Atypical Outcomes of Nasal and Lip Appearance After Unilateral Cleft Lip Repair: Judgment by Professionals, Patients, and Laypeople.

OBJECTIVE: To gain more insight into the assessment of "atypical" nasal and lip appearance outcomes compared to "typical" appearance outcomes after unilateral cleft lip and palate (UCLP) repair, when judged by professionals, patients with repaired UCLP, and laypeople. DESIGN: An online survey containing 3 series of photographs with various degrees of "typical" and "atypical" nasal and lip appearance outcomes after UCLP repair was sent to 30 professionals, 30 patients with repaired UCLP, and 50 laypeople in 2 countries. Participants were instructed to rank the photographs from excellent to poor based on overall appearance. Mean rank positions of photographs were analyzed and differences in mean rank score between "typical" and "atypical" results were assessed using a T-test. Agreement of ranking between the 3 groups was assessed with an analysis of variance analysis. SETTING: Amsterdam UMC, location VUmc, Netherlands and Boston Children's Hospital, Boston, USA. PATIENTS: Photographs of 6- to 18-year-old patients with repaired UCLP. RESULTS: "Atypical" appearance outcomes were ranked significantly less favorably (small nostril: P = 0.00; low vermillion border: P = 0.02; whistling deformity: P = 0.00) compared to "typical" outcomes. Difference between professionals, patients and laypeople in rank positioning the photographs was not statistically significant (P = 0.89). CONCLUSIONS: Noses with a smaller nostril and lips containing a whistling deformity were perceived as poorer outcome compared to the "typical" results. Professionals, patients, and laypeople are in agreement when assessing these outcomes.

Comparison of three PD-L1 immunohistochemical assays in head and neck squamous cell carcinoma (HNSCC).

Expression of programmed cell death-ligand 1 (PD-L1) is being used as predictive biomarker for immunotherapy in head and neck squamous cell carcinoma (HNSCC). Several antibodies are available for PD-L1 testing and multiple staining and scoring methods are used. This study aimed to compare the performance of two PD-L1 standardized assays (SP263 and 22C3 pharmDx) and one laboratory-developed test (LDT) (22C3) in HNSCC using the tumor proportion score (TPS) and the combined positive score (CPS). Pretreatment biopsies from 147 HNSCC patients were collected in a tissue-microarray (TMA). Serial sections of the TMA were immunohistochemically stained for PD-L1 expression using 22C3 pharmDx on the Dako Link 48 platform, SP263 on the Ventana Benchmark Ultra platform, and 22C3 as an LDT on the Ventana Benchmark Ultra. Stained slides were assessed for TPS and CPS. Cutoffs of ≥1% and ≥50% for TPS and ≥1 and ≥20 for CPS were used. Concordance between the different staining assays was moderate to poor for TPS (intraclass correlation coefficient (ICC) 0.46) as well as for CPS (ICC 0.34). When stratifying patients by clinically relevant cutoffs, considerable differences between the assays were observed: concordance was poor for both TPS and CPS. Generally, SP263 stained a higher percentage of cells than the other assays, especially when using the CPS. Moderate concordance was shown between three different PD-L1 immunohistochemical assays and considerable differences in PD-L1 positivity were observed when using clinically relevant cutoffs. This should be taken into account when using PD-L1 expression to guide clinical practice.

Evidence for different molecular parameters in head and neck squamous cell carcinoma of nonsmokers and nondrinkers: Systematic review and meta-analysis on HPV, p16, and TP53.

BACKGROUND: The goal of this review was to present an overview of the currently identified molecular parameters in head and neck squamous cell carcinoma (HNSCC) of nonsmokers and nondrinkers (NSND). METHODS: Following the PRISMA guidelines, a systematic search was performed using the electronic databases PubMed, Embase, and Google Scholar. RESULTS: Of the 902 analyzed unique studies, 74 were included in a quantitative synthesis and 24 in a meta-analysis. Human papillomavirus (HPV) was reported as a molecular parameter in 38 studies, followed by p16 and TP53 (23 and 14 studies, respectively). The variety of other molecular parameters concerned sporadic findings in small numbers of NSND. CONCLUSIONS: HNSCC in NSND is more often related to HPV and p16 overexpression compared to tumors of smokers-drinkers. In a third of virus-negative tumors, TP53 mutations were detected with a mutational profile associated with aging and ultraviolet light exposure rather than to tobacco consumption.

