Παρασκευή, 19 Απριλίου 2019

Oral Oncology

CorrespondenceAbstract only
Sanctuary site central nervous system relapse-refractory DLBCL responding to nivolumab and lenalidomide
Irappa V. Madabhavi, Swaroop Revannasiddaiah, Malay S. Sarkar, Mitul G. Modi
In Press, Corrected Proof, Available online 19 April 2019
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Despite improvement in survival in diffuse large B-cell lymphoma (DLBCL) with the introduction of rituximab, central nervous system (CNS) relapse continues to represent a clinical challenge. In diffuse large B-cell lymphoma (DLBCL), the incidence of CNS relapse is only ∼5% in unselected cohorts. Immunotherapy is the treatment that either boosts the patient's own immune system or uses man-made versions of the normal parts of the immune system to kill lymphoma cells or slow their growth. We are presenting a thirty-eight year old man who, presented with neck nodes, axillary nodes, altered sensorium, abnormal body movements, unconsciousness, weight loss and, fever, with a past history of DLBCL in May 2008, treated with 6 cycles of CHOP and completed in November 2008. After 9 years in April 2018, the patient developed similar symptoms and treated with salvage chemotherapy with R-DHAP which was completed in September 2018. Post-treatment PET-CT showed partial metabolic response and we started external beam radiotherapy to initial bulky disease. After completion of radiotherapy, the patient was very reluctant for any type of therapy and went home. After one month he presented to us with persistent vomiting, abnormal body movements and, altered sensorium. On examination, his Glasgow Coma Scale (GCS) was E2V3M2 and he was admitted in Intensive Care Unit. The patient was managed with mannitol, dexamethasone, antiepileptics, antibiotics and other supportive care medicines. His brain magnetic resonance imaging (MRI) was showing multiple heterogeneously enhancing lesions with surrounding vasogenic oedema and his cerebrospinal fluid analysis was positive for malignant cells. He was managed with triple intrathecal chemotherapy with methotrexate 12 mg, Cytarabine 50 mg, and Hydrocortisone 50 mg along with other supportive care medicines, and after 4–5 days he regained consciousness and he was able to talk and understand verbal commands. In view of improvement in general condition and performance status, we started biweekly triple intra-thecal therapy, and Inj. Nivolumab 3 mg per kg q 2 weekly. From the second cycle, we started Lenalidomide 10 mg once a day for 21 days with 7 days gap along with 2 weekly nivolumab and biweekly triple IT chemotherapy. After one month his CSF analysis was negative for malignant cells. Now he is on regular treatment with weekly IT chemotherapy, 2 weekly nivolumab and 3 weeks on and one week off lenalidomide. After 2 months of treatment, his MRI Brain was showing. At the time of submission of this article, he has completed the fifth cycle of immunotherapy and two cycles of lenalidomide. He was able to manage his daily ADL and able to walk with a stick. The patient tolerated immunotherapy, triple IT therapy and lenalidomide very well without much intolerable side effects. Therefore, we concluded that nivolumab and lenalidomide was well tolerated and exhibited antitumor activity in extensively pretreated patients with relapsed or refractory sanctuary site CNS B- cell lymphomas. Additional studies of Nivolumab and lenalidomide in these diseases are ongoing.

select article Human papillomavirus (HPV) vaccine and HPV-related head and neck cancer: What's next?
CorrespondenceNo access
Human papillomavirus (HPV) vaccine and HPV-related head and neck cancer: What's next?
F. De Felice, A. Polimeni, V. Tombolini
In Press, Corrected Proof, Available online 5 April 2019
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select article Oral tongue cancer in a patient with hereditary nonpolyposis colorectal cancer: A case report and review of the literature
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Oral tongue cancer in a patient with hereditary nonpolyposis colorectal cancer: A case report and review of the literature
Andrea Ziegler, Eric Thorpe
In Press, Corrected Proof, Available online 15 March 2019
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Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant disorder characterized by mutations of mismatch repair genes leading to the early development of multiple malignancies. The most common malignancy is colorectal cancer but there is a strong association with malignancies of the ovary, endometrium, small intestine, stomach, skin, brain, and pancreas. We report a case of a 35-year-old female with a history of known HNPCC who presented with adenocarcinoma of the small intestine as well as a synchronous oral tongue squamous cell carcinoma. The patient underwent a combined oncologic surgery involving a hemiglossectomy, selective neck dissection, and partial small bowel resection. Despite the wide range of malignancies seen in patients with HNPCC, no cases of oral cavity cancer have previously been reported. This represents the first case in the literature of oral cavity cancer in a patient with HNPCC.

select article Prognostic implications of pathologic lymph nodes in HPV-positive oropharyngeal cancers: Clinical validity and strategies for routine clinical practice
CorrespondenceNo access
Prognostic implications of pathologic lymph nodes in HPV-positive oropharyngeal cancers: Clinical validity and strategies for routine clinical practice
Rama Jayaraj, Chellan Kumarasamy, Madhav Madurantakam Royam, Shanthi Sabarimurugan, Siddhartha Baxi
In Press, Corrected Proof, Available online 9 March 2019
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select article Revisiting and revising the definition of oral submucous fibrosis
CorrespondenceNo access
Revisiting and revising the definition of oral submucous fibrosis
Mohit Sharma, Raghu Radhakrishnan
In Press, Corrected Proof, Available online 8 March 2019
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select article Ossified Carcinoma Ex Pleomorphic Adenoma in accessory lobe of parotid gland: Complexity in clinical, imaging and histologic diagnosis and minimally invasive surgery
CorrespondenceAbstract only
Ossified Carcinoma Ex Pleomorphic Adenoma in accessory lobe of parotid gland: Complexity in clinical, imaging and histologic diagnosis and minimally invasive surgery
Raffaele Rauso, Giuseppe Colella, Renato Franco, Andrea Ronchi, Fabrizio Chirico
In Press, Corrected Proof, Available online 7 March 2019
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Carcinoma ex pleomorphic adenoma is not common among malignant salivary tumors and an accessory lobe of parotid gland tumor with a carcinoma ex pleomorphic adenoma histology is even rarer. Management of these tumors include a high index of suspicion, good understanding of the anatomy and a meticulous surgical access. The exceptional localization of an ossified Carcinoma ex Pleomorphic Adenoma in the accessory lobe of the parotid gland, never reported to date in the literature, has prompted us to report this case to stress the challenging difficulties related to clinical and histologic diagnosis and to analyze a minimally invasive intraoral approach.

Anaesthesiology Clinical Pharmacology

ERAS – The dawn of a new era!
Ramachandran Gopinath, Kumar G Belani

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):1-2

Enhanced recovery after surgery
Neerja Bhardwaj

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):3-4

Enhanced recovery after surgery: An anesthesiologist's perspective
Srilata Moningi, Abhiruchi Patki, Narmada Padhy, Gopinath Ramachandran

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):5-13

Enhanced recovery after surgery (ERAS) protocols are a combination of multimodal evidence-based strategies, applied to the conventional perioperative techniques, to reduce postoperative complications and to achieve early recovery. These strategies or protocols, require a dedicated and organized team effort for their implementation to enable early discharge and thus reduce the length of hospital stay. Anesthesiologists play an important role in facilitating these protocols as some of the key elements such as preoperative patient preparation and assessment, perioperative fluid management, and perioperative pain relief are handled by them. This article discusses in detail the various components of ERAS and the anesthesiologist's role in implementing them. 

Preoperative patient preparation in enhanced recovery pathways
Usama Iqbal, Jeremy B Green, Srikant Patel, Yiru Tong, Marcus Zebrower, Alan D Kaye, Richard D Urman, Matthew R Eng, Elyse M Cornett, Henry Liu

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):14-23

Enhanced recovery pathways are a novel approach focused on enhancing the care of surgical patients. “Prehabilitation” is the term applied to any intervention administered before surgery to reduce surgery-related morbidity, decrease the length of hospital stay, expedite the return of organ function, and facilitate the patient's return to normal life. A PubMed search was performed with the following key words: enhanced recovery, preoperative preparation, cessation of smoking and euvolemia. The results from this Pubmed search revealed that female patients may have higher levels of anxiety than male patients. Intensive smoking and alcohol cessation 6–8 weeks before elective surgery may reduce the incidence of postoperative morbidity. Preoperative exercise can be effective for reducing the postoperative complications like pulmonary complications and shortening the length of hospital stay. It is safe to allow patients to drink clear fluids up until 2 h before elective surgery (Level II evidence). Perioperative normoglycemia is the single most important factor to prevent surgical site infection. Intermittent pneumatic compression devices and low molecular weight heparin are effective in preventing postoperative thromboembolism. No advantage is gained by preoperative mechanical bowel preparation in elective colorectal surgery. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. Mild perioperative hypothermia may promote surgical wound infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension. 

