Classification and volumetric assessment of cleft lip and palate malformations using cone beam computed tomography

Orientador: Solange Maria de Almeida BoscoloTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de PiracicabaResumo: presente estudo propôs-se a avaliar in vitro a acurácia de três métodos diferentes para mensuração do volume de fissuras orofaciais em imagens de tomografia computadorizada de feixe cônico (TCFC), e a influência do campo de visão (FOV) e voxel nessas medidas. Além disso, também objetivou-se apresentar uma classificação para fissuras alveolares e palatinas unilaterais baseada em imagens de TCFC, bem como estimar a quantidade de osso necessário para enxerto ósseo desses indivíduos e avaliar a relação desse volume com os escores atribuídos na aplicação da classificação. Para a avaliação in vitro, fissuras unilaterais foram simuladas em três crânios que foram subsequentemente preenchidas com cera e escaneados em equipamento de TCFC, usando quatro protocolos de aquisição variando os tamanhos de FOV e voxel. Usando três diferentes métodos, o volume do defeito/cera foi avaliado nas imagens definindo-se: (1) largura, altura e comprimento do defeito em projeção de máxima intensidade; (2) as áreas dos defeitos nas reconstruções axiais; (3) a variação dos tons de cinza da região de interesse e a segmentação do defeito. Os valores obtidos em cada método nos diferentes protocolos foram comparados ao volume real da cera (padrão ouro) por meio dos testes ANOVA e Tukey. Os métodos 2 e 3 não diferiram do padrão ouro (p>0,05). Contrariamente, o método 1 apresentou valores significativamente superestimados (p0.05). Os volumes calculados em exames de TCFC provaram ser confiáveis para avaliação volumétrica de fissuras alveolares e palatinas quando os métodos 2 e 3 foram utilizados, independentemente do tamanho de FOV e voxel. Para a avaliação in vivo, imagens de TCFC de 33 indivíduos com fissuras alveolares e palatinas unilaterais foram utilizadas. Três observadores avaliaram as imagens tomográficas atribuindo os devidos escores da classificação proposta pelos autores, denominada classificação GAND: defeito, arco, nasal e dental. Adicionalmente, uma avaliação quantitativa dessas fissuras foi realizada por um avaliador segmentando-se o defeito e calculando-se o volume necessário para enxerto ósseo dos mesmos. Os escores e reprodutibilidade da classificação GAND foram analisados por meio do teste Kappa ponderado. Já a associação da avaliação volumétrica com os quesitos defeito e nasal foi verificada usando-se ANOVA, enquanto a concordância intraobservador foi analisada por meio do coeficiente de correlação intraclasse (CCI). A reprodutibilidade intraobservador da classificação variou de 0,29 a 0,92 e de 0,29 a 0,91 entre os observadores. Não foram observados valores estatisticamente significantes quando avaliada a relação do volume com os parâmetros "defeito" e "nasal" da classificação GAND (p>0,05). A concordância intraobservador da avaliação volumétrica foi 0,97. A incorporação de imagens tomográficas no manejo de pacientes com fissuras permitiu uma maior compreensão das verdadeiras dimensões dos defeitos. A classificação GAND é um novo sistema que permite a avaliação rápida da extensão e complexidade da fenda. Para melhores resultados, recomenda-se incorporar resultados clínicos ao exame tomográfico, especialmente para o parâmetro arco. Não é possível estimar a quantidade de osso necessária para enxerto ósseo baseando-se na classificação; para tal, indica-se a segmentação individualizada para cada pacienteAbstract: The present study aimed to evaluate the accuracy of three different methods for volumetric assessment of orofacial clefts in cone beam computed tomography (CBCT) images, and the influence of the field of view (FOV) and voxel sizes in these measurements. In addition, it was also aimed to propose a classification for unilateral cleft lip and palate (UCLP) malformations based on CBCT images, as well as estimate the amount of bone necessary for grafting and evaluate the relation of this volume with the scores attributed in the classification. For the in vitro evaluation, unilateral defects were simulated in three skulls which were subsequently filled with wax and scanned in a CBCT unit using four acquisition protocols, varying FOV and voxel sizes. Using three different methods, the defect/wax volume was evaluated on the images by defining: (1) width, height and facial-palatal length of the defect in maximum intensity projection; (2) the areas of the defect on axial slices; (3) the threshold and segmentation of the region of interest. The values obtained for each method in different protocols were compared to the actual volume of the wax (gold standard) by ANOVA and Tukey tests. Methods 2 and 3 did not differ from the gold standard (p> 0.05). In contrast, method 1 had significantly overestimated values (p 0.05). The volumes calculated on CBCT images proved to be reliable for volumetric evaluation of alveolar/palatal clefts when methods 2 and 3 are used regardless FOV and voxel sizes. For the in vivo evaluation, CBCT images of 33 subjects with UCLP were used. Three observers evaluated the images assigning scores proposed in GAND classification: gap, arch, nasal and dental. Additionally, a quantitative assessment of these defects was performed by one examiner who segmented the defects and estimated the amount of graft needed for posterior alveolar bone grafting. The scores and reproducibility of GAND classification was analyzed using weighted Kappa test. The association of volume assessment with the classification (gap and nasal parameters) was verified using ANOVA, while the intraobserver agreement was analyzed using Intraclass correlation coefficient (ICC). The intraobserver reproducibility of the classification ranged from 0.29 to 0.92 and ranged from 0.29 to 0.91 between the observers. There were no statistically significant values when evaluating the association of the volume with the classification (p> 0.05). The intraobserver agreement in the volumetric assessment was 0.97. The incorporation of CBCT imaging in the management of patients with OFC has allowed for a greater understanding of the true dimensions of the defects. The GAND classification is a novel system that allows the quick estimation of the extent and complexity of the cleft. For better results, it is recommended to incorporate clinical findings to the CBCT examination, especially for the arch parameter. It is not possible to estimate the amount of bone needed for ABG based on the classification; individualized surgical planning should be done for each patient specificallyDoutoradoRadiologia OdontologicaDoutora em Radiologia Odontológic