Presence of Human Papillomavirus and Epstein-Barr Virus, but Absence of Merkel Cell Polyomavirus, in Head and Neck Cancer of Non-Smokers and Non-Drinkers.

OBJECTIVE: Determine the presence and prognostic value of human papillomavirus (HPV), Epstein-Barr virus (EBV), Merkel cell polyomavirus (MCPyV), and cell cycle proteins in head and neck squamous cell carcinoma (HNSCC) of non-smokers and non-drinkers (NSND). METHODS: Clinical characteristics and tumors of 119 NSND with HNSCC were retrospectively collected and analyzed on tissue microarrays. RNAscope in situ hybridization (ISH) was used to screen for the presence of HPV and MCPyV mRNA. Immunohistochemistry was performed for expression of p16 as surrogate marker for HPV, Large T-antigen for MCPyV, and cell cycle proteins p53 and pRb. Positive virus results were confirmed with polymerase chain reaction. For EBV, EBV encoded RNA ISH was performed. Differences in 5-year survival between virus positive and negative tumors were determined by log rank analysis. RESULTS: All oropharyngeal tumors (OPSCC) (n = 10) were HPV-positive, in addition to one oral (OSCC) and one nasopharyngeal tumor (NPSCC). The other three NPSCC were EBV-positive. MCPyV was not detected. Patients with HPV or EBV positive tumors did not have a significantly better 5-year disease free or overall survival. Over 70% of virus negative OSCC showed mutant-type p53 expression. CONCLUSION: In this cohort, all OPSCC and NPSCC showed HPV or EBV presence. Besides one OSCC, all other oral (n = 94), hypopharyngeal (n = 1), and laryngeal (n = 9) tumors were HPV, EBV, and MCPyV negative. This argues against a central role of these viruses in the ethiopathogenesis of tumors outside the oro- and nasopharynx in NSND. So, for the majority of NSND with virus negative OSCC, more research is needed to understand the carcinogenic mechanisms in order to consider targeted therapeutic options.

Aesthetics Assessment and Patient Reported Outcome of Nasolabial Aesthetics in 18-Year-Old Patients With Unilateral Cleft Lip.

OBJECTIVE: To determine if there is a correlation between objective nasolabial aesthetics assessment using the Cleft Aesthetic Rating Scale (CARS) and patient satisfaction. DESIGN: Retrospective analysis of a generic satisfaction questionnaire and independent assessment by three cleft surgeons of the nasolabial area of these patients on 2D frontal photographs, using the CARS. SETTING: The Vrije Universiteit Medical Center and The Academic Center for Dentistry Amsterdam. PATIENTS: Thirty-nine 18-year old patients with a repaired complete or incomplete unilateral cleft lip, with or without a cleft palate, and a completed satisfaction questionnaire. Exclusion criteria were an incomplete questionnaire; a history of facial trauma; and congenital syndromes affecting facial appearance. MAIN OUTCOME MEASURES: The correlation between surgeon evaluation (on a 5-point Likert scale) and patient satisfaction (not, moderately or very satisfied) on nasolabial appearance was assessed using Spearman rho (ρ). RESULTS: There was a negligible correlation between surgeon evaluation and patient satisfaction on nose assessment (ρ = 0.20) and a moderate correlation on lip assessment (ρ = 0.32). CONCLUSIONS: Most literature supports this discrepancy between different objective aesthetics evaluation methods and subjective patient-reported outcome measures, suggesting there are factors playing a role in patient satisfaction that are impossible to objectify with assessment methods. Therefore, a strong emphasis should remain on clear communication between the physician and patient regarding their expectations, perception, and satisfaction of surgery results.

Defining the Aesthetic Range of Normal Symmetry for Lip and Nose Features in 5-Year-Old Children Using the Computer-Based Program SymNose.