Implementing enhanced recovery pathways to improve surgical outcomes
Shilpadevi Patil, Elyse M Cornett, June Jesunathadas, Kumar Belani, Charles J Fox, Alan David Kaye, Lee A Lambert, Richard D Urman

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):24-28

An enhanced recovery pathway is a structured perioperative healthcare program that incorporates evidence-based interventions including protocols and guidelines with the aim of providing standardized care. Enhanced recovery pathways can help maintain operating room safety and efficiency, improve postoperative recovery and a variety of important patient outcomes, and reduce overall costs of patient care following major surgery. Postoperative complications are minimized, which, in part, are attributed to adjustments in fasting and postoperative nutrition, interventions aimed at improving early mobilization, and careful selection of pharmacological agents for anesthesia and analgesia. Major surgery can lead to a variety of physiological stressors including organ dysfunction, and hormonal and neurological disturbances. The current notion of fast-tracking (bypassing phase I recovery level of care) differs from enhanced recovery pathways as the principles of enhanced recovery pathways are often applied to inpatient and complex procedures and span the entire spectrum of patient care. Also, enhanced recovery pathways programs are being used for pediatric patients especially with the hope of minimizing opioid exposure and the quality of recovery. A PubMed literature search was performed for articles that included the terms enhanced recovery pathways to improve surgical outcomes. In this article, we summarized the clinical application of enhanced recovery pathways and highlighted the key elements that characterize implementing an enhanced recovery pathway in surgery. 

Goal-directed fluid therapy in the perioperative setting
Julia B Kendrick, Alan David Kaye, Yiru Tong, Kumar Belani, Richard D Urman, Christopher Hoffman, Henry Liu

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):29-34

Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The implementation of enhanced recovery pathway protocols has resulted in significant benefits to both the patients and hospitals, such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of goal-directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end-tidal CO2, central venous pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non-invasive monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low-risk patients undergoing low-risk surgery, a “zero-balance” approach is encouraged. For the majority of patients undergoing major surgery, GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can reduce postoperative complications. 

Enhanced recovery pathways in orthopedic surgery
Alan David Kaye, Richard D Urman, Elyse M Cornett, Brendon M Hart, Azem Chami, Julie A Gayle, Charles J Fox

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):35-39

The enhanced recovery after surgery (ERAS)©concept, sometimes referred to as “fast track”, “accelerated,” or “Rapid Recovery” surgery, was first introduced in 1997. The concept of ERAS targets factors that delay postoperative recovery such as surgical stress and organ dysfunction. ERAS protocols or programs are a care package of evidence-based interventions used in a multimodal and coordinated clinical care pathway. They represent a multidisciplinary approach directed to reducing postoperative complications, shortening length of hospital stay, improving patient satisfaction, and accelerating recovery. ERAS was initially centered on abdominal and colorectal surgery patients; however, ERAS protocols have been widely extended to include other specialties. Orthopedic surgery, particularly elective hip and knee arthroplasty is one of such areas where ERAS principles have been adopted. It has been associated with reduced length of hospital stay, readmission rate, and improved functional recovery. The common interventions used in orthopedic ERAS programs have been divided into those performed in the preoperative, intraoperative, and postoperative phases of care. A PubMed literature search was performed for articles that included the terms enhanced recovery and orthopedic surgery. In this article, we summarized the clinical application of ERAS and highlighted the key elements that characterize an enhanced recovery program. 

Multimodal analgesia as an essential part of enhanced recovery protocols in the ambulatory settings
Alan David Kaye, Richard D Urman, Yury Rappaport, Harish Siddaiah, Elyse M Cornett, Kumar Belani, Orlando J Salinas, Charles J Fox

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):40-45

Enhanced recovery after surgery protocols are multimodal perioperative care pathways designed to achieve early recovery in patients after surgical procedures by defining and maintaining preoperative organ function and minimizing the profound stress response following surgery. Enhanced recovery protocols have primarily been studied for major abdominal surgeries, however, the knowledge acquired from studying these protocols has facilitated treating patients in ambulatory settings. The key components of enhanced recovery protocols include preoperative counseling, preoperative nutrition, altering the standard perioperative fasting guidelines, and the value of carbohydrate loading up to 2 hours preoperatively, standardized analgesic, and anesthetic regimens (epidural and nonopioid analgesia) and early mobilization. A PubMed search was performed with the following key words: multimodal analgesia, enhanced recovery, ambulatory care, pain management, and opioids. We discuss the use of enhanced recovery protocols and multimodal pain care plans in the ambulatory setting. 

Perioperative surgical home models and enhanced recovery after surgery
Amir Elhassan, Ihab Elhassan, Amjad Elhassan, Krish D Sekar, Elyse M Cornett, Richard D Urman, Alan David Kaye

Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):46-50

In recent years, numerous initiatives have been introduced to address changes in health-care costs, delivery methods, reimbursements, and the health-care needs of our aging population. The American Society of Anesthesiologists (ASA) defines the Perioperative Surgical Home (PSH) as a patient-centric, team-based model of care to help meet the demands of a rapidly approaching health-care paradigm emphasizing value, patient satisfaction, and a reduction in costs. Enhanced recovery pathways were initially established by a group of surgeons from Europe who formed a research group with the aim to explore the ultimate care pathway for patients undergoing colonic resections. Similar protocols were later expanded to various surgical specialties with promising outcomes. A PubMed and World Wide Web search was performed with the following key words: “ERAS®,” “enhanced recovery after surgery,” “PSH,” “perioperative surgical home,” “protocols,” “outcomes.” Articles found were published over a 20-year time range (1997-2017). In the present investigation, the most common elements of enhanced recovery protocols are reviewed. Review of how existence of a PSH model facilitates the creation of an enhanced recovery protocol and improves cost-efficiency, patient satisfaction, and clinical outcomes observed in enhanced recovery studies that are applicable to health-care systems universally is described. 

Oral Radiology

A case of venous malformation of the mandible



Vascular malformations occur more rarely in bones than in soft tissue, with 0.5–1.0% of all intraosseous tumors occurring in the mandible. We report a diagnostically challenging case of unilocular venous malformation of the mandible.

Case report

A 76-year-old man presented with a heterogeneous, unilocular, radiolucent lesion with a well-defined border. Panoramic radiography and computed tomography imaging revealed a continuous white line on the cortical bone at the inferior border of the left mandibular molar region. A spherical lesion with a well-defined border and a clear round region in the left mandible were revealed on magnetic resonance imaging. The lesion had the same signal intensity as muscles on T1-weighted imaging, a homogeneous high-intensity signal on short T1-inversion recovery imaging, and a well-defined low-signal intensity region surrounded by a high-intensity signal region on T2-weighted imaging. Pathological findings indicated that the lesion was a venous malformation.


Although many studies have reported that venous malformations have a multilocular appearance, few have described the occurrence of unilocular lesions. Future investigations using magnetic resonance imaging and computed tomography are needed to increase the diagnostic accuracy for unilocular central vascular malformations of the jaw bone.

Schwannoma assumedly originating from the submandibular ganglion or glandular branches radiologically mimicking a submandibular gland tumor


Schwannoma is a benign nerve sheath tumor composed of Schwann cells. Schwannomas originating from ganglia are rare, and schwannomas of the submandibular ganglion or glandular branches have not been reported to date. We present a case of a Japanese woman in her sixties with a submandibular schwannoma originating from the submandibular ganglion, mimicking a submandibular gland tumor on radiological findings. As the radiological findings were nonspecific, the key finding in the present case may be the characteristic location of the tumor suspended from the undersurface of the lingual nerve and situated above the deep portion of the submandibular gland.

Radiological features of synovial chondromatosis affecting the temporomandibular joint: report of three cases


Synovial chondromatosis is a benign nodular cartilaginous proliferation that mainly occurs in large joints. The temporomandibular joint is considered to be rarely affected. Several cases of synovial chondromatosis of the temporomandibular joint have been reported with clinical and histological features. People with this disease may present with swelling, pain, intracapsular sounds, and limitation of mandibular movement. Radiographs are an important component in the diagnostic process for synovial chondromatosis. In this article, we report three cases of synovial chondromatosis occurring in the temporomandibular joint with a focus on the radiological features, including those on plain films, cone-beam computed tomography (CT) images, and conventional CT images. The three cases had totally different radiological features. The imaging differences were analyzed and compared to create combined diagnostic methods based on clinical features and examination techniques. The role of cone-beam CT examination in the diagnosis of the disease is discussed.

Effect of bisphosphonate treatment on the jawbone: an exploratory study using periapical and panoramic radiographic evaluation



This cross-sectional study aimed to explore potential jawbone changes secondary to bisphosphonate (BP) treatment of osteoporosis using digital panoramic and periapical radiography.


Thirty-nine women, previously examined with dual-energy X-ray absorptiometry, were radiographed by digital panoramic and/or periapical radiography. On periapical radiographs, trabecular bone structure and fractal dimension analyses of the mandibular first molar and edentulous regions were performed. On panoramic radiographs, the mandibular cortical width (MCW) was calculated, and trabecular bone structure and fractal dimension analyses of the trabecular bone in the alveolar and basal bones were performed. The results were compared between patients treated or not treated with BP using linear regression analysis to adjust for potential confounding factors.


