Here we report a unique case of chronic occipital neuralgia caused by pathological vascular contact of the left greater occipital nerve. After 12 months of left-sided, unremitting occipital neuralgia, a hypesthesia and facial pain developed in the left hemiface. The decompression of the left greater occipital nerve from pathological contacts with the occipital artery resulted in immediate relief for hemifacial sensory change and facial pain, as well as chronic occipital neuralgia. Although referral of pain from the stimulation of occipital and cervical structures innervated by upper cervical nerves to the frontal head of V1 trigeminal distribution has been reported, the development of hemifacial sensory change associated with referred trigeminal pain from chronic occipital neuralgia is extremely rare. Chronic continuous and strong afferent input of occipital neuralgia caused by pathological vascular contact with the greater occipital nerve seemed to be associated with sensitization and hypersensitivity of the second-order neurons in the trigeminocervical complex, a population of neurons in the C2 dorsal horn characterized by receiving convergent input from dural and cervical structures. It is well known that patients with primary headaches often report pain not only involving the frontal head innervated by the first  division of the trigeminal nerve, but also involving the occipital region innervated by the greater occipital nerve (GON), a branch of the C2 spinal root –3. LikewClinical evidence of referred pain in the frontal head with involvement of the TCC from cervical lesions has been reported in cases of posterior fossa tumors, stimulation of the infratentorial dura mater, direct stimulation of cervical roots, vertebral artery dissection, and stimulation of subcutaneous tissue innervated by the GON , 9. HoweA 53-year-old female with a 16-month history of chronic stabbing pain along the distribution of the left GON presented with a left-sided facial pain with 4 months of duration. A severe aching pain and tenderness over the left occipital area were associated during initial development of left occipital pain 16 months ago. There was no precipitating event before the onset of left occipital neuralgia. The onset was described as rather sudden. The pain was described as mainly stabbing and electric in nature with moderate severity  ranging from 0 to 10). It was not aggravated with neck motion. Daily activity did not influence the continuous occipital pain. Her medical history was unremarkable, including diabetes and gout. Under the impression of occipital neuralgia, she had been treated with several nonsteroidal anti-inflammatory drugs, including tramadol (150 mg/day), carbamazepine (400 mg/day), and pregabalin (225 mg/day), with some degree of relief. Pain was so agonizing that treatment of repeated occipital nerve blocks on a regular schedule of a month for a year was given. The occipital nerve block over the tender point along the course of the GON was quite effective for the initial two injections. However, its effect lasted 3 hours thereafter.Four months prior to presentation, an aching pain developed insidiously in the left orbit, cheek, temple, and left ear canal. Subsequently, paresthesia and numbness progressively developed in her left hemiface. Despite the development of left hemifacial pain and sensory disturbance, left occipital neuralgia was not aggravated. It remained present as it had been for the prior 16 months. Considering the chronic nature of left occipital neuralgia with superimposed occurrence of hemifacial pain and sensory changes, she was referred to us for further evaluation of the trigeminal and occipital pain.Upon examination, her left occipital pain was typically that of occipital neuralgia fulfilling the criteria of International Classification of Headache Disorders (ICHD) . The staLaboratory examinations were normal, including erythrocyte sedimentation rate and C-reactive protein, antinuclear antibody, and anti-DS-DNA. Cerebrospinal fluid examination was also normal. Pathological lesion to explain the left occipital and trigeminal pain was not observed in the enhanced MRI of the brain and cervical spine. Considering chronicity and medical intractability, exploration of the left GON was proposed. An approximately 8 cm sized hockey stick shaped incision and subcutaneous flap were elevated from the midline to identify the course of the GON. No entrapment of the GON was found in its course in the trapezius or semispinalis capitis. Upon dissection along the distal course of the GON, a severe adhesion to the surrounding connective tissue and entrapment of the GON between tributaries of the occipital artery were encountered . The occWe present a rare case of neurological deficit in addition to typical referred pain to ipsilateral V1 trigeminal pain from chronic occipital neuralgia. It is extremely difficult to find a case in the literature describing the development of hemifacial hypesthesia associated with referred facial pain from cervical pathology. Of particular interest with regard to our case is the occurrence of cluster headaches, a rare form of primary headache marked by unilateral excruciating pain in association with autonomic features, associated with an ipsilateral vertebral artery aneurysm  and vertThe upper cervical spinal roots can contribute to sensory innervation of cranial and cervical structures. Occipital and suboccipital structures such as vessels, the dura mater of the posterior fossa, deep paraspinal neck muscle, and zygapophyseal joints are recognized as sources of head and neck pain , 9, 13. Sensitization of the central nociceptive neurons in the TCC takes place in response to strong dural noxious inputs seen in secondary headache syndromes such as meningitis, subarachnoid hemorrhage, and experimental headaches . SensitiAn occurrence of hemifacial hypesthesia not confined to V1 trigeminal distribution was observed in this case. This type of extension of a sensory deficit has been described in complex regional pain syndrome (CRPS) , 21. SenWhile occipital neuralgia is mostly considered idiopathic, specific causes of occipital neuralgia should be excluded from individual cases –36. The An occurrence of hemifacial sensory disturbance associated with referred pain of trigeminal distribution from chronic occipital neuralgia due to pathological vascular contact of the greater occipital nerve is reported here. The present case may indicate that disturbance of sensory processing in higher central structures such as the thalamus may occur in addition to sensitization and hypersensitivity of the second-order neurons in the trigeminocervical complex, a population of neurons in C2 dorsal horn characterized by receiving convergent input from dural and cervical structures.


Rheumatoid arthritis is a polyarthropathy affecting approximately 1% of the population worldwide. Wrist involvement is observed around 75% of patients, resulting in substantial disability and morbidity. A multidisciplinary approach to management of such patients is undertaken to prevent disease progression, many go on to develop debilitating disease requiring surgical intervention. Total wrist arthroplasty and arthrodesis are the main options available for those with end-stage disease, with arthroplasty preferred due to its ability to preserve a good degree of wrist function. Where complications occur with total wrist arthroplasty, salvage surgery with arthrodesis can be considered, however this requires satisfactory bone stock to enable stable fusion of the joint following arthroplasty. We report our experience of Ulna strut allografts in wrist arthrodesis in the management of failed total wrist arthroplasty. Such ri2rd and 4th extensor compartment and ending at the distal portion of the 3rd metacarpal. Skin, fat, fascia and extensor retinaculum are incised at the wrist, exposing the distal radius and ulna. Soft tissues and periosteum are mobilised from the radius proximally and from the dorsum of metacarpal distally, taking care to retract and preserve the overlying extensor tendons. The metacarpal screws and component are removed. The uncemented radial component of the arthroplasty is removed carefully using osteotomies.An incision is made from the distal two thirds of the forearm, extending between the 3The ulna is inspected. The ulna head and associated TFCC and surrounding soft tissues have previously been removed during the total wrist arthroplasty. The distal ulna diaphysis was osteomtomised approximately 5cm proximal to its distal extent. All soft tissues were mobilised from the graft apart from the pronator quadratus muscle to allow some vascularity to this portion of the bone. The blood supply to the pronator quadratus comes from the anterior interosseous artery, which runs down the forearm along the interosseous membrane . The pro1). A standard fusion plate is fixed to the dorsum of the metacarpal, ulna graft and radial shaft using locking standard screws. A small volume of bone may also be used to provide additional packing at the proximal and distal ends of the strut graft. Repair of incised soft tissues are undertaken in layers.The proximal attachments act as pivot to allow 180 degree rotation of the strut graft between the radius and metacarpal .Initial management involved addressing symptoms within her dominant hand with the patient undergoing dorsal wrist synovectomy and EIP tendon transfer to address the ruptured EPL tendon. Whilst she recovered well from the above procedures, symptoms within the left hand continued to deteriorate with the patient developing profound neuropathic pain in the left side. Clinically, she was now exhibiting evidence of muscle wasting within the left forearm alongside inability to flex all digits with ongoing deformity of the wrist. Therefore a left total wrist replacement was undertaken to address these issues , henceforth underwent removal of the wrist replacement followed by arthrodesis of the wrist joint with an ulna strut graft .Post-operatively, the patient exhibited a drastic improvement in both symptoms and function with ability to dorsiflex and plantarflex to 455). She continues to remain under follow-up.She progressed well post-operatively, with imaging at 2 months post-operatively illustrating evidence of graft take and bone healing. Approximately, 12 months following the arthrodesis, the patient's main complaint was prominence of the distal portion of the fusion plate and subsequent skin irritation. She subsequently underwent removal of the fusion plate at 13 month post-arthrodesis with intra-operative imaging and direct inspection of the fusion site showing evidence of complete bone healing and graft take .A 68-year old right hand dominant psychotherapist with a background of RA, numerous previous tenosynovectomy procedures to both hands and FPL tendon reconstruction was referred to our unit with progressive bilateral wrist pain and deformity. Clinical and radiological evidence of severe RA was noted bilaterally with z-deformity at the wrists and ulnar tranlocation of the carpus on the radio-ulnar joints , with the patient demonstrating good post-operative function and ability to dorxsiflex and plantarflex to 50o and 10o at 2 months post-operatively . Unfortunatley, radiological evidence of dorsal progression of the distal prosthesis was evident at approximately 13 months post op, with the wrist replacement subluxing both clinically and radiologically at 24 months following the arthroplasty . Subsequently, the patient underwent revision of the right wrist arthroplasty, however presented with dorsal dislocation of the wrist 1 month later requiring manipulation under anaesthesia (MUA), with a good range of movement with improved grip in the hand post MUA .A right wrist arthroplasty was undertaken . Follow-up imaging has shown satisfactory bone healing and integration of the ulna graft at the fusion site at 9 months post-op .Despite the satisfactory radiological and clinical improvement, the patient went onto develop further migration of the distal component requiring a further revision. Unfortuantely, this did not resolve the issues relating to the migration of the prosthesis, thereby resulting in an eventual right wrist arthrodesis using an ulna bone graft in this patient  are utilised to address such issue and enable rigid fixation of the plate [Unfortunately, such fusions are limited by the lack of a robust and sufficient bone stock, which is usually not present in this patient cohort due to reasons highlighted previously . Therefohe plate . Given the plate .In this paper, we have discussed the use of the ulna strut graft, harvested locally from the surgical site following removal of components of the TWA. Such technique can be utilised to provide a healthy, strong bone graft, of adequate size, to allow satisfactory fusion of the wrist without significant shortening and destabilisation of the wrist joint in those with failed wrist arthroplasties. As highlighted above, the ulna strut graft remained viable and intergrated well with surrounding bone to provide stable fusion at the wrist joint with minimal donor-site morbidities.Where failure of total wrist arthroplasty occurs in rheumatoid arthritis, arthrodesis of the wrist joint is the primary salvage procedure, which is limited by lack of bone stock. In this paper, we describe a new technique utilised to undertake wrist arthrodesis, which provides a solution for limitations related to tradition methods. This is the first paper that we are aware of which describes the use of such technique in wrist fusions. We therefore recommend this method as a salvage procedure in those with multiple failed arthroplasties and extensive joint disease resulting from end-stage RA.