OBJECTIVE: To provide a normal comparison group against which to judge symmetry results after cleft surgery and to introduce the thin lip correction (TLC) feature in SymNose. A lip-aspect ratio algorithm has been added to the latest version of SymNose to compensate for the higher degree of overlap in thicker lips when compared to thin lips. DESIGN: Retrospective analysis of symmetry in healthy participants, using the computer-based program SymNose on both anteroposterior (AP) and base view images. Photographs of 91 noncleft children were traced twice by 3 independent investigators experienced with SymNose. PARTICIPANTS: Five-year-old healthy participants from a local state school in Tavistock (West Devon, United Kingdom). MAIN OUTCOME MEASURE: Asymmetry expressed as the perimeter mismatch percentage for nose and lip features on AP view images and for nose features on base view images. RESULTS: The perimeter mismatch reference range for the nose (AP view) was 2.65% to 30.91%, for the lip 2.13% to 15.44%, for the nose (base view) 1.69% to 14.84%, for the nostrils 4.68% to 26.6%, and for the width-height ratio 1.15% to 1.80%. The perimeter mismatch percentage for the lip without TLC was significantly higher compared to the perimeter mismatch percentage with TLC (P < .001). CONCLUSION: This article provides a noncleft reference range for all perimeters drawn from SymNose against which to compare results after cleft surgery at 5 years of age. Furthermore, it shows the importance of correcting for variance in lip volume per child.

Rating Nasolabial Aesthetics in Unilateral Cleft Lip and Palate Patients: Cropped Versus Full-Face Images.

OBJECTIVE: To determine if cropping facial images affects nasolabial aesthetics assessments in unilateral cleft lip patients and to evaluate the effect of facial attractiveness on nasolabial evaluation. DESIGN: Two cleft surgeons and one cleft orthodontist assessed standardized frontal photographs 4 times; nasolabial aesthetics were rated on cropped and full-face images using the Cleft Aesthetic Rating Scale, and total facial attractiveness was rated on full-face images with and without the nasolabial area blurred using a 5-point Likert scale. SETTING: Cleft Palate Craniofacial Unit of a University Medical Center. PATIENTS: Inclusion criteria: nonsyndromic unilateral cleft lip and an available frontal view photograph around 10 years of age. EXCLUSION CRITERIA: a history of facial trauma and an incomplete cleft. Eighty-one photographs were available for assessment. MAIN OUTCOME MEASURES: Differences in mean CARS scores between cropped versus full-face photographs and attractive versus unattractive rated patients were evaluated by paired t test. RESULTS: Nasolabial aesthetics are scored more negatively on full-face photographs compared to cropped photographs, regardless of facial attractiveness. (Mean CARS score, nose: cropped = 2.8, full-face = 3.0, P < .001; lip: cropped = 2.4, full-face = 2.7, P < .001; nose and lip: cropped = 2.6, full-face = 2.8, P < .001). CONCLUSION: Aesthetic outcomes of the nasolabial area are assessed significantly more positively when using cropped images compared to full-face images. For this reason, cropping images, revealing the nasolabial area only, is recommended for aesthetical assessments.

Comparison of two- and three-dimensional assessment methods of nasolabial appearance in cleft lip and palate patients: Do the assessment methods measure the same outcome?

OBJECTIVE: For the assessment of the nasolabial appearance in cleft patients, a widely accepted, reliable scoring system is not available. In this study four different methods of assessment are compared, including 2D and 3D asymmetry and aesthetic assessments. METHODS: The data and ratings from an earlier study using the Asher-McDade aesthetic index on 3D photographs and the outcomes of 3D facial distance mapping were compared to a 2D aesthetic assessment, the Cleft Aesthetic Rating Scale, and to SymNose, a computerized 2D asymmetry assessment technique. The reliability and correlation between the four assessment techniques were tested using a sample of 79 patients. RESULTS: The 3D asymmetry assessment had the highest reliability and could be performed by just one observer (Intraclass correlation coefficient (ICC): 0.99). The 2D asymmetry assessment of the nose was highly reliable when performed by just one observer (ICC: 0.89). However, for the 2D asymmetry assessment of the lip more observers were needed. For the 2D aesthetic assessments 3 observers were needed. The 3D aesthetic assessment had the lowest single-observer reliability (ICC: 0.38-0.56) of all four techniques. The agreement between the different assessment methods is poor to very poor. The highest correlation (R: 0.48) was found between 2D and 3D aesthetic assessments. Remarkably, the lowest correlations were found between 2D and 3D asymmetry assessments (0.08-0.17). CONCLUSION: Different assessment methods are not in agreement and seem to measure different nasolabial aspects. More research is needed to establish exactly what each assessment technique measures and which measurements or outcomes are relevant for the patients.