The analyses of periapical and panoramic radiological images showed no statistical differences in the jawbones between groups after bisphosphonate use for mean intervals of 4.3 and 5 years; respectively. Although the mandibular cortical width on panoramic radiography was correlated with BP use, it was not noted to be statistically significant.


The trabecular parts of the alveolar and basal bones and the MCW were not significantly altered by BP treatment in patients with osteoporosis over 4.3–5 years, as detected by digital periapical and panoramic radiography. The low dosages of bisphosphonates used in the treatment of osteoporosis may explain this lack of change in MCW. Dental radiographs should not be considered as a method to monitor BP-induced jaw bone alterations among osteoporotic patients.

Reproducibility of CBCT image analysis: a clinical study on intrapersonal and interpersonal errors in bone structure determination



For correct implant planning based on cone-beam computed tomography (CBCT), the bone contour must be accurately determined. Identification of the contour is difficult in bones with incomplete mineralization. In this clinical study, we investigated the intrapersonal and interpersonal reproducibilities of manual bone contour determination on CBCT images using a semi-automated computerized process.


The bone surface level in the area of the socket in 20 patients who had undergone tooth extraction from the upper jaw at 10 ± 1 weeks previously was determined on CBCT images. Two investigators with different levels of experience determined the bone structure initially (T0) and repeated the procedure after 3 months (T1). The bone structure marked on CBCT images was converted into a surface data set. The resulting data sets were superimposed on one another. In the analyses, the shortest distances between the datasets were identified and measured. The average deviations were statistically evaluated.


The intrapersonal evaluation resulted in an average deviation of 0.18 mm across both investigators. The interpersonal analysis comparing the two investigators resulted in average deviations of 0.15 mm at T0 and 0.26 mm at T1. Significant differences were not found.


The low intrapersonal deviation indicates that the procedure has satisfactory reproducibility. All deviations were within the range of the selected resolution of the CBCT device. Application of a semi-automated procedure to detect the bone border in areas with incomplete mineralization is a predictable process.

Trial registration

The study was registered in the German Clinical Trials Register and the International Clinical Trials Registry Platform of the WHO: DRKS00004769, date of registration: 28 February 2013; and DRKS00005978, date of registration: 09 November 2015.

Sonographic diagnosis in the head and neck region: from an educational lecture presented at the 56th General Assembly and Annual Scientific Congress of the Japanese Society for Oral and Maxillofacial Radiology


Sonography is a simple, inexpensive, and non-invasive diagnostic modality. Although tissues behind bony structures and deep tissues are not delineated, sonography can depict superficial soft tissues very clearly. In the head and neck region, however, it has not yet been used widely, as the anatomical structures are complicated, and considerable experience is needed both to perform an examination and to make a diagnosis. To perform examinations efficiently, operators must be familiar with the sonographic system in use, and take images at standard planes. To make a correct diagnosis, operators require knowledge of the sonographic anatomy on standard planes, representative sonographic signs and artifacts, and common diseases and their typical sonographic findings. In this paper, we have explained the sonographic anatomy on standard planes, and the sonographic findings of common diseases in the oral and maxillofacial region.

Radiological analysis of the sella turcica and its correlations with body mass index in a North Indian population



The sella turcica is an important component situated in the mid-third of the cranial fossa. Knowledge about its normal morphologies and dimensions may play a crucial role in diagnosing underlying pathologies. The present study aimed to analyze the principal morphological shapes of the sella turcica, measure its linear dimensions, and determine whether any correlations exist between its dimensions and body mass index (BMI) in subjects in a North Indian population.


The study was conducted on 100 subjects (50 men; 50 women) who underwent cone-beam computed tomography scans at our Oral Medicine and Radiology Department. The subjects had an age range of 20–60 years. The morphology of the sella turcica was examined according to age and various measurements were taken to determine its size. Possible correlations between the dimensions of the sella turcica and BMI were evaluated by statistical analysis.


In the present study, 69% of the subjects had a normal morphology. No uniform increases in length, width, and depth of the sella turcica were observed with aging. When Pearson correlation coefficients were calculated, no strong correlations were found between the dimensions of the sella turcica and BMI. A mild correlation was seen between the length and width of the sella turcica.


No significant correlations were found between the dimensions of the sella turcica and BMI in the present study. These findings may have arisen through the small sample size, and thus further studies with larger groups of subjects are warranted.

Comparison of cone-beam computed tomography with bitewing radiography for detection of periodontal bone loss and assessment of effects of different voxel resolutions: an in vitro study



The aim of the study was to compare intraoral radiographs and CBCT images for detection of horizontal periodontal bone loss, and to investigate the diagnostic effect of different voxel resolutions in CBCT imaging.


A total of 240 sites with horizontal bone loss were measured on the buccal, lingual, mesial, and distal surfaces of 60 posterior teeth in four maxillary and six mandibular bones obtained from cadavers (dry skulls). Direct measurements on the dry skulls were accepted as the gold standard values. Measurements on CBCT images at two different voxel resolutions (0.250 and 0.160 mm3) and intraoral bitewing radiographs were compared with one another and with the gold standard values.


The measurements on the CBCT images at two voxel resolutions and bitewing radiographs did not differ significantly (p > 0.05) from the direct measurements on the dry skulls. No significant difference was found between the bitewing radiographs and CBCT images for measurements in the mesial and distal regions (p > 0.05). There was no significant difference between the measurements on the buccal and lingual surfaces at the two different voxel resolutions (p > 0.05).


CBCT scans are recommended for evaluation of buccal and lingual bone loss to avoid intraoral radiographs that exceed routine examination of interproximal alveolar bone loss. Furthermore, instead of basing the voxel size on the required CBCT scans, it is recommended to select the smallest possible field of view to reduce the dose of radiation.

Incidental findings during head and neck MRI screening in 1717 patients with temporomandibular disorders



Magnetic resonance imaging (MRI) plays an important role in the evaluation of temporomandibular disorders (TMDs). At our institution, we perform additional head and neck screening using head coils when performing MRI screening of the temporomandibular joint (TMJ) to detect lesions in areas other than the TMJ (lesions discovered by chance, or incidental findings; IFs) and to conduct a diagnosis of exclusion. The objective of this study was to determine the number and frequency of IFs detected during head and neck screening, according to sites and diseases.

Materials and methods

The study evaluated 1717 patients with clinically suspected TMDs who underwent MRI of the TMJ. IFs were assessed on horizontal sections of images of the craniofacial region obtained by the short tau inversion recovery imaging technique.


The patients undergoing MRI of the TMJ comprised 433 males and 1284 females. Among the patients, at least one IF was detected on images in 461 patients. The most common IF site was the maxillary sinus. Based on diagnostic imaging, there were 21 IFs (1.2%) associated with TMD symptoms, or for which an association with TMD symptoms could not be ruled out.


Combination of conventional MRI imaging of the TMJ with craniofacial MRI screening may allow detection of lesions other than TMDs, thereby confirming the usefulness of MRI. Detection of IFs may require development of different therapeutic strategies than those for TMDs.

JAMA Otolaryngology–Head & Neck Surgery
Mission Statement:JAMA Otolaryngology–Head & Neck Surgery provides timely information for physicians and scientists concerned with diseases of the head and neck. Given the diversity of structure and function based in this anatomic region, JAMA Otolaryngology–Head & Neck Surgery publishes clinical, translational, and population health research from an array of disciplines. We place a high priority on strong study designs that accurately identify etiologies, evaluate diagnostic strategies, and distinguish among treatment options and outcomes. Our objectives are to (1) publish original contributions that will enhance the clinician's understanding of otolaryngologic disorders, benefit the care of our patients, and stimulate research in our field; (2) forecast important advances within otolaryngology—head and neck surgery, particularly as they relate to the prevention, diagnosis, and treatment of disease through clinical and translational research, including that of the human genome and novel imaging techniques; (3) address questions of clinical outcomes and cost-effectiveness that result from clinical intervention, which grow in importance as health care providers are increasingly challenged to provide evidence of enhanced survival and quality of life; (4) provide expert reviews of topics that keep our readers current with true advances and also to provide a valuable educational resource for trainees in the several disciplines that treat patients with diseases of the head and neck; (5) serve as a forum for the concerns of otolaryngologists such as socioeconomic, legal, ethical, and medical issues; (6) provide helpful critiques that enable contributing authors to improve their submissions. We encourage a concise presentation of information and employ an abstract format that efficiently assesses validity and relevance from a clinical perspective. This approach promotes succinct yet complete presentation for our readers and electronic information resources. We believe this approach typifies the commitment of JAMA Otolaryngology–Head & Neck Surgery to providing important information that is easily interpreted by its diverse readership.

February Issue Highlights

Error in Figure Labels
In the article titled "Is It Time to Rethink the Approach to Internal Nasal Valve Stenosis?," the 2 Figure labels (a and b) were transposed so that the labels corresponded to the incorrect descriptions in the Figure caption. The Figure has been corrected online.