Various strategies are used, which include the long-term follow-up of cohorts vaccinated in clinical trials, pooling of clinical trials data, postmarketing surveillance of safety and clinical outcomes, and review of large health databases to enable signal detection [A pooled analysis of the safety data from the GSK clinical trial development program (57 580 subjects and 96 704 vaccine doses) concluded that the incidence and distribution of AEs were similar among vaccine and control groups . The ratIn the study by Huang et al, all subjects received the AS04-HPV-16/18 vaccine. Medically significant conditions, defined as AEs prompting emergency room or physician visits with the exception of routine visits or common diseases, were to be reported throughout the study. Analysis of the 374 reported medically significant conditions did not reveal any event or cluster of events of potential concern. Serious AEs (SAEs) were reported by 72 participants, none of which were fatal. Appendicitis was the most frequently reported SAE, by 8 subjects. Most SAEs were reported only once per group. The pIMD case of systemic erythematosus lupus (SLE) described by Huang et al was assessed as causally related to vaccination by the investigator while the study was ongoing. The exact time to onset of the symptoms is unclear. The patient had right knee pain from an unspecified date and received a diagnosis of transient synovitis 6 months after first vaccination. A diagnosis of SLE was obtained almost 2 years after the initial vaccination. Retrospectively, the case did not fully meet criteria for SLE  and coulhttps://www.gsk-clinicalstudyregister.com), under study ID 114700.In conclusion, the safety data generated in the present study were in line with the known safety profile of the vaccine as described in the current product information . The ful


High tibial osteotomy (HTO) has been used widely for medial compartment knee osteoarthritis to correct the deformity and relieve symptoms, especially in young patients who are willing to maintain the high activity level. However, the change of bone morphology, ligament imbalance, limb malalignment, and other complications may influence the short-term outcomes of HTO. Some cases may even require conversion to TKA shortly after HTO because of the loss of correction or pain due to accelerated osteoarthritis.A 43-year-old female patient presented with persistent pain of both the left knee and the ankle. She underwent a lateral closing wedge HTO two years ago. Radiographies showed The Kellgren-Lawrence (K-L) grade IV osteoarthritic change and hyperextension (HE) of the left knee and the degeneration of the left ankle.A failed lateral closing wedge high tibial osteotomy with knee hyperextension and secondary ankle degeneration.A posterior-stabilized TKA conversion and postoperative rehabilitation were performed.The operation corrected the HE deformity and relieved the pain at the level of the left knee. However, the secondary change of the left ankle was irreversible.A failed lateral closing wedge HTO might speed up the degeneration of the knee and increase extra technical issues in the following TKA. What is more, the secondary osteoarthritis and deformity of the ankle cannot be ignored. By shifting the weight-bearing loading from the impaired medial compartment to the relatively unaffected lateral compartment, HTO can correct the varus deformity and relieve persistent pain of the knee. HTO is used widely to delay the need for TKA, especially among young or active patients with varus osteoarthritis and patients could retain high activity level post-surgery. HTO could provide favorable clinical outcomes in up to 80% patients with appropriate patient selection and careful operative techniques.,4 However, it was also reported that over 20% patients undergoing HTO may need conversion to TKA due to the progressing osteoarthritis and the major of the failures result from errors in surgical techniques.When HTO was introduced for the first time in 1960s, They have respective characteristics such as the change of the tibial slope, patellar height, and ligament tension. Compared to medial opening wedge HTO, lateral closing wedge HTO allows early weight bearing with the large contact surface of cancellous bone and the fast bone union at the osteotomy site. However, this procedure will shorten the lower limb and disrupt proximal tibiofibular joint, with the risk of neurovascular injury and compartment syndrome. What is more, the removal of the proximal tibial bone stock after lateral closing wedge HTO may increase the technical issues during the following TKA. In this case report, we described a TKA conversion in a patient who had a failed lateral closing wedge HTO. The secondary changes of knee and ankle and the surgical issues of the TKA following the failed lateral closing wedge HTO were also analyzed.Medial opening wedge HTO and lateral closing wedge HTO are the 2 most commonly performed HTO techniques.2A 43-year-old female patient, who complained serious pain of the left knee and ankle for about 3 years, presented to our clinic in October 2016. She underwent a lateral closing wedge HTO for the medial compartment knee osteoarthritis in an outside institution 3 years prior to this visit  grade IV osteoarthritic change of the left knee was documented Fig. C. The fived Fig. D.The TKA  was performed through a new anterior longitudinal incision and a medial parapatellar approach. The patella eversion was relatively easy because there were no apparent patella baja or patellar tendon shortening preoperatively. The cartilage on the front part of the tibial plateau was seriously worn. The cruciate ligaments, hyperplastic osteophyte, or soft tissue were cleared properly for the following resection. The distal femoral resection and the placement of the femoral component were performed normally as in a primary TKA. Given the bone stock loss of the proximal tibia resulting from the previous lateral closing wedge HTO, we minimized the amount of bone resection at the tibial plateau. To rebuild the posterior slope of the tibia, we increased the slope of the tibial resection and the thickness of the resection at the posterior tibial plateau was larger. The tibial component was placed slightly more medial to prevent impingement of tibial stem on the lateral cortex. A moderate degree of lateral laxity in varus stress was seen after the resection and medial release was adopted to balance the ligaments. A 13 mm polyethylene insert was used to reconstruct the JLH and the coronal ligament tension. The varus and HE deformity was corrected and the range of motion after suture was 0 to 160°.The postoperative weight-bearing x-ray Fig. A and B s3 In this case report, we discussed the radiographic and clinical outcomes of a lateral closing wedge HTO and its influence on the following TKA.Although HTO has been regarded as a good treatment for varus knee osteoarthritis for decades, conversion to TKA is still needed in some patients shortly after an HTO. Compared with medial opening wedge HTO, the disadvantages of lateral closing wedge HTO include relatively complex surgery procedures, loss of the bone stock, possible complications, and increased technical difficulty in the following TKA. The change of the tibial slope may have an influence on the kinematics and stability of the knee. Previous study has reported that decreasing the slope causes posterior translation of the tibia and overload on the posterior cruciate ligament (PCL) simultaneously. The posterior stability and the range of the knee are reduced consequently. In addition, the HE of the knee due to the slope reduction increases the load of the anterior part of the tibial plateau, which might speed up osteoarthritis progression. What is more, the secondary deformity and osteoarthritis of the ankle could not be ignored in this patient and this can be explained by the compensatory mechanism of the gait. To obtain a plant grade foot, the plantar flexion compensated for the HE of the knee. The ankle contact area decreases and moved posteriorly.,15 The higher contact pressure between the distal tibia and talus results in secondary degeneration and pain of the ankle.Excessive decrease of the tibial posterior slope mainly accounted for the failure of the HTO in this case. The tibia has a triangular shape with the apex directed anteriorly, so osteotomy may result in changes not only on the coronal plane, but also on the sagittal plane. The osteotomy causes more bone loss anteriorly and subsequent compression results in a reduction of the slope. In another situation when the knee is splinted, the patellar is kept in positon. It could cause tendon scaring and pseudo-patella baja  and make the surgery exposure of the TKA difficult. However, the patient in this case underwent a biplanar lateral closing wedge osteotomy with osteotomy exits distal to the tibial tuberosity. The Insall-Salvati ratio was 1.08 and changed little after HTO (Fig. For conventional Coventry closing wedge osteotomy, the change of the patellar height is another factor affecting the results of the HTO and the following TKA. The site of the osteotomy is proximal to the tibial tuberosity and the tuberosity moves closer to the knee joint line. The patella may ride proximally because of the retinaculum, creating a pseudo-patella alta.HTO Fig. . The dis–9 Previous studies have compared the TKA following a failed lateral closing wedge HTO and the standard primary TKA on the postoperative radiographic and clinical outcomes with inconsistent conclusions. Some authors reported no substantially difference in clinical outcomes between these 2 groups although a previous closing wedge HTO may cause some important changes including malalignment, patella baja, bone stock loss, and the morphological change of the proximal tibia,,20 whereas the others advocated the opposite views and reported inferior results in those with a previous HTO.,22 However, it is recognized that there will be increasing technical complexity in converting a closing wedge HTO to a TKA than a primary TKA. The patellar baja and patellar tendon shortening make the surgery exposure difficult. Some cases need quadriceps snip and tibial tuberosity osteotomy. The tibial bone stock loss increases the risk of impingement between the stem of the tibial tray and the lateral cortex. The surgeon need to use undersized tibial trays, leave the lateral tibial plateau uncovered partially or put the tibial tray medially to solve the problem. In addition, extra operation time is spared to remove the residual hardware, reconstruct the JLH, adjust the tibial posterior slope, and balance the ligaments.In addition to the change of the tibial slope and patellar height, the lower limb shortening, JHL reduction and lateral ligament resection laxity are also intrinsic characteristics of lateral closing wedge HTO.4The favorable outcomes of a lateral closing wedge HTO rely on reasonable patient selection, careful preoperative planning, and exquisite surgical techniques. A failed HTO could result in unexpected knee malalignment on the sagittal plane and accelerate the progression of the knee osteoarthritis. The secondary deformity and degeneration of the ankle can neither be ignored. What is more, extra technical issues should be considered in converting a failed lateral closing wedge to TKA.


