Three dimensional study to quantify the relationship between facial hard and soft tissue movement as a result of orthognathic surgery

Introduction Prediction of soft tissue changes following orthognathic surgery has been frequently attempted in the past decades. It has gradually progressed from the classic “cut and paste” of photographs to the computer assisted 2D surgical prediction planning; and finally, comprehensive 3D surgical planning was introduced to help surgeons and patients to decide on the magnitude and direction of surgical movements as well as the type of surgery to be considered for the correction of facial dysmorphology. A wealth of experience was gained and numerous published literature is available which has augmented the knowledge of facial soft tissue behaviour and helped to improve the ability to closely simulate facial changes following orthognathic surgery. This was particularly noticed following the introduction of the three dimensional imaging into the medical research and clinical applications. Several approaches have been considered to mathematically predict soft tissue changes in three dimensions, following orthognathic surgery. The most common are the Finite element model and Mass tensor Model. These were developed into software packages which are currently used in clinical practice. In general, these methods produce an acceptable level of prediction accuracy of soft tissue changes following orthognathic surgery. Studies, however, have shown a limited prediction accuracy at specific regions of the face, in particular the areas around the lips. Aims The aim of this project is to conduct a comprehensive assessment of hard and soft tissue changes following orthognathic surgery and introduce a new method for prediction of facial soft tissue changes.   Methodology The study was carried out on the pre- and post-operative CBCT images of 100 patients who received their orthognathic surgery treatment at Glasgow dental hospital and school, Glasgow, UK. Three groups of patients were included in the analysis; patients who underwent Le Fort I maxillary advancement surgery; bilateral sagittal split mandibular advancement surgery or bimaxillary advancement surgery. A generic facial mesh was used to standardise the information obtained from individual patient’s facial image and Principal component analysis (PCA) was applied to interpolate the correlations between the skeletal surgical displacement and the resultant soft tissue changes. The identified relationship between hard tissue and soft tissue was then applied on a new set of preoperative 3D facial images and the predicted results were compared to the actual surgical changes measured from their post-operative 3D facial images. A set of validation studies was conducted. To include: • Comparison between voxel based registration and surface registration to analyse changes following orthognathic surgery. The results showed there was no statistically significant difference between the two methods. Voxel based registration, however, showed more reliability as it preserved the link between the soft tissue and skeletal structures of the face during the image registration process. Accordingly, voxel based registration was the method of choice for superimposition of the pre- and post-operative images. The result of this study was published in a refereed journal. • Direct DICOM slice landmarking; a novel technique to quantify the direction and magnitude of skeletal surgical movements. This method represents a new approach to quantify maxillary and mandibular surgical displacement in three dimensions. The technique includes measuring the distance of corresponding landmarks digitized directly on DICOM image slices in relation to three dimensional reference planes. The accuracy of the measurements was assessed against a set of “gold standard” measurements extracted from simulated model surgery. The results confirmed the accuracy of the method within 0.34mm. Therefore, the method was applied in this study. The results of this validation were published in a peer refereed journal. • The use of a generic mesh to assess soft tissue changes using stereophotogrammetry. The generic facial mesh played a major role in the soft tissue dense correspondence analysis. The conformed generic mesh represented the geometrical information of the individual’s facial mesh on which it was conformed (elastically deformed). Therefore, the accuracy of generic mesh conformation is essential to guarantee an accurate replica of the individual facial characteristics. The results showed an acceptable overall mean error of the conformation of generic mesh 1 mm. The results of this study were accepted for publication in peer refereed scientific journal. Skeletal tissue analysis was performed using the validated “Direct DICOM slices landmarking method” while soft tissue analysis was performed using Dense correspondence analysis. The analysis of soft tissue was novel and produced a comprehensive description of facial changes in response to orthognathic surgery. The results were accepted for publication in a refereed scientific Journal. The main soft tissue changes associated with Le Fort I were advancement at the midface region combined with widening of the paranasal, upper lip and nostrils. Minor changes were noticed at the tip of the nose and oral commissures. The main soft tissue changes associated with mandibular advancement surgery were advancement and downward displacement of the chin and lower lip regions, limited widening of the lower lip and slight reversion of the lower lip vermilion combined with minimal backward displacement of the upper lip were recorded. Minimal changes were observed on the oral commissures. The main soft tissue changes associated with bimaxillary advancement surgery were generalized advancement of the middle and lower thirds of the face combined with widening of the paranasal, upper lip and nostrils regions. In Le Fort I cases, the correlation between the changes of the facial soft tissue and the skeletal surgical movements was assessed using PCA. A statistical method known as ’Leave one out cross validation’ was applied on the 30 cases which had Le Fort I osteotomy surgical procedure to effectively utilize the data for the prediction algorithm. The prediction accuracy of soft tissue changes showed a mean error ranging between (0.0006mm±0.582) at the nose region to (-0.0316mm±2.1996) at the various facial regions.