Labels Reversed in Figure 1
In the Original Investigation titled "Association of Adjuvant Radiation Therapy With Survival in Patients With Advanced Cutaneous Squamous Cell Carcinoma of the Head and Neck" by Harris et al, the labels in Figure 1 were reversed. This article has been corrected online.

Traumatic Lower Lip Myiasis
This is the report of a case of a homeless man in his 50s who presented with traumatic lower lip myiasis.

Aspiration in Infants With Laryngomalacia and Respiratory and Feeding Difficulties
This study evaluates the medical records of infants with laryngomalacia and associated breathing and feeding difficulties to determine the prevalence of aspiration among this pediatric patient population.

Silent Aspiration in Laryngomalacia?
Laryngomalacia is the most common laryngeal anomaly in infants, with a presentation of inspiratory stridor being nearly ubiquitous. In addition, young children with laryngomalacia can demonstrate feeding difficulty, dysphagia, aspiration, failure to thrive, apnea, cyanosis, and/or obstructive sleep apnea. Managing the balancing act between sucking, breathing, and swallowing is anticipated to carry additional challenge in infants with airway abnormalities, potentially leading to dysphagia, aspiration, and feeding difficulties. Somewhat unsurprisingly, infants with laryngomalacia may cough and choke during feeding, take their feeds slowly, or develop a worsening of their stridor during feeding. The association between laryngomalacia and feeding disorders is further strengthened by a biological gradient relationship, with more severe laryngomalacia cases shown to be more likely to have symptoms of feeding difficulty. In addition to dyscoordination, other proposed causes for feeding challenges in patients with laryngomalacia include decreased laryngeal sensation secondary to acid reflux and an alteration in the sensorimotor integrative function of the larynx. The association between acid reflux and laryngomalacia is well established, although evidence is lacking for causality or even direction of causality (ie, which is the chicken and which is the egg). Sensorimotor impairment in laryngomalacia is evidenced by the finding that children with laryngomalacia have higher rates of neurologic abnormalities such as hypotonia, central apneas and developmental disorders, and histopathologic nerve differences in their laryngeal mucosa.

Drug-Induced Sleep Endoscopy Findings in Supine vs Nonsupine Body Positions in Obstructive Sleep Apnea
This cross-sectional study examines drug-induced sleep endoscopy findings in the supine vs nonsupine body positions in positional and nonpositional obstructive sleep apnea using VOTE classification criteria.

Adjuvant Radiation Therapy in Patients With Advanced CSCC of the Head and Neck
This study examines the association of adjuvant radiation therapy vs surgery alone with survival in patients with advanced cutaneous squamous cell carcinoma and assesses which patients benefit the most from addition of adjuvant therapy to surgical treatment.

Variation in the Quality of US Head and Neck Cancer Care
This evaluation of quality metrics uses data from the National Cancer Database to summarize hospital-level overall quality of care for patients with head and neck cancer in the United States.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos


Pasteurized osteo-articular autologous graft for the reconstruction of proximal humerus after resection of osteosarcoma
Adel Refaat Ahmed

The Egyptian Orthopaedic Journal 2018 53(2):89-95

Objectives For skeletal reconstruction in surgery for bone tumors, pasteurization of the bone has been used with favorable results over other methods of recycling. Patients and methods Ten patients with osteosarcoma of the proximal humerus were treated by wide margin resection and reconstruction with pasteurized osteo-articular autologous bone graft. They were seven females and three males, between 9 and 30 years of age who were followed up for at least 3 years (mean, 48 months). The International Society of Limb Salvage graft evaluation method was used for the evaluation of the radiographs. Results Six (60%) patients had complete incorporation of the graft and three (30%) patients had partial incorporation. The mean radiographic scoring rate was 84%. Viability of the grafts was evaluated by bone scintigraphy. Of the nine patients evaluated, uptake was detected in seven patients from ∼6 months postoperatively after which it increased gradually. The functional results were assessed by the system of the Musculoskeletal Tumor Society and the mean functional rating was 90%. Seven patients have been disease free and three have died of the disease. Resorption of the graft was seen in a single, 9-year-old patient (10%); no fractures or infections were seen. No local recurrence was detected. Conclusion These results indicate that pasteurization of the bone may be a useful option for reconstruction after resection of osteosarcoma of the proximal humerus. The advantages of extracorporeal pasteurization include convenience of use, avoidance of intraspecies infection and allogenic reactions, and satisfactory bone remodeling. 

Minimally invasive percutaneous plate osteosynthesis for distal radius fractures with metaphysio-diaphyseal comminution
Hosam Elsayed Farag, Ahmed Shawkat Rizk

The Egyptian Orthopaedic Journal 2018 53(2):96-102

Background Distal radius fractures following high-energy trauma are common injuries, usually associated with metaphysio-diaphyseal comminution with marked soft tissue injury making effective treatment a real challenge with high risk of complications. Minimally invasive percutaneous plate osteosynthesis (MIPPO) is a fixation technique giving priority for soft tissues and vascularity of the bone fragments achieving a relatively stable fracture construct while preserving a biological environment insuring rapid bone healing. This study aims to evaluate the outcomes of the MIPPO technique for the treatment of distal radius fractures with metaphysio-diaphyseal comminution. Patients and methods This prospective, case series study comprised 11 cases of closed distal radial fractures with varying degrees of displacement and metaphysio-diaphyseal comminution following high-energy trauma. All fractures were treated by the MIPPO technique through two volar longitudinal incisions using a volar locking plate bridging the comminuted segment. The patients were followed up clinically and radiologically and the functional outcome was evaluated according to the Dienst wrist scoring system. Results All fractures united with a mean union time of 12.5±1.6 weeks (range, 11–16 weeks) with no reported loss of fixation with secondary displacement, implant failure, or deep wound infection. No cases needed any secondary surgical intervention to achieve union. The follow-up period extended for a mean duration of 16.7±3.2 months with satisfactory (excellent and good) clinical and radiological results compared with the other side achieved in all cases. The radiological results (radial inclination, radial height, and volar tilt) were excellent in eight cases and were good in three cases, but the clinical results (range of motion of the wrist and grip strength) were excellent in all the 11 studied cases. Conclusion The results are very satisfactory. MIPPO minimizes soft tissue compromise with preservation of vascularity of the comminuted fracture fragments, thus improving the healing rate, shortening the time for union with no need for initial or delayed bone grafting for such comminuted fractures with few potential complications. 

Functional and radiological outcome of proximal femoral locking compression plates in the treatment of unstable trochanteric fractures
Mohamed S. A. Mohamed Ismail, Mohamed A Ibrahim

The Egyptian Orthopaedic Journal 2018 53(2):103-109

Introduction Intertrochanteric femoral fracture is extracapsular fracture of the proximal femur between the greater and lesser trochanters. They represent about 50% of all hip fractures. Considerable complications such as pulmonary embolism, deep venous thrombosis, and pneumonia are frequently seen with these fractures mainly due to prolonged immobilization and specifically in elderly patients. These fractures can be categorized into stable and unstable according to the bony construct displacement after a fracture. Approximately 35–40% will be classified as unstable three-part and four-part fractures; unstable fractures are difficult to manage with dynamic hip screw alone and are technically much more challenging and the treatment is more controversial. Patients and methods During the period from 1 July 2016 till 1 February 2017, 44 patients with unstable trochanteric fractures AO A2 and A3 who were admitted in the Causality Department in Kasralainy Hospital, Cairo University were randomly selected in our study to be treated by fixation with proximal femoral locking compression plate according to the standardized protocol. Results Patient demographics: 28 women and 16 men were included with a mean age of 61.75 years (SD 8.7); eight patients were diabetic; four patients were hypertensive, and three were cardiac. The total hospital stay was a mean of 8.95 days, mean preoperative period was 4.44 days, and the mean postoperative period was a mean of 4.73 days (SD 1.16).The mean operative time was 106 min; the mean blood loss intraoperative was 308 ml; postoperative infection was three (6.8%) cases; and all of them resolved with a single session of debridement. One case of deep venous thrombosis (DVT) was treated by conservative measures and four cases of varus malunion with no functional deficit. The mean time for fracture union was 17.9 weeks and the mean time till weight-bearing was 12 weeks. Mean harris hip score (HHS) at 6 months was 62.3 which is fair and 81.2 at 12 months which is good. Conclusion Proximal femoral locking compression plate was an effective treatment for unstable trochanteric fracture in terms of time to full weight-bearing. It can be used in these fractures with good functional outcomes and low complication rates. Level of Evidence: Level II randomized, prospective trial. 