The purpose of this study is to critically assess recent studies concerning the use of probiotics to control periodontal diseases, dental caries and halitosis .Clinical studies have shown that probiotics when allied to conventional periodontal treatment can ameliorate microbial dysbiosis and produce significant improvement in clinical indicators of disease. However, this effect is often not maintained by the host after the end of probiotic use. Current probiotics also show limited effects in treating caries and halitosis. Novel approaches based up on replacement therapy and using highly abundant health-associated oral species, including nitrate-reducing bacteria, have been proposed to improve persistence of probiotic strains and maintain oral health benefits.Probiotics have potential in the management of multifactorial diseases such as the periodontal diseases and caries, by more effectively addressing the host-microbial interface to restore homeostasis that may not be achieved with conventional treatments. Thus, probiotic therapy could be accomplished by the introduction of NRB into neonates, which have yet to acquire these bacteria or adults after the use of broad-spectrum antibiotics to firstly reduce tongue populations of bacteria. Bacterial metabolism of nitrate to nitrite within the oral cavity and the subsequent formation of biologically active nitrogen oxides are unlikely to have wider undesirable effects; however, disruption of the intestinal microflora remains a possibility.Lactobacillus brevis CD2 has been shown to delay the development of gingivitis in a clinical model by the downregulation of the inflammatory cascade via the competitive utilisation of the NO substrate arginine [It is well established that salivary glands may respond to periodontitis through the enhancement of the protective effects of saliva •. An incarginine •.Streptococcus mutans in saliva or dental plaque; and/or the flow, pH or buffering capacity of saliva. However, only a limited number of studies have used clinical indicators, for both dental caries and the periodontal diseases to demonstrate the efficacy of probiotics. A recent systematic review and meta-analysis provide a useful guide to clinical decision making and direction for further research [The prevalence of dental caries continues to increase worldwide and remains the most common chronic condition during childhood. The assessment of the use of probiotics in the control of dental caries has been limited by the number of subjects needed, prolonged treatment duration and high cost. Most studies have measured counts of research •.Lactobacillus rhamnosus, L. casei, L. reuteri and Bifidobacterium spp. have all demonstrated the potential to alter colonisation of cariogenic bacteria and thus prevent dental caries [Streptococcus oralis, S. uberis and a lactic acid-deficient variant of S. rattus, whereby the probiotic mouthwash used was able to markedly affect the levels of cariogenic bacteria in saliva together with periodontal pathogens in subgingival plaque [Streptococcus dentisani, a species isolated from individuals who are caries-free, could be a particularly beneficial probiotic species through its production of bacteriocins and acid buffering capacity [Streptococcus salivarius M18, also a producer of bacteriocins, was able to reduce caries development in children as assessed by a number of caries-related risk factors [Strains of l caries . To achil plaque , 84. It capacity . As repo factors .S. mutans has been considered for replacement therapy in the control of dental caries. A strain of S. mutans was made lactate dehydrogenase deficient by the deletion of virtually all of the genetic sequence encoding this enzyme. To compensate for the resulting metabolic imbalance, an alcohol dehydrogenase gene from Zymomonas mobilis was then introduced with no detectable lactic acid being produced from the resulting clone. This strain was also significantly less cariogenic than the parent strain as tested in gnotobiotic- and conventional-rodent models of dental caries. In addition, it was found to colonise the teeth of conventional rats to the same extent as the parent strain using both aggressive-displacement and pre-emptive-colonisation approaches. The clone was also shown to be genetically stable and did not revert to producing acid with in vivo and in vitro test systems [S. mutans clone (SMaRT Replacement Therapy product has recently been developed by Oragenics Inc.) could provide a lifetime of protection in humans against dental caries, but may require occasional re-applications.‘Replacement therapy’ based upon biotechnological approaches has also been investigated. Techniques used include gene inactivation to remove harmful metabolites and the incorporation of genes to encode for antimicrobial compounds, for example bacteriocins.  systems . It has Probiotics could have an important role to play in the clinical management of dental caries and the periodontal diseases, although the evidence is less convincing as regards halitosis. Both long-term efficacy and safety of probiotics should be established in preventative or treatment contexts, in order to inform safe clinical recommendations. Studies must determine strain specific and synergistic effects of strains in vitro to help inform in vivo mechanisms. Innovative approaches using oral microbiome transplants could further increase the role of probiotics in personalised treatment, while other approaches that involve use of more abundant indigenous oral strains may yield long-term benefits in the maintenance of health by the host . Study o


Introduction: The techniques used to fixate osteotomized segments of bone have evolved alongside the treatment of craniosynostosis. The use of nonresorbable metal plates and screws offered a method of rigidly stabilizing repositioned segments of bone. Several reports specify the tendency for these fixation systems to “migrate” transcranially. Methods: We present a unique case of a patient who initially underwent treatment of multisuture craniosynostosis utilizing titanium miniplates at 6 months of age. At 16 years of age, the patient was returned to the operating room with complaints of pain and contour irregularities, and intracranial migration of the screws and plates was observed. Results: The hardware was extracted and the cranium reconstructed. Symptoms resolved and bony contour was improved. Conclusion: The craniofacial surgeon considering metal plate fixation in the pediatric population should be aware of the possibility for transcranial plate and screw migration. Craniosynostosis results from premature fusion of the calvarial sutures and affects 1 in 2500 births worldwide.,While over the years fixation methods and materials have evolved, the main goal remains to achieve absolute rigid stability to aid in direct bone healing. Titanium microfixation plates and screws are demonstrated to be safe and effective in the adult population but may present complications in the pediatric population. In particular, some surgeons have noted upon reoperation of infants who underwent cranial plate fixation the presence of plate adherence to the inner table of the skull in children and plate and screw isolation on bone islands.2Our patient presented in infancy with right coronal and bilambdoidal craniosynostosis. At 6 months of age, he underwent a fronto-orbital advancement, and at 15 months of age, a posterior vault remodeling procedure. Titanium miniplates and screws were used for stabilization of the bony components. Fifteen years later, the patient presented with symptoms of pain and persistent deformation of the orbit with contour irregularities of the forehead. CT scan revealed intracranial transposition of the screws, penetrating the dura -3.The 16-year-old patient was brought to the operating room for hardware removal, possible dural repair, and reconstruction of the forehead and the orbital rim. Intraoperatively, extensive hardware was found extending to the cranionasal junction, up to and beyond the sphenoid wing into the middle cranial fossa. The hardware was imbedded within the bone, with approximately 2 to 3 mm of screw sticking beyond the inner table . The har-With the advancement of technology, rigid fixation methods for craniofacial surgery have evolved from stainless steel wiring to metal plates and screws to absorbable plating systems. Since the mid-1990s, there have been several reports describing transcranial migration of fixatives, including wire sutures and metal plates, in children.2Alternative fixation methods include utilizing absorbable sutures or bioabsorbable plates. A prospective randomized trial of 16 children with craniosynostosis who underwent bilateral fronto-orbital advancement surgery with either absorbable sutures or rigid fixation (titanium miniplates and absorbable plates) showed that the choice of the fixation material was of minor importance.


