II molecules differed extensively in their spectrum of anti-tumor activity. The anti-proliferative effects of the different c-Met inhibitors were tested in 359 cancer cell lines in vitro. The activity of class I molecules was exclusively restricted to cell lines that harbor MET amplification. Western blotting in sensitive or resistant cell lines showed that c-Met inhibitors effectively block signaling downstream of c-Met only in MET amplified cell lines. In vivo, class I molecules inhibited only the growth of tumor models that are highly dependent on c-Met activity due to MET amplification or due to a hepatocyte growth factor (HGF)-driven autocrine loop. The same models that were sensitive to class I inhibitors were also sensitive to class II inhibitors. However, class II inhibitors had additional anti-tumor activities in vitro and in vivo in models that did not respond to class I inhibitors. The majority of cell lines that responded only to a class II molecule in vitro required much higher drug concentrations than those required to inhibit the growth of MET amplified cell lines. Finally, the growth inhibitory effects observed in vitro and in vivo were consistent with the selectivity profiles of the different c-Met inhibitors. Together our data demonstrate that MET amplification is a clinically identifiable, potential sensitivity biomarker for selective c-Met kinase inhibitors. c-Met expression alone is not a sensitivity biomarker in preclinical models. The spectrum of c-Met inhibitor sensitive models defined in this work could be used to understand whether other small molecule c-Met inhibitors are exquisitely selective for c-Met or harbor additional activities.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3558. doi:10.1158/1538-7445.AM2011-3558

Mandibular Osteoradionecrosis in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx

Objective. Mandibular osteoradionecrosis (ORN) is a serious complication of radiotherapy (RT) in head and neck cancer patients. The aim of this study was to analyze the incidence of and risk factors for mandibular ORN in squamous cell carcinoma (SCC) of the oral cavity and oropharynx.

Study Design. Case series with chart review.

Setting. University tertiary care center for head and neck oncology.

Subjects and Methods. Seventy-three patients treated for stage I to IV SCC of the oral cavity and oropharynx between 2000 and 2007, with a minimum follow-up of 2 years, were included in the study. Treatment modalities included both RT with curative intent and adjuvant RT following tumor surgery. The log-rank test and Cox model were used for univariate and multivariate analyses.

Results. The incidence of mandibular ORN was 40% at 5 years. Using univariate analysis, the following risk factors were identified: oral cavity tumors ( P < .01), bone invasion ( P < .02), any surgery prior to RT ( P < .04), and bone surgery ( P < .0001). By multivariate analysis, mandibular surgery proved to be the most important risk factor and the only one reaching statistical significance ( P < .0002).

Conclusion. Mandibular ORN is a frequent long-term complication of RT for oral cavity and oropharynx cancers. Mandibular surgery before irradiation is the only independent risk factor. These aspects must be considered when planning treatment for these tumors.

Abnormal prefrontal activation directly related to pre-synaptic striatal dopamine dysfunction in people at clinical high risk for psychosis

Schizophrenia is characterized by altered prefrontal activity and elevated striatal dopaminergic function. To investigate the relationship between these abnormalities in the prodromal phase of the illness, we combined functional Magnetic Resonance Imaging and (18)F-Dopa Positron Emission Tomography. When performing a verbal fluency task, subjects with an At-Risk Mental State showed greater activation in the inferior frontal cortex than controls. Striatal dopamine function was greater in the At-Risk group than in controls. Within the At-Risk group, but not the control group, there was a direct correlation between the degree of left inferior frontal activation and the level of striatal dopamine function. Altered prefrontal activation in subjects with an At-Risk Mental State for psychosis is related to elevated striatal dopamine function. These changes reflect an increased vulnerability to psychosis and predate the first episode of frank psychosis.

[How to cope with recurrent aphthous stomatitis]

Recurrent aphthous stomatitis (RAS) is the most common oral mucosa ailment. This condition is frequently considered as idiopathic due to the doubts about its etiology, probably related to a minor immunological dysregulation in a context of genetic predisposition. However, ulcers that resemble recurrent aphthous stomatitis in some respects can be found in systemic disorders that must be ruled out for the differential diagnosis of SAR, particularly when they appear after adolescence and/or when associated lesions exist out of the oral cavity. SAR management lies on the elimination of predisposing factors (drugs, oral trauma, food allergies...) and if needed, topical corticosteroids are the first choice regimen. More severe cases may require systemic regimens.

Impaired verbal self-monitoring in individuals at high risk of psychosis

BACKGROUND

Cognitive models suggest that auditory verbal hallucinations arise through defective self-monitoring and the external attribution of inner speech. We used a paradigm that engages verbal self-monitoring (VSM) to examine whether this process is impaired in people experiencing prodromal symptoms, who have a very high risk of developing psychosis.

METHOD

We tested 31 individuals with an At-Risk Mental State (ARMS) and 31 healthy volunteers. Participants read single adjectives aloud while the source and pitch of the online auditory verbal feedback was manipulated, then immediately identified the source of the speech they heard (Self/Other/Unsure). Response choice and reaction time were recorded.

RESULTS

When reading aloud with distorted feedback of their own voice, ARMS participants made more errors than controls (misidentifications and unsure responses). ARMS participants misidentified the source of their speech as 'Other' when the level of acoustic distortion was severe, and misidentification errors were inversely related to reaction times.

CONCLUSIONS

Impaired VSM is evident in people with an ARMS, although the deficit seems to be less marked than in patients with schizophrenia. Follow-up of these participants may clarify the extent to which the severity of this impairment predicts the subsequent onset of psychosis and development of positive symptoms.

Bisphosphonate-related osteonecrosis of the jaws: how to manage cancer patients

Bisphosphonate related osteonecrosis of the jaw (BRONJ) is defined as exposed necrotic bone appearing in the jaws of patients treated by systemic IV or oral BPs never irradiated in the head and neck area and that has persisted for more than 8 weeks. More than 90% of cases of osteonecrosis of the jaw have been in patients with cancer who received IV-BPs. The estimate of cumulative incidence of BRONJ in cancer patients with IV-BPs ranges from 0.8% to 18.6%. The pathogenesis of BRONJ appeared related to the potent osteoblast-inhibiting properties of BPs which act by blocking osteoclast recruitment, decreasing osteoclast activity and promoting osteoclast apoptosis. Dental extractions are the most potent local risk factor. Cancer patients wearing a denture could also be at increased risk of BRONJ. Non-healing mucosal breaches caused by dentures could be a portal for the oral flora to access bone, while the oral mucosa of patients on IV-BPs could also be defective. Whether periodontal disease is a risk factor for BRONJ remains controversial. Preventive measures are fundamental. Nevertheless, some teams have questioned its cost-effectiveness. The perceived limitations of surgical therapy of BRONJ led to the restriction of aggressive surgery to symptomatic patients with stage 3 BRONJ. The evidence-based literature on BRONJ is growing but there are still many controversial aspects.