Percutaneous locked plating for complex distal tibial fractures
Khaled M Balam

The Egyptian Orthopaedic Journal 2018 53(2):110-114

Objective To evaluate the clinical outcome and advantages of percutaneous plate fixation for complex distal tibial fractures using locking compression plate-distal tibial plate (LCP-DTP). Design This is a prospective case series study. Setting Urban, level I trauma center. Patients and methods Twenty-seven adult patients, who met the inclusion criteria, with closed traumatic distal tibia with or without fibular fractures were treated using the minimally invasive plate osteosynthesis technique with LCP-DTP. According to the AO fracture classification, there were 12 AO 43A fractures and 15 AO 43B fractures. The fibula was fractured in 15 patients and it was fixed in all of them. Main outcome measurements Perioperative complications following percutaneous fixation of the distal tibia such as infection, deformity, leg length discrepancy, ankle joint function, bony union, and metal failure within 1 year after the surgery. Results This study included 27 adult patients with traumatic fracture distal third tibia, 21 of them were men and six were were women. They were followed up for a period ranging from 14 to 19 months with an average of 16. None of the patients developed early perioperative complications. Deep venous thrombosis occurred in three patients, who were treated medically, residual loss of a few degrees of ankle motion in six and late infection related to the proximal screws was also observed in three obese uncontrolled diabetic patients. Union was achieved in all of them within 12–20 weeks with an average of 16. Conclusion Minimally invasive plate osteosynthesis for the distal tibia using the LCP-DTP is safe and effective in the treatment of complex distal tibial fractures. 

Subtalar extra-articular screw arthroereisis for the treatment of flexible flatfoot in children
Amr El Gazzar

The Egyptian Orthopaedic Journal 2018 53(2):115-118

Background Subtalar arthroereisis has been described as a minimally invasive, effective, and low-risk procedure for the treatment of flatfoot in children. Purpose To test the effectiveness of subtalar extra-articular screw arthroereisis procedure as a corrective measure for flexible flatfoot (FFF) in children. Patients and methods From 2012 till 2014, 12 feet of eight children with FFF were treated with subtalar extra-articular screw arthroereisis at Banha University and Banha Insurance Hospitals. With a mean age of 10.5 years and ranges between 5 and 16, five male and three female patients were selected and were required to follow-up every 18 months (range, 15–27 months). Results This technique offered worthy results to correct idiopathic flatfoot in children, due to its less invasive and less damaging nature for the structures of the sinus tarsi. On the basis of clinical inspections and radiographic measurements, there was clear improvement of foot function. Conclusion Subtalar arthroereisis is an effective procedure for FFF correction as it is simple and can be performed rapidly. Additionally, the screws mechanical and proprioceptive effect result in notable correction of the deformity. 

Management of post-traumatic extra-articular proximal tibial nonunion by Ilizarov external fixation
Wael S Mahmoud

The Egyptian Orthopaedic Journal 2018 53(2):119-124

Background The Ilizarov technique has been used in Egypt for the past 20 years in the management of nonunion of long bones. This method uses fine wires and pins inserted percutaneously, which are attached to provide a strong frame construct. Most tibial and femoral nonunions can be treated successfully by internal fixation. However, proximal tibial nonunion can prove a difficult problem. The Ilizarov method can prove useful for treating these complex injuries. Objective The aim was to evaluate and analyze the clinical and radiological outcomes of Ilizarov external fixation in treatment of proximal tibial nonunion prospectively while focusing on its effectiveness, advantages and complication. Patients and methods A total of 16 patients (11 male and five female; average age: 33.5 years) who had post-traumatic extra-articular proximal tibial nonunion between April 2010 and October 2011 treated with the Ilizarov technique were included. Intervention method was Ilizarov technique, and main outcome measures include functional and radiological outcomes assessed using the Association for the Study and Application of Methods of Ilizarov criteria. Results All 16 patients showed union. None required amputation. According to the Association for the Study and Application of Methods of Ilizarov score regarding bone/radiological results, eleven were classed as excellent, four were good and one patient was fair. Functionally 10 patients were graded as excellent, five as good and one as fair. Conclusion The Ilizarov method is a reliable tool allowing early definitive treatment with a low complication rate and a good clinical outcome in treatment of patients with proximal tibial nonunion. 

Arthroscopic acromioclavicular joint excision with subacromial decompression
Ahmed O Youssef, Ahmed S. Abdel Fattah, Mohamed M. BahieElDin ElShafae, Khaled Abdel Salam Shohieb, Ahmed N.S. El Said

The Egyptian Orthopaedic Journal 2018 53(2):125-131

Background Shoulder impingement syndrome and acromioclavicular joint (ACJ) osteoarthritis often occur simultaneously and are easily missed. Arthroscopic resection of the distal clavicle and subacromial decompression (SAD) can avoid complications arising from the open method. Patients and methods In this prospective study, arthroscopic SAD as well as ACJ resection was done in 15 patients with subacromial impingement syndrome and ACJ arthritis, who were treated between March 2009 and April 2013 at Minia University Hospital after failure of a minimum of 6 months of conservative treatment. The patients were followed up for 12 months. Results University of California at Los Angeles score is recorded preoperatively and at final follow-up 12 months after arthroscopic SAD concomitant with arthroscopic ACJ resection. The patients’ total University of California at Los Angeles score was significantly improved postoperatively (P<0.01) in relation to the preoperative one. Conclusion Arthroscopic SAD and ACJ resection gives best results in patients who failed conservative treatment and had persistent symptoms, and it helps in detection of any intra-articular pathology such as biceps tendon degeneration. 

Outcome of management of Kienböck disease by limited carpal fusion
Bahaa Z.M Hasan, Ahmed A.I.W Salam

The Egyptian Orthopaedic Journal 2018 53(2):132-139

Objectives To evaluate the clinical and radiological outcome of Kienbӧck’s disease treatment by scaphocapitate fusion in 20 patients. Background Kienböck’s disease remains a difficult entity to treat till understanding the etiology and natural history of the disease. Treatment will continue to be based on trails to decrease load across the lunate or revascularizing it. Patients and methods This study was retrospectively performed on 20 patients, with age of 19–59 years. All of the patients presented with Kienböck disease grades II and IIIa and with no evidence of arthritis. They were treated with scaphocapitate arthrodesis using the dorsal approach. The mean follow-up period was 6 months. Complications and adverse events were recorded. Results The clinical results were classified on subjective base and were graded as excellent outcome in six (30%) patients, good in 10 (50%) patients, and fair in 4 (20%) patients. Conclusion Scaphocapitate arthrodesis is a good procedure that mechanically decompresses the lunate and prevents progressive carpal instability with minimal complications. 

Primary arthrodesis for treatment of special types of Lisfranc fracture dislocation
Mohamed Ebrahim Ali Al-Ashhab

The Egyptian Orthopaedic Journal 2018 53(2):140-146

Background Lisfranc fracture dislocation is a devastating trauma affecting usually young active age group, with a high rate of missing or misdiagnosis, resulting in prolonged recovery and significant long-term morbidity. Objective This study describes the indications, contraindications, technique, and results of treating severe Lisfranc fracture dislocation by primary arthrodesis. Patients and methods A prospective study was conducted on 10 patients with closed Lisfranc fracture dislocation, who had been treated at Benha University Hospital and Benha Insurance Hospital between January 2010 and March 2013. Mechanism of injury was high-velocity injury in five patients, fall from a height in four patients, and a hyperplanterflexion foot trauma during descending stairs in one patient. Mean age at time of surgery was 27.7 years (range, 19–38 years). All patients were followed up with a follow-up period of 21.3 months (range, 6–36 months). Results According to the American Orthopedic Foot and Ankle Society scale, the clinical outcome was 81.7 (range, 79–84). Complications met in this study were as follows: three patients had a postoperative Sudeck’s atrophy, one patient developed superficial wound problem, and two patients had forefoot stiffness and difficulties in shoe wearing. Conclusion Open reduction and internal fixation of severe Lisfranc fracture dislocation with screws and primary arthrodesis is the treatment of choice, as these fracture dislocations are known for their affinity for post-traumatic arthritis and subsequent need for a second operation. The level of evidence for this article was case series type IV. 

Split versus full tibialis anterior tendon transfer in treatment of residual dynamic supination in treated idiopathic clubfoot by Ponseti method
Sameh M. Abo El-Fadl

The Egyptian Orthopaedic Journal 2018 53(2):147-152

Background Dynamic supination is a common sequelae following successful nonoperative treatment of clubfoot with the Ponseti technique. It is resulted from a strong tibialis anterior muscle and weak antagonists, particularly the peroneal and tibialis posterior muscles. Tendon-balancing procedure is the most reasonable solution. Use of tibialis anterior tendon transfer (TATT) in recurrent clubfoot deformities has been described since 1940. Patients and methods Through this study, we compare the results of split versus full TATT in the treatment of residual dynamic supination in treated idiopathic clubfoot by Ponseti method. Patients were divided into two groups. The first group (nine patients with 10 feet) (group I) consists of the patients who were managed with split tendon transfer and the second group (nine patients with 10 feet) (group II) consists of the patients who managed with full tendon transfer. Garceau and Palmer’s clinical criteria and a grading system proposed by Thompson and colleagues were used for evaluation of the results of tendon transfer either split or full. Results A total of 18 children (13 males and five females) were involved in this study. The average of the age of the children in group I was 4.3 years and in group II was 4 years at the time of surgery. According to Garceau and Palmer’s clinical criteria, in group I, the preoperative ratings of 10 feet were as follows: four feet were good and six feet were fair, with scores of 3 points and 2 points, respectively. The postoperative ratings were five feet were excellent and five feet were good, with scores of 4 points and 3 points, respectively, with a statistically significant improvement (P<0.05). In group II, the preoperative ratings of 10 feet were six feet were good and four feet were fair, with scores of 3 points and 2 points, respectively. The postoperative ratings were six feet were excellent and four feet were good, with scores of 4 points and 3 points, respectively, with a statistically significant improvement (P<0.01). In comparing the results of both groups, no statistically significant relation could be found (P>0.05). According to the grading system proposed by Thompson and colleagues for restoration of muscle balance, in group I, eight feet achieved good results and two feet achieved fair results, whereas in group II, seven feet achieved good result and three feet achieved fair results. In comparing the results of both groups, we found there was no statistically significant relation (P>0.05). Conclusion TATT is an excellent method of correcting residual dynamic clubfoot deformity and there is no significant difference in the results by either full transfer or split transfer, and the surgeon’s preference plays a major role in selection of the procedure. 