The sense of coherence  of Austrian psychotherapists was assessed and compared with a standard sample, as well as with the sense of coherence (SOC) of members of other professions. In addition, the question as to whether psychotherapists who had completed more extensive individual training therapy/self-awareness sessions had a higher SOC than do those with fewer, was addressed. Forty psychotherapists who worked in private practices and various psychosocial health care institutions in Styria, Austria took part in the study. The investigation was conducted in the form of a questionnaire assessment. The evaluation showed that the overall SOC value of the professional group in question was significantly higher than that of the standard sample (162.3 vs. 145.7), as well as other samples . Concerning whether psychotherapists who had completed more individual training therapy/self-awareness sessions had higher SOC values than did those with fewer, we found no difference in regard to the overall SOC score or SOC scores for individual components. The SOC of psychotherapists did not seem to depend on the number of additional training therapy/self-awareness sessions.


Matsuoka and Yamaguchi reviewed the social and psychological risk factorsfor Alzheimer’s disease using the theory of path dependence. According to this theory,an earlier choice or event largely determines successive ones. The authors emphasizedthe role of education as one of these early experiences in life which determines a paththat predisposes individuals to several psychosocial risk factors for dementia. Theyreinforced that resources for dementia prevention should be directed toward individualswith a low level of education.Souza-Talarico et al. reviewed the effects of stress hormones on the brainand cognition in normal and pathological aging. Glucocorticoid receptors are mainlyfound in the amygdala, prefrontal cortex and the hippocampus, regions that are involvedin emotional behavior, executive functions. and learning and memory. The acute andchronic effects of glucocorticoids are presented and the relevance of this area ofresearch is emphasized by the authors. Strategies for decreasing stress levels may bebeneficial for older adults.Anghinah et al. presented a review on traumatic brain injury (TBI) frombasic concepts of mechanisms of injury to rehabilitation. Cognitive rehabilitation inTBI is an area which calls for multidisciplinary action. TBI is a highly frequent anddisabling condition that warrants further study in developing countries.Brucki et al. investigated the influence of education on performance in theMini-Mental State Examination (MMSE) using years of schooling or score on aquestionnaire of literacy- the short version of the Test of Functional Health Literacyin Adults (S-TOFHLA). The authors found that both years of schooling and S-TOFHLA werestrongly correlated with MMSE scores, but that S-TOFHLA had the strongest correlationwith the MMSE scores.Wachholz and Yassuda evaluated the capacity to understand the meaning ofproverbs by elderly with different educational backgrounds. The authors also analyzedthe association of the interpretation of proverbs with other cognitive functions anddomains. The authors found that the capacity to interpret proverbs is stronglyassociated with education and performance on other tests of executive functions.Marques da Silva et al. performed a systematic review of the literature toevaluate the current evidence for the use of antipsychotics in demented patients withpsychotic symptoms. Their conclusion is that antipsychotics still have a place intreatment of more serious psychotic symptoms after the failure of other pharmacologicaland non-pharmacological treatments. The authors also concluded that new treatmentalternatives are greatly needed.Bello and Schultz performed a retrospective analysis of the files of 193patients with dementia seen at an outpatient clinic of a university-associated hospitalin São Paulo, Brazil. The authors found that 37 (19.17%) of the patients studiedhad a diagnosis consistent with a potentially reversible or preventable dementia, withhead injury and alcohol-related dementias as its leading causes.Aramaki and Yassuda investigated whether the gains documented aftercognitive training based on metamemory and mental images were still present 18 monthsafter the completion of the cognitive training program. Although they were only able tore-investigate approximately 45% of the original sample, the results were consistentwith the maintenance of the effects of the previous training after this relatively longperiod of time.Schultz and Bertolucci reported a case of congenital prosopagnosia in a46-year-old woman, who also had impairment in recognizing animals. The authors reviewedthe literature on this phenomenon and concluded that in the case reported, the agnosiashould be classified as an associative agnosia.Caixeta and Lopes reported a case of trichotillomania in an 87-year-old manwith dementia due to probable Binswanger disease. The authors described trichotillomaniaas a poorly understood complex disorder and suggested that the pathogenesis oftrichotillomania in this case may related to a defect in connectivity in thefrontal-subcortical circuit.News and Perspectives. In this novel section of the journal, SoniaMaria Dozzi Brucki, the area editor, presented a few brief reviews ofrelevant and recent papers to our readers.Ricardo NitriniEditor-in-Chief


Clefting of the secondary palate is one of the most common human birth defects and results from failure of the palatal shelves to fuse during embryonic development. Palatogenesis is traditionally considered to be a highly conserved developmental process among mammalian species. However, cleft palate phenotypes in humans are considerably more variable than those seen in mice, the most common animal model for studying palatal development and pathogenesis of cleft palate. In this investigation, we utilized macroscopic observations, histology and 3D imaging techniques to directly compare palate morphology and the oral-nasal cavity during palate closure in mouse embryos and human conceptuses. We showed that mouse and human palates display distinct morphologies attributable to the structural differences of the oral-nasal cavity. We further showed that the palatal shelves interact differently with the primary palate and nasal septum in the hard palate region and with pharyngeal walls in the soft palate region during palate closure in mice and humans. Knowledge of these morphological differences is important for improved translation of findings in mouse models of human cleft lip/palate and, as such, should ultimately enhance our understanding of human palatal morphogenesis and the pathogenesis of cleft lip/palate in humans. The palate forms the roof of the mouth and separates the oral and nasal cavities in humans. In mammals, the palate is formed from two distinct components: the primary and the secondary palates. The primary palate constitutes the most anterior part of the palate (anterior to the incisive foramen) and is formed through posterior expansion of the frontal-nasal process. The secondary palate constitutes the majority of the palate (posterior to the incisive foramen) and is formed through fusion of paired palatal shelves that derive from medial outgrowths of the maxillary processes. Development of the secondary palate is a multi-step process that includes palatal shelf growth, elevation and fusion . Embryos were dissected from the uterus in PBS, fixed in 4% paraformaldehyde overnight at 4°C, and stored in 70% ethanol. For gross assessment of the palatal shelves, the tongue and lower jaw were removed from specimens. As reported previously  and 54 days (n = 4) showed an open palate with a large gap along the AP length. Specimens at the ages of 56 days (n = 2), 57 days (n = 7) and 58 days (n = 2) showed a partially fused palate with a small gap at the posterior end region. Specimens at 59 days of age showed various morphologies at the posterior end region that included a small posterior gap (n = 3), split uvula (n = 2) or complete fusion (n = 1). The palate was completely fused in specimens at the ages of 63 days (n = 1), 64 days (n = 1) and 67 days (n = 3). Human palate morphology at each age examined was largely consistent with that of a recent study except that we did not observe any substantial palatal shelf fusion at the age of 54 days . The age for human specimens was estimated by a combination of gestational ultrasound and fetal foot length measurements where possible Shepard, . The genMouse and human craniofacial tissue was embedded in paraffin and sectioned either in the coronal or sagittal plane. 4 μm paraffin sections were stained with hematoxylin and eosin (H&E) for morphological analysis. Von Kossa staining was used to detect mineralized bone tissues as described previously . Standard settings were used for imaging of craniofacial bones  and micro-computed tomography (microCT) were conducted in the Small ANimal Tomographic Analysis (SANTA) Facility at the Seattle Children's Research Institute. Samples for OPT were prepared and imaged under UV light as described in Zovein et al.  using a Palatal shelf elevation marks the onset of palate closure, during which the palatal shelves overcome the tongue obstruction and move to a horizontal position for contact and fusion at the midline of the oral-nasal cavity. Despite differences in the conceptual age between mouse and human embryos at the time palatal shelf elevation occurs, both embryos are actually at a similar developmental stage during embryogenesis (Theiler Stage 22 in mice and Carnegie Stage 20–21 in humans) when most of the craniofacial structures including the primary palate, nasal cavity and tongue have been fully developed Theiler, . We therTo determine craniofacial tissue interactions during palate closure, we examined the position of the elevated shelves in an intact oral-nasal cavity environment using 3D imaging that allows multi-axis analysis of each specimen. Generally, the elevated shelves are located between the nasomaxillary complex and the tongue. However, mouse and human palatal shelves show distinct relationships with these craniofacial tissues in the oral-nasal cavity. For example, the elevated shelves are entirely inferior to the nasomaxillary complex in humans Figure , but areStudies of mouse palatogenesis have suggested that different palatal regions along the AP axis display distinct morphological changes that may result from region-specific gene expression during development  and the formation of midline epithelial seam (MES), the degeneration of which results in continuity of the palatal mesenchyme and the completion of palate closure . At gross observation, this gap looks similar in terms of the shape and size in both species Figures . HoweverIn this study, we compared palate morphology between mice and humans at the time of palate closure. We find that mouse and human palates show distinct shelf morphological changes that at least in part could be due to differences in craniofacial structure between the species. Therefore, although palatogenesis is a conserved developmental process in mammals, the presence of species-specific factors can result in divergence in terms of the regulation of palate formation between species. As the mouse is the most commonly used animal model to study the mechanism of palate development and pathogenesis of cleft palate, our study has implications for the interpretation and translation of findings to humans.Palate development is commonly studied on coronal sections of embryonic heads that allows researchers to visualize cellular and morphological changes within the palatal shelves and determine mediolateral differences on gene expression during palatal shelf growth, elevation and fusion  occurs more frequently than cleft palate only (CPO) in humans Mossey, . On the Our observations also suggest that fusion of the palatal shelves and nasal septum plays a crucial role for human palate formation, but likely a lesser role in mouse. As fusion between the palatal shelves and nasal septum occurs prior to the fusion of the palatal shelves in humans, this may help to maintain the palatal shelves in the horizontal position that facilitates palatal shelf contact before fusion. Moreover, the extended fusion of the palatal shelves and nasal septum along the AP axis in humans could functionally separate the nasal and oral cavities even in the absence of palatal shelf fusion. This may explain the occurrence of unilateral cleft palate (in association with cleft lip) in humans as the palatal shelf on the unaffected side could be held in the horizontal position through the fusion with the nasal septum Sperber, .The soft palate is the most posterior part of the secondary palate and consists of several muscles that are important for breathing, swallowing and speech (Grimaldi et al., While closure of the soft palate in mice is mediated by palatal shelf fusion (Walker and Fraser, KY and TC conceived the study. All the mouse work was performed by KY. Coordination, collection and histological sectioning and staining of human conceptal tissues was performed by MD and TN. OPT and microCT imaging and analyses were conducted by TC. Coordination, oversight and management of the research was conducted by KY, TC, and IG. The manuscript was written by KY and TC.