Micro-ct Evaluation Of The Radioprotective Effect Of Resveratrol On The Mandibular Incisors Of Irradiated Rats

The purpose of this study was to perform a microcomputed tomographic evaluation of the radioprotective effect of resveratrol on the volume of mandibular incisors of irradiated rats. A second aim was to make a quantitative assessment of the effect of x-ray exposure on these dental tissues. Twenty adult male rats were divided into four groups: control, irradiated control, resveratrol, and irradiated resveratrol. The resveratrol groups received 100 mg/kg of resveratrol, whereas the irradiated groups were exposed to 15 Gy of irradiation. The animals were sacrificed 30 days after the irradiation procedure, and their mandibles were removed and scanned in a microcomputed tomography unit. The images were loaded into Mimics software to allow segmentation of the mandibular incisor and assessment of its volume. The results were compared by One-way ANOVA and Tukey's post hoc test, considering a 5% significance level. The irradiated groups showed significantly diminished volumes of the evaluated teeth, as compared with the control group (p < 0.05). The resveratrol group presented higher values than those of the irradiated groups, and volumes similar to those of the control group. High radiation doses significantly affected tooth formation, resulting in alterations in the dental structure, and thus lower volumes. Moreover, resveratrol showed no effective radioprotective impact on dental tissues. Future studies are needed to evaluate different concentrations of this substance, in an endeavor to verify its potential as a radioprotector for these dental tissues.30

Comparison of different methods to assess alveolar cleft defects in cone beam CT images

This study aimed to evaluate the accuracy of three different methods for assessing the volume of cleft defects in CBCT images. The influence of field of view (FOV) and voxel sizes was also assessed

Volumetric nasal cavity analysis in children with unilateral and bilateral cleft lip and palate