Occupational Therapy

OTICON' 2019 and the all India occupational therapists' association's forthcoming academic activities in 2019–2020
Anil K Srivastava

The Indian Journal of Occupational Therapy 2019 51(1):1-2

To investigate the association between sleep and happiness among nurses with different personality traits: A cross-sectional study
Sushant Deepak Sarang, Rakesh Bharat Shitole, Arthi Govardhan Karnam

The Indian Journal of Occupational Therapy 2019 51(1):3-7

Background: Sleep and happiness play an important role in the functioning of a person. This study investigated the association between sleep and happiness among nurses and also studied if individual personality traits play a role. Objectives: To measure perceived stress, sleep, happiness and personality trait among nurses & To analyze the relationship between the sleep, happiness and personality trait. Study Design: A cross-sectional study design was chosen for the research. Methods: Thirty nursing staff (females, aged 22–53 years) were selected for the study. The Perceived Stress Scale (PSS) was used for screening stress. Those who scored low (0–13) on the PSS were included in the study. Written informed consent was obtained. Sleep quality, happiness, and personality traits were measured using the Pittsburgh Sleep Quality Index, Oxford Happiness Questionnaire, and Big Five Personality Test, respectively. Scores were analyzed using MedCalc Statistical Software. Results: The mean age of nursing staff with good sleep was 28 years and that with poor sleep was 36 years. It was found that 63% of nursing staff had poor sleep and 37% had good sleep. Among nursing staff with good sleep, 36% were unhappy and 64% were happy. Among nursing staff with poor sleep, 47.7% were unhappy and 52.6% were happy. The mean score for neuroticism was higher in patients with poor sleep (t-test, P = 0.003, 95% confidence interval: -7.96 to -1.76). Conclusions: Nursing staff with good sleep were happier compared to nurses with poor sleep though the difference was not significant. Sleep disturbances increased with age among nurses. The personality trait of neuroticism was higher in patients with poor sleep. 

Occupational therapists' perception of efficacy of sensory integration in Tamil Nadu, India: A Statewide Survey
Karthik Mani

The Indian Journal of Occupational Therapy 2019 51(1):8-13

Background: Perception regarding efficacy of any intervention may influence clinical reasoning and treatment choice. Despite the fact that the current evidence on the effectiveness of sensory integration (SI) interventions is equivocal, practitioners use them widely in practice. This could be due to the perceived effectiveness. Objectives: This study aimed to gain an understanding of Tamil Nadu (TN) occupational therapy (TNOT) practitioners' perception of the efficacy of SI interventions in pediatric practice. Study Design: The survey research design was used to conduct this study. A ten-item electronic survey was developed based on the research question. Methods: The survey was e-mailed to 295 occupational therapists in TN identified through convenience sampling. The survey link was also shared on three WhatsApp Messenger groups (TNAIOTA Official Group, OTist Group, and OT Friends Group) with a large number of TN occupational therapists (snowball sampling). Data were collected between March 30, 2018, and April 30, 2018. Results: Forty-nine occupational therapists responded to the survey. Many respondents believed that SI interventions are effective, citing positive therapeutic outcomes and the child-centric nature of the interventions as the reasons behind their beliefs. Respondents also believed that for SI interventions to be effective, therapists' knowledge and skill on SI are critical. Gender, years of experience, additional training on SI, and level of education did not have any influence on practitioners' perceptions regarding the efficacy of SI. Conclusion: Pediatric OT practitioners in TN have a favorable attitude toward SI interventions and use them in practice. Although practitioners report perceived positive therapeutic outcomes, they need validation through clinical research. TNOT practitioners must collaborate with researchers to add to the scientific evidence base of SI. 

Visual-perceptual training for handwriting legibility and speed in children with handwriting difficulties: A single-arm interventional study
Pooja Pankaj Mehta, Hemant Parshuram Nandgaonkar

The Indian Journal of Occupational Therapy 2019 51(1):14-20

Background: Empirical evidence relating motor-free visual-perception (VP) skills and handwriting (HW) legibility and speed is sparse, despite the theoretical belief that VP is necessary for letter recognition and is an essential component of HW. Therefore, the study was carried out to investigate the effect of VP training on scanning skills, motor-free VP skills, and HW legibility and speed. Objectives: The main objective is to study the effect of VP training on HW legibility and speed; motor-free VP skills and scanning skills. Study Design: This was a single-arm interventional study design was chosen for the research. Methods: Single arm of 10 children of either gender between 6 and 10 years of age, with HW difficulties meeting the inclusion and exclusion criteria, was recruited by convenience sampling. They were assessed pre- and post-training (6th and 12th week) using the letter cancellation test (LCT), Test of VP Skills-3rd Edition (TVPS-3) and Evaluation Tool of Children's Handwriting (ETCH). The intervention included individualized VP training weekly twice along with home program. Results: The mean scores of LCT, TVPS-3, and Evaluation Tool of Children's Handwriting-Manuscript (ETCH-M) of n = 10 were analyzed. Post 12-week intervention, statistically significant improvement were found in mean scores of LCT (P < 0.05, 95% confidence interval [CI] [0.411,0.699]) and on TVPS-3 subtests (P < 0.05, 95% CIs [13.14, 17.46], [11.60, 15.60], [11.46, 14.14], 11.73, 15.87], [11.33, 15.27], [11.66, 15.44] and [11.56, 15.44] sequentially) and on overall mean scores (P < 0.05, 95% CI [12.67, 16.13]). Statistically significant improvements were calculated on ETCH-M subtests- total letter, number, and word legibility scores (P < 0.05, 95% CIs [88.91, 95.69] [100,100] and [79.01, 93.19] respectively); and on near-point copying speed (P < 0.05, 95% CI [35.98, 55.42]) but non-significant improvement was seen on far-point copying speed (FPS) (P = 0.103, 95% CI [23.69, 36.31]). Conclusion: VP training, without HW practice, has an effect in improving scanning skills, motor-free VP skills, and HW legibility and speed (except FPS). Thus, VP training may influence HW legibility and speed. 

Severity of cerebral palsy and its impact on level of stress in the caregivers: A correlational study
Kiran Kriti, Ankita Pradhan, Saba Tufel

The Indian Journal of Occupational Therapy 2019 51(1):21-25

Background: Cerebral palsy (CP) is the leading cause of chronic disability in children making them physically and mentally challenged and socially aloof. CP children also experience a range of comorbidities such as seizures disorder and visual and hearing impairments. Parenting is inherently stressful at times, and studies have shown that being a caregiver of a disabled child is more stressful. Objectives: The objectives of the study were (1) to evaluate the correlation between the level of severity of CP children and its impact on stress on their caregivers, (2) to find the effect of co-morbid factors on the level of stress in caregivers, and (3) to evaluate the relationship between the socioeconomic status (SES) of caregivers and their stress. Study Design: This was correlation study. Methods: One hundred caregivers with the age group between 21 and 62 years participated in the study, of them 13 were male and 83 were female. CP children aged between 1 and 12 years were included in the study. The Gross Motor Function Classification System (GMFCS) for assessing severity level, the Parental Stress Scale (PSS) for parental stress, and the Kuppuswamy Scale for SES were utilized for objective assessment. Results: Weak nonsignificant correlation found between GMFCS and PSS (P = 0.943, 95% of confidence interval [CI] of difference: −2.04–4.01). Strong significant positive correlation between comorbid factors and parental stress (P = 0.000, 95% CI of difference: 4.5–13.2 for visual impairment, P = 0.000, 95% CI of difference: 2.1–15.1 for hearing impairment, and P = 0.000, 95% CI of difference: 4.4–13.3 for seizure disorder); however, a negative nonsignificant correlation was found between parental stress and SES (P = 0.634, 95% CI of difference: 1.4–0.6). Conclusion: The severity of the child's disability had no influence over the degree of parenting stress. Total family income was found to be weakly and inversely correlated with the degree of parenting stress. However, there was a strong relationship between comorbid factors and parental stress. 