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background. Surgical approaches to the parapharyngeal space (PPS) are challenging by virtue of deep location and neurovascular content. Juvenile Nasopharyngeal Angiofibroma (JNA) is a formidable hypervascular tumor that involves multiple compartments with increase in size. In tumors with extension to parapharyngeal space, the endonasal approach was observed to be inadequate. Combined Endoscopic Endonasal Approaches and Endoscopic Transoral Surgery (EEA-ETOS) approach has provided a customized alternative of multicorridor approach to access JNA for its safe and efficient resection. Methods. The study demonstrates a case series of patients of JNA with prestyloid parapharyngeal space extension operated by endoscopic endonasal and endoscopic transoral approach for tumor excision. Results. The multiport EEA-ETOS approach was used to provide wide exposure to access JNA in parapharyngeal space. No major complications were observed. No conversion to external approach was required. Postoperative morbidity was low and postoperative scans showed no residual tumor. A one-year follow-up was maintained and there was no evidence of disease recurrence. Conclusion. Although preliminary, our experience demonstrates safety and efficacy of multiport approach in providing access to multiple compartments, facilitating total excision of JNA in selected cases. JNA is a hypervascular benign neoplasm known for its peculiar local aggressive spread along the pathways of least resistance. This tumor is of considerable scientific interest due to its vascularity and high incidence of recurrence. Numerous open surgical approaches have been employed traditionally, based on the tumor extensions, like transpalatine, lateral rhinotomy, midfacial degloving, and neurosurgical approaches in cases with intracranial extension . The mulThe adoption of endoscopes in surgery for the resection of JNA came in vogue in the late 1990 and thereafter evolved rapidly . The advThe parapharyngeal extension is a surgical challenge due to its vicinity to neurovascular structures. The endonasal approach was observed to be inadequate for total control of the inferolateral part of the lesion . Thus, cEhrlich first described the transoral approach to the parapharyngeal space in 1950 but concluded to discourage this approach due to complications . In 2010In this study we present our experience of two cases of JNA with prestyloid parapharyngeal space involvement, surgically managed by an alternative approach to the parapharyngeal space, a combined endoscopic endonasal approach (EEA), and endoscopic transoral approach (ETOS) ensuring complete resection. The advantages and limitations of this technique were evaluated.A retrospective analysis of two patients of JNA operated on in 2015 at our center by combined multiport EEA and ETOS was conducted. Local ethical committee approved the study. Any extension to the poststyloid compartment of the parapharyngeal space was excluded from the study.The patients were subjected to a thorough preoperative workup, which included history taking and detailed examination including cranial nerve function, endoscopic examination, and Contrast Enhanced Computed Tomography (CECT) of paranasal sinus and oral cavity. The CECT was analyzed closely for the extent of tumor, parapharyngeal compartment involvement, skull base erosion, and vicinity to neurovascular structures. A Digital Subtraction Angiography ruled out the presence of any feeders from the parapharyngeal part of internal carotid artery or any aberrant anastomosis. No embolization procedures were done in any of the patients.The patients were fully informed about the details of the planned surgical procedure, complications, and chances of resorting to an open procedure in case of inadequate control. They were also counseled about the advantages and drawbacks of the possible alternative therapies. A written informed consent was obtained from all the patients. A single experienced skull base surgeon performed surgical procedures.Postoperatively the hospital stay was around 1 week. Prophylactic IV antibiotics were administered and nasogastric feeding was initiated to allow faster healing of oropharyngeal wounds. Special attention was paid towards maintaining optimal oral hygiene, apart from routine postoperative care. Nasal packing was removed after 36 hours and saline douching was advised. A surveillance CECT scan was done after 36–48 hours to confirm no residual tumor. A monthly follow-up with endoscopic nasal and oral examination was done for two months and then every six months. The surveillance scan was done after one year to evaluate for any recurrence.The surgery was performed under controlled hypotension using four-handed binostril endoscopic technique. Navigation system was installed for anatomical orientation during the surgery. Rod lens endoscopes  with 0-degree lenses coupled to a high-definition camera and monitor  gave excellent visualization during the surgery. The control of the external carotid artery was performed in the neck on the same side by ligating it to devascularize the tumor.On the basis of tumor extension an intraoperative surgical trajectory was selected to provide maximal exposure with minimal invasiveness. The principle of centripetal approach was employed for complete exposure of the tumor before resection. The nasal part of the tumor was debulked by segmental and piecemeal resection to increase access and surgical maneuverability in mobilizing the distal part of the tumor. Four-handed technique ensured good visibility of surgical field and identification of the tumor planes for dissection.The surgical procedure can be divided into 3 steps, tailored according to the tumor extensions.(1) Transnasal Approach. Modified endoscopic Denker's procedure was performed to provide adequate exposure. Using a knife, under endoscopic guidance, an incision was placed on the anterior edge of the pyriform aperture. Freer's elevator was then used to elevate a flap in the subperiosteal plane to expose the anterolateral wall of the maxilla. The superior limit of the exposure was up to the infraorbital nerve. Care was taken not to injure the nerve during the dissection. Using a 4 mm cutting burr the anterolateral wall of the maxillary sinus was drilled. The nasolacrimal duct was exposed and transected. The exposure of the bone medially was done posteriorly till the level of the junction of the palatine bone and the medial pterygoid plate in which the descending palatine neurovascular bundle was located and cauterized. Laterally posterior wall of maxilla is removed till the lateral most extend of the tumor. Posterior septectomy was performed. The tumor in the nasal cavity was debulked to increase space for instrumentation. Bilateral ethmoidectomy and sphenoidotomy was done using a microdebrider to achieve control of the posterior most extent of the tumor.(2) Transoral Approach. A Boyle Davis mouth gag was inserted to expose the soft palate. The tumor bulge was identified and an incision was placed over it. The mucosa, submucosa, and fibers of superior constrictors were dissected to expose and visualize the tumor (he tumor . The tumhe tumor . With cohe tumor . The tumhe tumor  and 5. T(3) Transpterygoid Approach. The tumor in the infratemporal and sphenoidal part was mobilized. Posteriorly its attachment to buccopharyngeal fascia in nasopharynx was dissected. The tumor was debulked in front of the pterygoid wedge to get access to the cancellous bone of the greater wing of sphenoid. The pterygoid wedge was drilled using a diamond burr and the residual tumor was cleared until the vidian nerve was identified. The clinical report of each case is described in detail.A 21-year-old male patient presented to our Out Patient Department (OPD) with complaints of right sided nasal obstruction and intermittent epistaxis of 3 years duration. Endoscopic examination revealed a smooth fleshy mass occupying the right nasal cavity extending up to the external nares. A CECT scan of the paranasal sinuses revealed a homogenous mass, contrast enhancing, occupying the right nasal cavity, sphenoid sinus, pterygopalatine, and infratemporal fossa with deep extensions into the prestyloid upper parapharyngeal space laterally and skull base superiorly . SurgeryAn 18-year-old male patient presented to our OPD with complaints of right sided progressive nasal obstruction and headache of 2-year duration. Endoscopic findings were consistent with that of a fleshy nasal mass in the right nasal cavity. MRI scan revealed an enhancing mass lesion in the right nasal cavity, pterygopalatine, and infratemporal fossa with lateral extension into the parapharyngeal space . The patDetails of both cases have been summarized in With the introduction of endoscopes, both purely endoscopic and endoscope-assisted resections of JNA have proved to be safe and efficient techniques . The useThe tumor spreads along the paths of least resistance and extends into multiple compartments such as parapharyngeal and intracranial space. Most of these areas can be easily accessed by endoscopic approaches; however the surgical access to the inferolateral part of tumor in parapharyngeal space is beyond limits of endoscopic transnasal surgery, posing a surgical challenge. In such cases the surgeon often has to resort to open approaches.Many surgical approaches to the parapharyngeal space have been described in literature; the most commonly employed are transcervical, transparotid, transmandibular, and infratemporal approaches or a combination of these . HoweverGoodwin and Chandler first described the transoral approach to parapharyngeal space in 1988 . The advHowever along the years, advances in surgical techniques and instrumentation have made the transoral route an acceptable choice for small tumors in prestyloid compartment . The incDallan et al. first gave a step-by-step detailed description of the transoral access. They concluded that it is an excellent surgical window which provides great exposure for resection of parapharyngeal space lesions . Turri-ZRecently several authors have described Transoral Robotic Surgery (TORS) as a viable approach for resection of neoplasms of the parapharyngeal space with minimal morbidity. However this novel approach needs further evaluation . The limIn this study we applied these principles of EEA-ETOS to our carefully selected cases of JNA with parapharyngeal space involvement. We understand that this approach can be applied only with proper planning by experienced surgeons who can convert to an open approach when the need arises. We did not go for preoperative embolization as in our opinion it carries the risk of complications with increased procedural morbidity. It is also reported that surgical manipulation of tumor increasing chances of residual and recurrent disease . Lloyd eTwo surgical trajectories provided best exposure to both nasal and parapharyngeal parts of the tumor. In the transnasal corridor, modified Denker's approach provided lateral access up to infratemporal fossa. Posterior septectomy and ethmosphenoidectomy gave access to nasopharyngeal and sphenoid part of tumor. We also routinely drill the pterygoid wedge to ensure complete removal.The 4-handed technique with 2 experienced surgeons allowed for the use of four hands in the operating field, considerably