OBJECTIVES/HYPOTHESIS: Children with cleft lip and palate (CLP) often suffer from nasal obstruction that may be related to effects on nasal volume. The objective of this study was to compare side:side volume ratios and nasal volume in patients with unilateral (UCLP) and bilateral (BCLP) clefts with age-matched controls. STUDY DESIGN: Retrospective case-control study using three-dimensional (3D) nasal airway reconstructions. METHODS: We analyzed 20 subjects (age range = 7-12 years) with UCLP and BCLP from a regional craniofacial center who underwent cone beam computed tomography (CT) prior to alveolar grafting. Ten multislice CT images from age-matched controls were also analyzed. Mimics software (Materialise, Plymouth, MI) was used to create 3D reconstructions of the main nasal cavity and compute total and side-specific nasal volumes. Subjects imaged during active nasal cycling phases were excluded. RESULTS: There was no statistically significant difference in affected:unaffected side volume ratios in UCLP (P = .48) or left:right ratios in BCLP (P = .25) when compared to left:right ratios in controls. Mean overall nasal volumes were 9,932 ± 1,807, 7,097 ± 2,596, and 6,715 ± 2,115 mm(3) for control, UCLP, and BCLP patients, respectively, with statistically significant volume decreases for both UCLP and BCLP subjects from controls (P < .05). CONCLUSIONS: This is the first study to analyze total nasal volumes in BCLP patients. Overall nasal volume is compromised in UCLP and BCLP by approximately 30%. Additionally, our finding of no major difference in side:side ratios in UCLP and BCLP compared to controls conflicts with pre-existing literature, likely due to exclusion of actively cycling scans and our measurement of the functional nasal cavity

Volumetric nasal cavity analysis in children with unilateral and bilateral cleft lip and palate: Nasal Cavity Volume in Cleft Lip and Palate

Children with cleft lip and palate (CLP) often suffer from nasal obstruction which may be related to effects on nasal volume. The objective of this study is to compare side:side volume ratios and nasal volume in patients with unilateral (UCLP) and bilateral (BCLP) clefts with age-matched controls

Micro-CT evaluation of the radioprotective effect of resveratrol on the mandibular incisors of irradiated rats

Abstract The purpose of this study was to perform a microcomputed tomographic evaluation of the radioprotective effect of resveratrol on the volume of mandibular incisors of irradiated rats. A second aim was to make a quantitative assessment of the effect of x-ray exposure on these dental tissues. Twenty adult male rats were divided into four groups: control, irradiated control, resveratrol, and irradiated resveratrol. The resveratrol groups received 100 mg/kg of resveratrol, whereas the irradiated groups were exposed to 15 Gy of irradiation. The animals were sacrificed 30 days after the irradiation procedure, and their mandibles were removed and scanned in a microcomputed tomography unit. The images were loaded into Mimics software to allow segmentation of the mandibular incisor and assessment of its volume. The results were compared by One-way ANOVA and Tukey’s post hoc test, considering a 5% significance level. The irradiated groups showed significantly diminished volumes of the evaluated teeth, as compared with the control group (p < 0.05). The resveratrol group presented higher values than those of the irradiated groups, and volumes similar to those of the control group. High radiation doses significantly affected tooth formation, resulting in alterations in the dental structure, and thus lower volumes. Moreover, resveratrol showed no effective radioprotective impact on dental tissues. Future studies are needed to evaluate different concentrations of this substance, in an endeavor to verify its potential as a radioprotector for these dental tissues

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Avaliação da ferramenta invert do software eFilm para o exame de imagens por ressonância magnética de articulações temporomandibulares

A Articulação Temporomandibular (ATM) constitui um complexo sistema de estruturas intimamente associadas que, juntamente com outros componentes, compõem o sistema estomatognático. O estudo por imagem do movimento mandibular relacionado à anatomia da fossa, eminência articular e disco articular foi possível apenas através dos recursos fornecidos pelos exames de ressonância magnética e seus softwares correspondentes. No software e-film, a ferramenta "inverting" permite que os pixels de baixo valor (escuros) tornem-se de alto valor (claros). No entanto, não se sabe se essa função traz benefícios de diagnóstico para o profissional. Então, este trabalho avaliou a aplicabilidade da ferramenta "invert" do software eFilm Workstation. Sobre 30 imagens de ressonância magnética do disco articular foi confeccionada uma grade milimetrada. Cinco examinadores desenharam em folha de papel quadriculada a imagem do disco observada com e sem o uso da ferramenta "invert" sendo a imagem do disco quantificada pela quantidade de quadrados preenchidos. Os resultados foram submetidos ã análise estatística. Valores dos coeficientes de correlação íntra-classe apresentaram r>0,05 o que não demonstrou diferença estatisticamente significante entre os grupos