Biofeedback as an adjunct to conventional stress management and relaxation techniques in substance abuse disorders: A randomized controlled interventional study
Anand Manohar Ghadse, Lokesh Kumar Ranjan, Pramod Ramlakhan Gupta

The Indian Journal of Occupational Therapy 2019 51(1):26-30

Background: Biofeedback has been employed in substance abuse disorder over the last three decades. Stress, anxiety, and depression are commonly seen in patients with substance abuse disorders. Biofeedback employed in conjunction with other relaxation therapies may be useful in enhancing certain outcome of therapy. Biofeedback either alone for alcoholism or in combination with other relaxation techniques for stimulant and mixed substance abuse and combined with residential treatment program is probably efficacious. Objectives: This study is aimed at assessing effectiveness of biofeedback-assisted relaxation techniques and stress management for substance abuse population. Study Design: A randomized controlled interventional study design was chosen for the research. Methods: The study sample consisted of 60 in-patient males aged 18–55 years, diagnosed with mental and behavioral disorders due to multiple drug use and use of other psychoactive substance, according to the International Classification of Diseases-10, Diagnostic Criteria for Research (1992) criteria (30 in biofeedback and 30 in control groups). The patients were first screened for inclusion criteria and then recruited from CIIMHANS Mental Health Institute of Central India using lottery method for random allocation. A randomized controlled interventional study design was chosen for the research. Sociodemographic data and clinical details of all the patients were assessed using Depression-Anxiety-Stress Scale followed by biofeedback-assisted relaxation techniques, which was conducted for 30 days. Results: The present study shows that there was significant difference in the stress (t = 3.841, P < 0.01, 95% confidence interval [CI]: 3.06–9.73), anxiety (t = 3.849, P < 0.01, 95% CI: 2.06–6.53), and depression (t = 2.03, P < 0.05, 95% CI: 0.03–0.67) among patients of substance abuse disorders in the biofeedback group as compared to control group. Conclusion: The present study found that the biofeedback-assisted relaxation technique is efficacious in decreasing level of depression, anxiety, and stress in patients with substance abuse disorders. 

Play-based occupational therapy intervention on social skills in children with autism spectrum disorder and attention deficit hyperactivity disorder: A case series
Kinkuri Sahib Kaur, Ranjit Pathak

The Indian Journal of Occupational Therapy 2019 51(1):31-36

The profound deficit in social reciprocity skills is the core underlying feature of the autism spectrum disorder. Inattention and impulsivity of attention deficit hyperactivity disorder children interferes with their ability to accurately identify, imitate, and model appropriate social behaviors. Social skill is any skill that facilitates interaction and communication with others, and evidence suggests that they can be acquired with specific training, opportunities, and practices. Literature suggests that in a developmental approach to social skills training, play is used as the primary medium for intervention, especially with younger children. Three children in the age group of 4–5 years were selected for the study. Socialization domain of the Vineland adaptive behavior scales-second edition was used to get the baseline scores. The children participated in the play-based occupational therapy intervention and each session was carried out for 60 min, twice a week. The children were reassessed after 6 months. The scores' data showed an upward trend and the socialization score of child 1, 2, and 3 improved by 11.6%, 14.8%, and 8.3%, respectively. 

News and information

The Indian Journal of Occupational Therapy 2019 51(1):37-39

Dermatologie Vénéréologie

Dermite de rappel induite par le vémurafénib

Publication date: Available online 10 April 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): A. Greliak, A. Le Guern, M. Bataille, D. Lebas, T. Wiart, P. Modiano


La dermite de rappel est une réaction inflammatoire survenant sur un site précédemment irradié et provoquée par l'administration d'un traitement. Dans de rares cas, il s'agit d'un traitement par inhibiteurs de BRAF ou de MEK.

Cas clinique

Nous rapportons le cas inhabituel d'une dermite de rappel survenue trois mois après l'introduction de l'association vémurafénib/cobimétinib.


La dermite de rappel est une réaction cutanée qui doit être connue et qui peut exceptionnellement, comme dans notre observation, survenir tardivement après la fin de la radiothérapie.


Radiation recall dermatitis is an uncommon inflammatory reaction of the skin appearing after several days to several years at the site of previous irradiation; it is precipitated by the use of triggering drugs, although rarely by BRAF or MEK inhibitors.

Patients and methods

We report an unusual case of recall dermatitis induced 3 months after initiation of vemurafenib and cobimetinib therapy.


Radiation recall dermatitis is a cutaneous reaction that must be known and which in rare cases such as ours may occur a long time after the end of radiotherapy.

Psoriasis de l'enfant vu en milieu libéral : les aspects cliniques et épidémiologiques diffèrent des données habituellement publiées

Publication date: Available online 4 April 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): E. Mahé, F. Maccari, M. Ruer-Mulard, N. Bodak, H. Barthelemy, C. Nicolas, E. Pépin, M. Pillette-Delarue, C. Buzenet, P.-L. Delaire, M. Nadaud, F. Bouscarat, D. Drouot-Lhoumeau, C. Lepelley-Dupont, A. Acher, A. Beauchet, F. Corgibet, Fédération française de formation continue et d'évaluation en dermatologie-vénéréologie et le GEM Resopso


Le psoriasis touche 0,2 à 0,7 % des enfants et est associé à l'obésité. Les études publiées ont été réalisées en milieu hospitalier. L'étude PsoLib a évalué le psoriasis de l'enfant consultant dans des cabinets privés en évaluant les aspects épidémiologiques et cliniques, ainsi que les comorbidités.


Il s'agissait d'une étude multicentrique, transversale et non interventionnelle d'enfants (0 à 18 ans) atteints de psoriasis, réalisée par 41 dermatologues travaillant dans des cabinets privés. Les aspects cliniques et thérapeutiques et les comorbidités ont été évalués de manière systématique. Nous avons comparé les données à l'étude χ-Psocar réalisée avec la même méthodologie dans des hôpitaux français.


Au total, 207 enfants (filles : 60,4 % ; âge moyen : 10,5 ± 4,2 ans) ont été inclus. Le psoriasis du cuir chevelu (40,6 %) était le type clinique le plus fréquent, tandis que le type en plaques généralisées ne représentait que 26 % des cas. L'atteinte des ongles ou de la langue et le rhumatisme psoriasique étaient rarement observés. Moins de 1 % des enfants souffraient d'hypertension, de diabète de type 1 ou de dyslipidémie, mais 16,4 % étaient en surpoids et 7,0 % étaient obèses. La gravité (PGA maximum ≥ 4) était associée au surpoids (p = 0,01).


Le psoriasis du cuir chevelu est le type clinique de psoriasis le plus fréquent chez l'enfant. Les comorbidités et la localisation extracutanée sont rares. Même dans les cabinets privés, la gravité de la maladie est associée au surpoids.


Psoriasis affects 0.2–0.7 % of children and is associated with obesity. Published studies have been conducted in hospital settings (tertiary care). The PsoLib study evaluated childhood psoriasis in private practice (secondary care) in terms of epidemiology, clinical aspects and comorbidities.

Patients and methods

This was a non-interventional, cross-sectional, multicenter study of children with psoriasis performed by 41 dermatologists working in private practice. The clinical and therapeutic aspects and comorbidities were systemically evaluated. We compared data to the χ-Psocar study performed in hospitals using the same methodology.


In all, 207 children (girls: 60.4 %; mean age: 10.5 ± 4.2 years) were included. Scalp psoriasis (40.6 %) was the most frequent clinical type, while plaque psoriasis represented 26 % of cases. Nail, tongue, and arthritic involvement were rare. Less than 1 % of children suffered from hypertension, diabetes or dyslipidemia, but 16.4 % were overweight and 7.0 % were obese. Severity (PG ≥ 4 at peak) was associated with excess weight (P = 0.01).


Scalp psoriasis is the most frequent clinical type of psoriasis in childhood. Comorbidities and extracutaneous localization are rare. Even in private practice, the severity of the disease is associated with excess weight.

Réponse des auteurs à la correspondance à propos de l'article : « Maladie de Paget sur sein surnuméraire »

Publication date: Available online 3 April 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): M.-H. Jegou, E. Lorier-Roy, Groupe Dermatolist, I. Roche

Engelures unilatérales associées à une monoparésie : 2 observations

Publication date: Available online 29 March 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): P. Couture, P. Moguelet, F. Chasset, A. Barbaud, P. Senet, J.-B. Monfort


Les engelures sont des lésions dermiques inflammatoires liées à une hypersensibilité au froid, qui siègent de manière bilatérale et symétrique sur les extrémités. Leur survenue lors de pathologies pro-thrombogènes ou de pathologies auto-immunes est bien décrite mais leur association à des causes locorégionales favorisantes est peu connue.