improving visualization and reducing the surgical time. Endoscopes provided magnified view of the parapharyngeal space, allowing for safe dissection in correct plane under direct vision and preventing any unwanted injury to the surrounding neurovascular structures.It was observed that a combined endonasal and transoral approach gave a good control of the tumor and allowed for complete resection under direct visualization. Also the total obviation of an open approach led to less blood loss, faster healing, and less morbidity and scarring. Avoidance of osteotomies in young patients helped in preventing disruption of the growing bony centers.The rarity of JNA is evident from its low incidence of 0.4 cases per million and very few cases fit the inclusion criteria. The small number of patients, short follow-up, and the lack of control group are drawbacks of this study. The aim of our paper is to demonstrate use of multiport approach to enable individualized access to multiple compartments of JNA to facilitate its safe and efficient excision. The illumination and magnification provided by endoscopes render these techniques superior to external approaches in selected cases. This technique provides safe and effective alternative to both open approaches and TORS in selected cases.The advent of endoscopic approaches for the skull base has paved the way for minimally invasive surgeries in complex lesions. Creating auxiliary surgical corridors can widen the limited trajectories to deep lateral areas. A total endoscopic approach has several obvious advantages over the open approaches that have been employed traditionally. The evolution of multiport approaches is a new dimension in management of complex skull base lesion with parapharyngeal extension. The concept of multiport surgery can provide a safe strategy for resection of selected case of benign and malignant lesions of skull base.


In vitro assays using these compounds appear to show good dissociation. However, in vivo, the dissociation appears to be lost and these compounds still produce many of the side effects associated with conventional GCs. A better understanding of the molecular mechanisms behind GC-induced effects would allow the design of novel selective GR modulators with an improved therapeutic index.Glucocorticoids (GCs) are some of the most important drugs in clinical use today. They are mainly used to suppress disease-related inflammation and are widely used for the treatment of many inflammatory diseases including asthma and arthritis. However, GCs are also associated with debilitating side effects that place limitations on the long-term use of these drugs. The development of a GC with reduced side effects would allow more effective treatments for patients who require long-term suppression of inflammation. GCs exert their effects by binding and activating the GC receptor (GR). The activated receptor then binds GC response elements (GREs) in the promoter of genes, and activates transcription (transactivation) or interferes with the activation of transcription by inhibiting the transactivating function of other transcription factors, such as AP-1 and NF-ĸB (transrepression). Transrepression is believed to be responsible for the majority of the beneficial anti-inflammatory effects of GCs, whereas transactivation is believed to play a bigger role in the unwanted side effects of GCs. Compounds that can dissociate the transactivation function of GCs from the transrepression function may, therefore, have an improved therapeutic index. A number of these dissociated corticosteroids have been developed.


Although Central Giant Cell Granuloma (CGCG) is a benign tumor of the jaw and aneurysmal bone cyst seen in children, its aggressive behavior causes extensive loss of hard tissue requiring wide excision and extensive rehabilitation. We report a rare case of concomitant CGCG and aneurysmal bone cyst in a two-year-old male child, involving the coronoid and condylar process. Young age, large tumor, its aggressive nature, and future growth of orofacial region pose a significant challenge in the management of such conditions. For a successful outcome, the systematic approach to the presurgical evaluation and appropriate treatment planning is essential for such conditions. Bony pathology in the region of head and neck in children is often seen as a morbid prognostic value. Since most of the lesions erode the jaws leading to disfigurement, or otherwise, the growth potential in children exaggerates the recurrence of the lesions.Central Giant Cell Granuloma (CGCG) is a benign tumor of the jaw seen in children and young adults. CGCG accounts for approximately 7% of all benign tumors of the jaws; however, the aggressive nature of the lesion causes resorption of the tooth and bone in the area of the lesion leading to massive destruction of the bone, displacement of the erupted tooth, and germs of the unerupted tooth , 2. It iAneurysmal bone cysts (ABC) are expansile osteolytic blood-filled cystic lesions seen commonly in the mandible . FemalesWide excision of the aggressive lesion is the time-tested treatment modality in bony lesions of the jaw because of recurrence, but they usually disfigure the patients face. Rehabilitation following excision can also be challenging given the dynamic changes concerning growth of orofacial region occurring in the children. Hence the management of aggressive tumors of the jaw in children needs to be a continuous process with regular timed intervention keeping growth in the mind. The aim of this article is to report a rare case of concomitant CGCG and ABC in a two-year-old male child in the posterior region of the lower jaw.A two-year-old male child presented with a unilateral swelling on the right side of the face. The patient's mother noticed the swelling four months back, and since then the lesion had been progressively increasing in size. There was no history of trauma, trismus, fever, or familial history of a musculoskeletal disorder associated with the appearance of this swelling. On extraoral examination, the diffuse swelling was present with posterior region of the right side of the lower third of the face. Overlying skin was normal in color and texture with no signs of local inflammation . On palpLaboratory investigations revealed normal serum values of calcium, phosphorus, urea, creatinine, and PTH. Alkaline phosphatase values were marginally raised. Screening radiographs for chest ribs and skull bones did not reveal the presence of such similar radiolucent lesions. On performing an ultrasonography, normal glandular echotexture and multiple benign upper deep cervical lymph nodes were noted bilaterally.Contrast enhanced CT scan showed large multiloculated expansive lesion measuring 4.2 cm anteroposteriorly, 3.5 cm mediolaterally, and 4 cm superoinferiorly, arising from right ramus of mandible extending to involve coronoid and condylar processes. Images showed uniform expansion resulting in the ballooning of the mandibular ramus Figures . The infThe hematoxylin and eosin stain (H&E stain) section revealed a highly cellular stroma comprising abundant multinucleated giant cells, plump spindle cells, and stromal mononuclear cells. The multinucleated giant cells were diffusely distributed throughout the stroma with areas of hemorrhage, few chronic inflammatory cells, and many dilated RBC filled capillaries. Cysts-like spaces were also evident in certain areas which were lined by cellular connective tissue wall suggesting both Central Giant Cell Granuloma and aneurysmal bone cyst-like appearance Figures . AlthougWith the histopathological diagnosis, the resection of right ramus condylar unit of mandible followed by reconstruction with costochondral grafting was planned. The surgical intervention includes curettage or wide excision depending on the nature and behavior of the lesion. The decision of resection was taken given the extensive bony involvement and multiple cortical bone perforation. In our case, since the lesion showed multiloculated radiographic appearance and was aggressive in nature surgical resection was planned over curettage to avoid recurrence.A seven-centimeter-long extraoral submandibular incision was given along the neck crease. By layered sharp and blunt dissection, the inferior border of the mandible was exposed. Upon reflecting masseter and the periosteum, the surgically exposed bone showed ballooning and had a brownish hue. The inferior border of the angle of the mandible and ramus were involved. The bony lesion was resected, into healthy bony limits . Dark reThe behavior of the lesion is a critical factor in deriving a diagnosis of swelling seen in head and neck region in children. If one can categorize the swellings into groups based on the site of lesion, progression, and onset and duration of swelling, then a correct differential diagnosis can be obtained . An acutThe fibroosseous diseases of the jaws represent a diverse group of entities. They commonly include lesions of primary or secondary hyperparathyroidism, fibrous dysplasia including cherubism, Central Giant Cell Granuloma, and aneurysmal bone cyst. The histopathological findings of these lesions may be remarkably similar, and hence they have to be differentially diagnosed by the clinical and radiographic presentation.The clinical presentation of bony hard swelling with normal overlying skin color and normal cutaneous and subcutaneous echotexture on ultrasonography do not favor the diagnosis of neurofibroma, hemangioma, lymphangiomas, and vascular malformation. Certain intraosseous variants of vascular malformation and hemangiomas are reported; the radiographic presentation of multiloculated “soap bubble appearance” as seen in our case does not coincide with such intraosseous lesions of vascular origin. The absence of any intraoral infectious foci rules out osteomyelitis or similar chronic infectious lesions. The normal values of serum calcium, phosphorus, and alkaline phosphatase along with unilateral presentation indicate that the lesion was not cherubism or fibrous dysplasia.Probable diagnosis of Central Giant Cell Granuloma (CGCG) can, therefore, be derived by sequentially ruling out another differential diagnosis. Radiographic “ballooning” of the ramus of mandible and “soap bubble appearance” further support the possible diagnosis. CGCG is predominantly found in children and young individuals but has not been commonly reported in a child as young as our patient. The coronoid and condylar process is rarely involved by the lesion . The hisThe conventional treatment of lesions like CGCG or ABC of the jaw bones is surgical excision either by curettage or en bloc resection depending on the behavior (aggressive or nonaggressive), location, the size of the lesion, and radiographic appearance . Other tWhen conservative options like Denosumab are used a complete response is rarely obtained; hence additional surgery becomes necessary to remove the tumor in case of tumor progression, to remove a remnant, or to remodel bone. Moreover, these drugs have frequent local or systemic side effects such as osteonecrosis and growth deficiencies –13.Because of high recurrence rate of up to 70% after local curettage wide excision of the lesion is preferred as the choice of treatment , 14. A rThe recent follow-up of our case revealed spontaneous regeneration of bone. It is an interesting finding to report since only a few reports exist on the spontaneous regeneration of bone after surgical resection of jaw lesions , 19. It Usually CGCG and ABC are seen with higher female predilection but in our case, it was seen in a very young boy and in unusual site with involvement of coronoid and condylar process. Proper histopathological examination and radiographic examination are much essential in establishing an accurate diagnosis, as in our case histopathological examination reported the presence of an aggressive case of concomitant CGCG and aneurysmal bone cyst. With this kind of unusual presentations, the clinician should always bear differential diagnosis in mind while examining bony swelling in head and neck region in children. With the evidence of spontaneous regeneration of resected portion of the mandible in our case, we suggest that when considering reconstructive options in such aggressive lesion of the jaw in children one must keep the host's growth potential in mind.