Perceptions of climate change, environmental variability and the role of agricultural adaptation strategies by small-scale farmers in Africa: the case of Mwanga district in Northern Tanzania

Abstract The potential impacts of climate change and environmental variability are already evident in most parts of the world, which is witnessing increasing temperature rates and prolonged flood or drought conditions that affect agriculture activities and nature-dependent livelihoods. This study was conducted in Mwanga District in the Kilimanjaro region of Tanzania to assess the nature and impacts of climate change and environmental variability on agriculture-dependent livelihoods and the adaptation strategies adopted by small-scale rural farmers. To attain its objective, the study employed a mixed methods approach in which both qualitative and quantitative techniques were used. The study shows that farmers are highly aware of their local environment and are conscious of the ways environmental changes affect their livelihoods. Farmers perceived that changes in climatic variables such as rainfall and temperature had occurred in their area over the period of three decades, and associated these changes with climate change and environmental variability. Farmers’ perceptions were confirmed by the evidence from rainfall and temperature data obtained from local and national weather stations, which showed that temperature and rainfall in the study area had become more variable over the past three decades. Farmers’ knowledge and perceptions of climate change vary depending on the location, age and gender of the respondents. The findings show that the farmers have limited understanding of the causes of climatic conditions and environmental variability, as some respondents associated climate change and environmental variability with social, cultural and religious factors. This study suggests that, despite the changing climatic conditions and environmental variability, farmers have developed and implemented a number of agriculture adaptation strategies that enable them to reduce their vulnerability to the changing conditions. The findings show that agriculture adaptation strategies employ both planned and autonomous adaptation strategies. However, the study shows that increasing drought conditions, rainfall variability, declining soil fertility and use of cheap farming technology are among the challenges that limit effective implementation of agriculture adaptation strategies. This study recommends further research on the varieties of drought-resilient crops, the development of small-scale irrigation schemes to reduce dependence on rain-fed agriculture, and the improvement of crop production in a given plot of land. In respect of the development of adaptation strategies, the study recommends the involvement of the local farmers and consideration of their knowledge and experience in the farming activities as well as the conditions of their local environment. Thus, the findings of this study may be helpful at various levels of decision making with regard to the development of climate change and environmental variability policies and strategies towards reducing farmers’ vulnerability to current and expected future changes.

From physics to metaphysics: philosophy and style in the critical writings of T. S. Eliot (1913-1935)

This thesis considers Eliot's critical writing from the late 1910s till the mid-1930s, in the light of his PhD thesis - Knowledge and Experience in the Philosophy of F. H. Bradley - and a range of unpublished material: T S. Eliot's Philosophical Essays and Notes (1913- 4) in the Hayward Bequest (King's College, Cambridge University); T. S. Eliot's Family Papers in the T. S. Eliot Collection at the Houghton Library (Harvard University); and items from the Harvard University Archives at the Pusey Library. 'Me thesis offers a comprehensive view of Eliot's critical development throughout this important period. It starts by considering The Sacred Wood's ambivalence towards the metaphysical philosophy of F. H. Bradley and Eliot's apparent adoption of a scientific method, under the influence of Bertrand Russell. It will be argued that Eliot uses rhetorical strategies which simultaneously subvert the method he is propounding, and which set the tone for an assessment of his criticism throughout the 1920s. His indecision, in this period, about the label 'Metaphysical' for some poets of the seventeenth century, reveals the persistence of the philosophical thought he apparently rejects in 1916, when he chooses not to pursue a career in philosophy in Harvard. This rhetorical tactic achieves its fulfilment in Dante (1929), where Eliot finds a model in the medieval allegorical method and 'philosophical' poetry. Allegory is also examined in connection with the evaluation of Eliot's critical writings themselves to determine, for instance, the figurative dimension of his early scientific vocabulary and uncover metaphysical residues he had explicitly disowned but would later embrace. Finally, it is suggested that, the hermeneutics of allegory are historical and it is used here to test the relationship between Eliot's early and later critical writings, that is the early physics and the later metaphysics.

Pressure ulcer management in Oman: nurses’ knowledge and views

Background: Pressure ulcers (PrUs) have a significant impact on health system expenditure and patient’s quality of life. It is a global problem. Many studies were undertaken in regard to PrU prevention and management. In Oman, no studies have been conducted to investigate nurses’ knowledge on prevention and management of PrUs. The purpose of this descriptive sequential explanatory mixed-method study was to explore the nurses’ level of knowledge in relation to prevention and management of PrUs in Oman. Methods: A mixed method design was used and the study was conducted over two Phases. In Phase I, a questionnaire was developed to explore nurses’ knowledge on PrU, policy, and resources. The main section of the questionnaire was the Pieper-Zulkowski Pressure Ulcer knowledge test (PZ-PUKT) which tests the knowledge on PrU. Another two sections were developed including questions about wound policy and resources available for PrU prevention and management in Oman. The questionnaire was distributed to nurses who were working in surgical, medical, orthopaedic, CCU, and ICU wards/units in seven hospitals. In Phase II study, semi-structured qualitative interviews were conducted with 16 of the questionnaire respondents. Interviews took approximately 30 minutes, were recorded and transcribed verbatim. Qualitative data were analysed using the Knowledge, Attitudes and Practice (KAP) model as the a priori framework. Results: In Phase I, 478 questionnaires were analysed. The knowledge test results showed the overall mean percent score for correctly answered questions was 51% suggesting a low level of knowledge. There was a significant relationship between nurses’ knowledge and age (P=0.001) and between knowledge and years of experience (P=0.001) with knowledge increasing with age and years of experience. In Phase II, four themes were identified from the interviews: knowledge, attitude, and practice (framework themes) and perception of role. Findings indicated positive and negative attitudes towards the care of PrUs. Some nurses stated feeling rewarded when they see wounds improving while others said they could not work with patients independently because they lacked the knowledge and the skills needed. There was variation in the management of PrU between hospitals. Both studies indicated that the wound management policy did not include enough information to guide nurses. Conclusion: Overall the nurses’ level of knowledge on PrU was relatively low. Most nurses were not familiar with wound management policy or different PrU prevention and management strategies. Nurses are aware of the risk of PrUs and try their best to manage them with the available resources however more training is required.