Proximity of Vital Structures to the Clavicle: Comparison of Fractured and Non-fractured Side.

BACKGROUND: Previous anatomic and radiological studies have described the relationship of the clavicle to major neurovascular structures in healthy subjects. We were curious about this relationship in patients with a clavicle fracture and if it is different from non-fractured clavicles. METHODS: We retrospectively identified all patients with a clavicle fracture between July 2001 and October 2013 in two level 1 trauma centers. Patients aged 18 years or greater with an acute unilateral clavicle fracture and a chest CT scan in the supine position displaying both clavicles and the complete fracture were included. Seventy patients were available for study. The distance was measured from the fracture site and from the closest clavicular cortex to the closest major artery, major vein, and inner surface of the thoracic cavity. CT data was evaluated in OsiriX DICOM viewer software with the use of three-dimensional Multiplanar Reconstruction. RESULTS: Compared to the fractured side, the clavicle was significantly closer to the artery and vein on the non-fractured side (P<0.001 and p=0.0025 respectively). There was a significant difference in the median distance of the fracture site to the artery, vein, and inner surface of thoracic cavity between the different types of fractures (P<0.001). A post-hoc comparison showed significant differences in all distances between fracture types, except for the distance of proximal third compared to middle third fractures to the closest artery (P=0.41). There was no significant difference in distance when the arm is up overhead compared to down by the side of the body in computed tomography (CT) scans. CONCLUSIONS: A fracture of the clavicle changes the relationship of the clavicle to major vital structures. The minimum distance of the clavicle to the closest artery and vein is significantly less on the non-fractured side, compared to the fractured side.

A comparison of actual and theoretical treatments of glenoid fractures.

BACKGROUND: There is no consensus on the operative treatment of glenoid fractures. The purpose of this study was to see whether there was a difference between how patients with a glenoid fracture would receive treatment according to theoretical operative indications based on the measurement of computed tomography (CT) scans and radiographs and the treatment they actually received in our institutions. METHODS: A total of 457 patients with a scapular fracture were treated in two level 1 trauma centres between January 2002 and August 2011. Ninety-eight patients with a glenoid fracture were retrospectively analyzed. Intra-articular gap, medial or lateral (M/L) displacement, angular deformity, and glenopolar angle (GPA) were measured on CT scans or radiographs to determine theoretical indications for operative treatment. RESULTS: Twenty-four patients (25%) actually had operative treatment, while 35 patients (36%) fulfilled at least one theoretical criterion to proceed with operative treatment with a medium correlation between theoretical indications for surgery and the actual operative treatment. All the patients with a theoretical indication for surgery had an intra-articular gap with a step-off of >4 mm. A bony Bankart lesion with shoulder dislocation and injury in sports was retained in the best multivariable model as indications for the actual surgery. CONCLUSION: Theoretical guidelines for surgery on glenoid fractures may not have much influence on the current treatment. LEVEL OF EVIDENCE: Therapeutic, level III.

Trigger finger: assessment of surgeon and patient preferences and priorities for decision making.

PURPOSE: To test the null hypothesis that there are no differences in the priorities and preferences of patients with idiopathic trigger finger (TF) and hand surgeons. METHODS: One hundred five hand surgeons of the Science of Variation Group and 84 patients with TF completed a survey about their priorities and preferences in decision making regarding the management of TF. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. RESULTS: Patients desired orthotics more and surgery less than physicians. Patients and physicians disagreed on the main advantage of several treatment options for TFs and on disadvantages of the treatment options. Patients preferred to decide for themselves after receiving advice, whereas physicians preferred a shared decision. Patients preferred booklets, and physicians opted for Internet and video decision aids. CONCLUSIONS: Comparing patients and hand surgeons, there were some differences in treatment preferences and perceived advantages and disadvantages regarding idiopathic TF-differences that might be addressed by a decision aid. CLINICAL RELEVANCE: Information that helps inform patients of their options based on current best evidence might help them understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.

Small Finger Metacarpal Shaft Wedged between Ring and Small Metacarpal Bases: a Report of 2 Cases.

We present two patients with a displaced fracture of the small finger metacarpal base, where the shaft of the small finger metacarpal was wedged between the bases of the ring and small finger metacarpals. The striking appearance on radiographs led to initial recommendations for surgery, but both patients preferred non-operative treatment and did well in the short term without surgery.