Recognition and matching of litchi fruits are critical steps for litchi harvesting robots to successfully grasp litchi. However, due to the randomness of litchi growth, such as clustered growth with uncertain number of fruits and random occlusion by leaves, branches and other fruits, the recognition and matching of the fruit become a challenge. Therefore, this study firstly defined mature litchi fruit as three clustered categories. Then an approach for recognition and matching of clustered mature litchi fruit was developed based on litchi color images acquired by binocular charge-coupled device (CCD) color cameras. The approach mainly included three steps: (1) calibration of binocular color cameras and litchi image acquisition; (2) segmentation of litchi fruits using four kinds of supervised classifiers, and recognition of the pre-defined categories of clustered litchi fruit using a pixel threshold method; and (3) matching the recognized clustered fruit using a geometric center-based matching method. The experimental results showed that the proposed recognition method could be robust against the influences of varying illumination and occlusion conditions, and precisely recognize clustered litchi fruit. In the tested 432 clustered litchi fruits, the highest and lowest average recognition rates were 94.17% and 92.00% under sunny back-lighting and partial occlusion, and sunny front-lighting and non-occlusion conditions, respectively. From 50 pairs of tested images, the highest and lowest matching success rates were 97.37% and 91.96% under sunny back-lighting and non-occlusion, and sunny front-lighting and partial occlusion conditions, respectively. Litchi is one of the most popular fruits. The average annual yield of litchi in China was about 1.45 million tons during the last decade [Multiple fruit harvesting robots have been developed by researchers ,4,5,6,7.In order to overcome the influences caused by the natural environment such as varying illumination, random occlusion and color similarity, many studies have been reported by resreachers, which analyzed fruit images acquired by using cameras integrating vision sensors for the recognition and localization of fruit. However, there has not been an ideal method yet. Bulanon et al.  used a tDirect analysis of fruit color images acquired using a much less expensive red-green-blue (RGB) color camera may be a more feasible method for fruit detection and fruit harvesting robot development. Numerous articles focused on RGB color image analysis-based detection algorithm of fruit. Rajendra et al.  proposedK-means clustering. Although the highest average recognition rates for non-occluded and partially occluded litchi were 98.8% and 97.5%, respectively, the recognition method was based on red color component extraction, which did not take into account various characteristics of litchi such as texture features and clustered growth.It is clear from the above fruit detection approaches that fruit detection based on analyzing RGB color images is challenged by varying illumination and occlusion conditions. In the case of litchi fruit detection using color images, Xiong et al.  proposedFrom the above, we see that current color image analysis-based studies for mature litchi detection in the natural environment have focused on color-based segmentation, whose main aims were to identify the mature litchi targets for the litchi harvesting robot ,20,21. HIn the case of fruit matching using color images, Jian et al.  proposedInspired by fruit recognition based on the color image segmentation methods, the machine learning methods and the fruit matching methods, this paper mainly focused on the combination of the three methods to find a robust method for recognition and matching of clustered mature litchi fruits. In the litchi orchard, varying illumination, random litchi growth such as clustered growth with the uncertain number of the fruit and random occlusion by leaves, branches and other fruits make the robustness of unsupervised machine learning methods difficult. Therefore, in order to eliminate the influences caused by complicated environments and improve the detection rate of litchi fruits in the orchard, a method of recognition and matching of clustered mature litchi fruits was developed based on litchi color images acquired by binocular CCD color cameras. Firstly, after calibration of binocular color cameras, litchi image acquisition was carried out under litchi orchard conditions. Due to the randomness of litchi growth, such as clustered growth with the uncertain number of fruits, the mature litchi fruit clustering patterns were manually defined as three categories by analyzing litchi growth. They were single litchi fruit (category A), two clustered litchi fruits (category B) and multiple clustered litchi fruits (category C). They were also the most common cases of clustered litchi fruits. By defining the three categories, recognition and matching can be easily implemented. Secondly, litchi fruits and non-fruits were manually cropped from litchi images. Four different kinds of classifiers were trained by using the features of litchi fruits and non-fruits. After combining the classification results of the four classifiers, a pixel threshold method was presented for recognizing the pre-defined categories of clustered litchi fruit. Finally, a geometric center-based matching method was proposed for matching the recognized clustered litchi fruit.As shown in In order to determine the parameters of the cameras and obtain real-world coordinates, camera calibration is a necessary process. In a binocular vision system, the aim of the binocular calibration is to calculate the relative positional relationship between the two cameras, that is, to obtain the rotation matrix  cameras . For eacAfter calibrating the cameras, litchi color images from the orchard under sunny and cloudy daylight conditions were obtained.As shown in Single litchi fruit (category A): If the Euclidean distance between the geometric center of one litchi fruit and the geometric center of any other litchi fruit is greater than the average diameter of the single litchi fruit , the litchi fruit will be defined as the single litchi fruit like A region;Two clustered litchi fruits (category B): If the Euclidean distance between the geometric centers of only any two litchi fruits is smaller than the average diameter of the single litchi fruit , the litchi fruits will be defined as the two clustered litchi fruits like B region;Multiple clustered litchi fruits (category C): If the Euclidean distance between the geometric centers of more than two litchi fruits is smaller than the average diameter of the single litchi fruit , the litchi fruits will be defined as the multiple clustered litchi fruits like C region.Shape, color, and texture-based analyses are usually used to detect fruits in a color image . As showThe litchi color images were transformed from RGB color space to HSI color space, YCbCr color space and L*a*b color space. By extracting color components of each color space, the color difference between the litchi fruits and background  was contrasted by using the visual evaluating methods as shown in Naive Bayes classifier, KNN classifier, artificial neural network and SVM classifier are supervised learning techniques, which are most commonly used for automatic classification . TherefoNaive Bayes classifier is a simple probabilistic classifier based on applying Bayes theorem with strong independence assumptions, which can predict the probability that a given sample belongs to a certain category. The training and classification processes using naive Bayes classifier for mature litchi fruit recognition are as follows. We used a 40 × 40 sub-window to slide on the image for searching the fruit, and use the posterior probability shown as Equation (3)  to judgeThe KNN is used to test the degree of similarity between documents and k training data, and to store a certain amount of classification data, thereby determining the category of test documents. This method is an instant-based learning algorithm that categorizes objects based on closest feature space in the training set. The training and classification processes using the KNN classifier for mature litchi fruit recognition are as follows. We set tion (4)  to measuArtificial neural network is a description of the first order characteristics of the human brain system, which is a mathematical model consisting of many simple parallel processing units. In this study, we selected BP neural network as the artificial neural network classifier. The training and classification processes by using the BP neural network for mature litchi fruit recognition are as follows. BP neural network with three layers was applied and 3 × 3 neighbor pixels with feature tion (5) .(5)J=m+SVM is one of the discriminative classification methods which are commonly recognized to be more accurate. The SVM classification method is based on the structural risk minimization principle from computational learning theory. The training and classification processes using the SVM for mature litchi fruit recognition are as follows. We used vectors equation .