Cas 1 : un homme de 57 ans, tabagique à 80 paquets-années, qui souffrait d'un déficit des releveurs du pied droit séquellaire d'une lombosciatique paralysante L5, consultait pour des lésions nécrotiques unilatérales des orteils, récidivant chaque hiver uniquement sur le membre paralysé. Cas 2 : un homme de 60 ans avait eu un liposarcome de cuisse droite traité par radiothérapie et chirurgie, qui s'étaient compliquées d'une monoparésie séquellaire et d'une artérite post-radique. Il présentait des macules purpuriques unilatérales des orteils du pied droit, sans évolution nécrotique, récidivant chaque hiver. Dans les deux cas l'examen clinique, le recul évolutif, l'histologie et les examens complémentaires confirmaient le diagnostic d'engelures idiopathiques.


Les hypothèses physiopathologiques expliquant l'unilatéralité des engelures en cas de paralysie sont une diminution du flux sanguin dans le membre paralysé, un déséquilibre des neuromédiateurs, un dysfonctionnement du système nerveux autonome, une atrophie cutanée avec hypertrophie des tissus mous sous-jacents et enfin une hypoesthésie qui vient aggraver les troubles trophiques.


Chilblains are inflammatory dermal lesions associated with hypersensitivity to cold, and they occur on the extremities bilaterally and symmetrically. Their onset during the course of pro-thermogenic and autoimmune diseases has been widely reported, but the association with predisposing locoregional causes is not well known.

Patients and methods

Case 1: a 57-year-old man, who smoked 80 packets per year, presenting a deficit of the levator muscles in his right foot following lumbar sciatica with paralysis of L5, consulted for unilateral necrotic lesions of the toes recurring each winter in the paralysed limb only. Case 2: a 60-year-old man had a previous history of liposarcoma of the right side treated with radiotherapy and surgery, resulting in sequelae of monoparesis and radiation-induced arteritis. Each winter, he presented recurring unilateral purpuric macules of the toes on his right foot, with no necrotic progression. In both cases, clinical examination, disease progression over time, histology and laboratory tests confirmed the diagnosis of idiopathic chilblains.


The physiopathological hypotheses posited to account for the unilateral appearance of chilblains in the event of paralysis include decreased blood flow to the paralysed limb, imbalance in neuromodulators, dysfunction of the autonomous nervous system, cutaneous atrophy with hypertrophy of underlying soft tissues, and finally, hypoesthesia aggravating the trophic disorders.

Actualisation des recommandations françaises de traitement du pemphigus

Publication date: Available online 29 March 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): L. Jelti, C. Prost-Squarcioni, S. Ingen-Housz-Oro, F. Caux, P. Bernard, C. Bedane, M. Alexandre, O. Dereure, G. Quereux, E. Le Bidre, J. Plée, C. Picard-Dahan, C. Le Roux-Villet, S. Duvert-Lehembre, M.-A. Richard, E. Delaporte, S. Debarbieux, D. Jullien, M. D'Incan, M.-P. Konstantinou

Myopathie nécrosante auto-immune à anticorps anti-HMGCR induite par les statines et révélée par un tableau évocateur de dermatomyosite

Publication date: Available online 29 March 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): M. Merlant, C. Fite, D. Kottler, L. Maisonobe, A. Dossier, L. Deschamps, V. Descamps


Les myopathies nécrosantes auto-immunes (MNAI) induites par les statines ont été récemment individualisées. Nous rapportons le troisième cas de MNAI se présentant avec une éruption cutanée évocatrice de dermatomyosite (DM).


Une femme de 61 ans présentait une éruption cutanée des régions photoexposées touchant le visage, le décolleté et le dos des mains, associée à une faiblesse musculaire proximale bilatérale. Un traitement par rosuvastatine avait été introduit 8 mois auparavant. Le taux de créatinine phosphokinase (CPK) était augmenté. L'histologie cutanée était compatible avec un lupus ou une dermatomyosite (DM). L'histologie musculaire montrait des fibres musculaires nécrosées avec des zones de régénération, sans inflammation ni atrophie périfasciculaire. Les anticorps anti-3-hydroxy-3-méthylglutaryl-coenzyme A réductase (HMGCR) étaient présents au taux de1658 UA/ml (normale < 13,0 UA/mL). Le diagnostic de MNAI était retenu.


La MNAI est une myopathie auto-immune caractérisée par une faiblesse musculaire proximale bilatérale et symétrique. Les anticorps anti-HMGCR, connus depuis 2011, sont spécifiques de la MNAI. Peu de signes extra-musculaires ont été décrits. Nous rapportons ici la troisième description d'éruption cutanée évoquant une DM survenant au cours d'une MNAI induite par les statines. Dans notre cas, l'éruption cutanée était évocatrice de connectivite et le diagnostic a été porté sur les résultats immunologiques et la biopsie musculaire.


La MNAI avec présentation cutanée est une entité rare. Les dermatologues doivent pouvoir évoquer le diagnostic devant un tableau de « pseudo-dermatomyosite », arrêter les statines le cas échéant et poursuivre les investigations avec la biopsie musculaire et les explorations immunologiques.


Statin-induced necrotizing autoimmune myopathy (NAM) has been recently characterized. Herein we report an accurate description of the clinical and histological characteristics of cutaneous rash associated with NAM.

Patients and methods

A 61-year-old woman presented a skin rash involving the face, the chest and the back of the hands with heliotropic distribution coupled with proximal symmetrical muscle weakness. Rosuvastatin had been introduced 8 months earlier. Creatinine kinase levels were dramatically raised. Screening for lupus and dermatomyositis antibodies were negative. The cutaneous histology was consistent with neutrophilic lupus while a muscle biopsy revealed no inflammation but showed necrotic and regenerative myofibres. Finally, antibodies directed against 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) were found at high levels (1658 UA/ml vs. normal < 13.0 UA/ml), resulting in diagnosis of necrotizing autoimmune myopathy (NAM). Intensive immunosuppressive therapy resulted in excellent improvement.


NAM is a severe acquired autoimmune myopathy characterised by severe proximal weakness and specific positive antibodies (anti-HMGCR or anti-signal recognition particle). It is classically associated with statin use. Some extra-muscular symptoms have been described in previous studies. We report the third accurate description of cutaneous rash associated with statin-induced NAM involving HMGCR antibodies. The skin rash was evocative of connective tissue disease and our diagnosis was based on immunology and muscle histology.


Dermatologists must be able to recognise this rare entity of "pseudo-dermatomyositis" and then discontinue statin intake if present and carry out further investigations consisting of muscle biopsy and serological tests.

Correspondance à propos de l'article : « Maladie de Paget sur sein surnuméraire »

Publication date: Available online 28 March 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): C. Perrin

Psoriasis and male sexuality

Publication date: Available online 28 March 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): J.-N. Dauendorffer, S. Ly, M. Beylot-Barry


Since sexual satisfaction is a key factor in quality-of-life scores, the aim of this review article is to examine current knowledge concerning the impact on male sexuality of psoriasis, particularly genital psoriasis. Risk factors for sexual dysfunction, and more specifically erectile dysfunction, demonstrated to date include severity of psoriasis, genital psoriasis, psoriatic arthritis, smoking, psychological disorders (anxiety-depression), cardiovascular comorbidities and side effects of psoriasis treatments. Studies evaluating the burden of genital psoriasis on male sexuality are contradictory: while the link between genital psoriasis and global sexual functioning has been clearly established in relation to question 9 of the DLQI, discrepancies exist between the scoring systems used concerning sexual satisfaction. Finally, psoriasis patients have expressed a wish to receive more care from their dermatologist in terms of their genital psoriasis and its impact on their sexual activity.


La satisfaction sexuelle étant un des éléments de la qualité de vie, cet article se propose de faire le point sur les connaissances actuelles concernant le retentissement sur la sexualité masculine du psoriasis en général, et du psoriasis génital en particulier. Les facteurs de risque de dysfonction sexuelle globale et de dysfonction érectile chez les hommes psoriasiques sont la sévérité du psoriasis, l'atteinte psoriasique génitale ou articulaire, l'impact psychologique du psoriasis (anxiété-dépression), les habitudes de vie (tabagisme), les comorbidités cardio-vasculaires et la iatrogénie. Les résultats des études évaluant le retentissement du psoriasis spécifiquement génital sur la sexualité masculine sont contradictoires: si le lien entre psoriasis génital et fonction sexuelle globale évaluée par la question 9 du DLQI est bien démontré, les résultats sont divergents lorsque la satisfaction sexuelle est évaluée par des scores spécifiques. Enfin, les patients psoriasiques souhaitent une attention accrue de leur dermatologue vis-à-vis de leur psoriasis génital d'une part et du retentissement sexuel de leur psoriasis d'autre part, qu'il soit génital ou extra-génital.

Pityriasis rubra pilaire : trois cas traités par biothérapie

Publication date: Available online 28 March 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): C. Sarles, A. Valois, S. Abed, T. Boyé, B. Fouet, J.-J. Morand

Place de l'Androcur® dans le traitement de l'alopécie féminine diffuse

Publication date: Available online 27 March 2019

Source: Annales de Dermatologie et de Vénéréologie

Author(s): A.-D. Pham, B. Guillot, M. Beylot-Barry, O. Chosidow, P. Reygagne, P. Joly