(6)cj={The construction and training of these classifiers using the features of litchi fruit and non-fruit are described below. We set feature vector After segmenting the original litchi color image a using ti indicated the number of circle centers and the value of j ranged from 1–4, which indicated the number of the four vertices of the corresponding minimum circumscribed rectangle. Therefore, the Euclidean distance between any two circle centers was calculated. Compared to the preset threshold (40 pixels) stated in If the Euclidean distance between one circle center and the center of any circle was greater than the threshold, the litchi fruit represented by the circle would be categorized as a single litchi fruit. The coordinates of its circle center and four vertices of its label would not change.If the Euclidean distance between the centers of only any two circles was smaller than the threshold, the litchi fruits represented by the two circles would be categorized as two clustered litchi fruits. The coordinates of their circle centers were deleted. The labels were combined into a large label, whose four vertices were the minimum and maximum abscissas and the minimum and maximum ordinates of the two labels.If the Euclidean distance between the centers of more than two circles was smaller than 40 pixels, the litchi fruits represented by the circles would be categorized as multiple clustered litchi fruits. The coordinates of their circle centers were deleted. The labels were combined into a large label, whose four vertices were the minimum and maximum abscissas and the minimum and maximum ordinates of all the labels.Based on the label extraction of mature litchi fruits in the previous section, the coordinates of the center of each circle and four vertices of the label were stored as Using the above process, the categories recognition of clustered litchi fruit based on the pixel threshold were completed as shown in Matching based on binocular stereo vision was the process that searched for the corresponding point of left image in the same image scene in the right image. This search process could be seen as a template matching process. CHT-based matching method has been applied in fruit matching ,27. HoweY values of coordinate of the matching points in the two images were equal. Therefore, matching in the different rows should be discarded. Furthermore, by triangulation, if the baseline is shorter, both the position of litchi in the left and right images will be more consistent, which makes the matching of features easier. The shorter baseline will also make distance measurement errors larger. We fixed the baseline at 200 mm in this study.A sub-window was the minimum circumscribed rectangle of clustered litchi fruit contour, and its sides were parallel to the Using the above sections, clustered litchi fruit matching result was shown in Missed single litchi fruit: If the recognized fruit was less than 25% of the actual fruit in the category of single litchi fruit, the single litchi fruit would be considered as the missed single litchi fruit;Missed two clustered litchi fruits: If there were one or two recognized fruits less than 25% of the actual fruits in the category of two clustered litchi fruits, the two clustered litchi fruits would be considered as the missed two clustered litchi fruits;Missed multiple clustered litchi fruits: If there were two or more recognized fruits less than 25% of the actual fruits in the category of multiple clustered litchi fruits, the multiple clustered litchi fruits would be considered as the missed multiple clustered litchi fruits.In order to illustrate the performance of the proposed recognition algorithm of clustered litchi fruit under natural environmental conditions, litchi color images were captured under sunny front-lighting conditions, sunny back-lighting conditions and cloudy day conditions, which were shown in Therefore, true positive rates, false positive rates, false negative rates, precision, recall and F1 of the proposed method under three different illumination and two kinds of occlusion conditions are shown in The matching result of single litchi fruit based on CHT seen from By comparison, 93.75% of the total numbers of the clustered litchi fruits were successfully matched under six different conditions by using the proposed method. The highest matching success rate was 97.37% under sunny back-lighting and non-occlusion conditions. The lowest matching success rate was 91.96% under sunny front-lighting and partial occlusion conditions. The matching success rates were 96.00%, 95.15%, 92.66% and 93.33% under other conditions. The time consumed by the proposed algorithm mainly occurred during clustered litchi fruit extraction and clustered litchi fruit matching based on the geometric centers of the fruit label. The time consumed by the extraction of clustered litchi fruits mainly occurred during searching the fruit regions based on the four different classifiers, and the total average time of processing which achieved 1092 ms. Moreover, traversing the label template of the clustered litchi fruit of the left image into the right image to search for the optimal matching window based on the normalized cross-correlation similarity measure function cost time; the average processing time for a pair of images was 1364 ms. However, the proposed method of clustered litchi fruit label extraction operating on the binary image consumed few time. The average time consumed from the extraction of clustered litchi fruit to fruit localization was 2536 ms.To recognize and match mature litchi fruit under natural environment, the fruits firstly were categorized into three categories of clustered fruits. Then, four different classifiers were used to extract mature litchi fruits from the litchi color images, respectively. By combining the results, a pixel threshold method was proposed for the recognition of the clustered litchi fruit, which could take advantage of the four classifiers and weaken the effect of varying illumination and occlusion on fruit recognition. The litchi fruits in the orchard under different lighting conditions were tested by combining the recognition results of the four different classifiers and the label extraction method of the clustered litchi fruit. The experimental results demonstrated that the method could well identify the clustered litchi fruit from background . The performance tests of the fruit recognition method indicated that the method could partly account for the robustness against the influence of the varying illumination and occlusion. Based on the successful fruit recognition, a clustered litchi fruit matching method based on a geometric center of the cluster label was proposed, which could not only utilize the regular graph advantages of the label in matching, but also avoid mistaken matching disadvantages of the single litchi under occlusion conditions. The experimental results implied that the proposed matching method could obtain more accurate matching result than the result of single litchi matching obtained by using CHT. From the interactive performance of the developed approach in the tests, the average processing time from the extraction of clustered litchi fruit-to-fruit matching was 2536 ms, so it could meet the requirements of harvesting robots [However, there were still some shortcomings of the developed method. First, when the illumination intensity in the orchard changes dramatically, the color and texture of the acquired litchi color images will inevitably change. Although the training samples of the constructed classifier have included three kinds of different illumination and six primary textures, it could not cover all illumination conditions, so some parts of the pixels may be wrongly classified and recognized. Second, when most of the clustered litchi fruits was occluded, some clustered litchi fruits may not be mistakenly matched. Therefore, further research is needed to improve the matching accuracy of occluded clustered litchi fruit in the orchard. Based on the discussions above, it can be seen that the proposed method can be used for a litchi harvesting robot working in the orchard under natural environment. However, additional research is still needed to improve the recognition and matching rates for satisfying more varied natural environments.(1)The proposed litchi recognition method based on the results of combining the four different classifiers had better recognition results than the results obtained by using single classifier.(2)The proposed method recognized and matched the clustered litchi fruits instead of single litchi fruits, which made the effects of varying illumination and occlusion on fruit recognition much weaker and improved the recognition and matching accuracy.(3)The recognition method was able to automatically separate clustered litchi fruits from background, and the accuracy of the classifications could achieve 94.17% under sunny back-lighting and partial occlusion conditions, 91.07% under sunny front-lighting and partial occlusion conditions and 92.82% under natural environment.(4)The highest and lowest matching success rates of clustered litchi fruits of the proposed method were 97.37% and 91.96% under sunny back-lighting and non-occlusion and sunny front-lighting and partial occlusion conditions, respectively, which were superior to single litchi matching using CHT.(5)The interactive performance of the proposed algorithm was investigated, and the average consumed time from the extraction of clustered litchi fruit to fruit localization was 2536 ms, which can meet the requirements of litchi harvesting robots.To comply with the development of fruit harvesting robots, an approach to recognize and match clustered mature litchi fruits under natural environmental conditions was developed in this paper. At the beginning of the approach, mature litchi fruits were categorized into three different categories of clustered litchi fruits based on the distance relationship between fruits. The effective color components of R-B, I, Cb and b*, and six primary texture features, which could well separate the mature litchi fruits from background were extracted, based on which the four different classifiers were built, respectively. To identify the clustered litchi fruits, the result of single litchi recognition using each classifier was converted into a binary image, based on which morphology operation and CHT were implemented for label extraction of the single fruit. Then, the four label extraction results based on the four different classifiers were combined for the final single litchi recognition. Lastly, the recognition of the clustered litchi fruit was accomplished by dividing litchi fruits into predefined categories based on the distance between the geometric centers of the single litchi labels. Finally, based on the successful recognition of clustered litchi fruits, the fruit matching was completed using the label of the fruit in the left image to be a template to traverse the right image to search for an optimal window based on the similarity measure method of normalized cross-correlation. Three experiments were implemented by using the litchi images from the real natural environment, and the results were quantitatively assessed and compared with other corresponding methods. The main results are as follows:In conclusion, the developed approach can effectively recognize and match the harvesting targets under a complex natural environment. However, the accurate recognition of the litchi fruits under sever varying illumination conditions and matching of the fruits under fruit occlusion conditions are still issues that need to be solved and will require further research. To solve these tricky problems, in future research we will consider recognition methods of illumination normalization and the matching methods of fruit occlusion.