Revision temporomandibular joint arthroplasty for the treatment of acquired metal allergy and review of the literature

The purpose of this study was to examine the outcomes of patients who received revision temporomandibular joint (TMJ) arthroplasty for the treatment of acquired metal allergy. It was hypothesized that subjects would have significant improvements in pain, swelling, and function. Patients who underwent TMJ revision due to nickel allergy were identified retrospectively. Outcomes documented included the presence or absence of facial erythema and facial swelling. Maximum incisal opening was also measured. Additional outcomes collected included age at initial surgery, initial TMJ device type, presenting symptoms, and TMJ device used for surgical revision. Four patients were identified with a nickel allergy to their TMJ prosthesis (containing nickel). All subjects experienced pain and swelling as their primary symptoms prior to the revision, with two subjects showing dermatological symptoms of overlying erythema. The four female subjects underwent exchange of their previously implanted prosthesis with a titanium alloy prosthesis. Postoperatively, all subjects showed improvements in pain score, resolution of swelling and erythema, and improvements in maximum incisal opening. This small case series suggests that revision TMJ arthroplasty with a titanium alloy prosthesis is a potential treatment for acquired metal allergy from traditional TMJ prosthesis implantation.

Fetal myocardial performance index in assessment and management of small-for-gestational-age fetus: a cohort and nested case-control study

OBJECTIVE

To assess the clinical utility of the fetal myocardial performance index (MPI) in assessment and management of the small-for-gestational-age (SGA) fetus/growth-restricted fetus (FGR).

METHODS

This was a prospective cohort study in metropolitan Australia of patients referred in the period June 2012 to March 2015 to fetal medicine services at 24-38 weeks' gestation for suspected singleton SGA/FGR (estimated fetal weight (EFW) < 10^th centile with or without abnormal umbilical artery (UA) Doppler) pregnancy. Patients had MPI assessed in addition to routine measures, and were followed through to birth. We compared MPI values against those of a local reference population and gestational age-matched controls, and assessed the correlation with perinatal outcome and other Doppler measures.

RESULTS

Fifty-two cases were included, 38 diagnosed < 32 weeks and 14 diagnosed ≥ 32 weeks. None demonstrated significantly elevated left, right or delta MPI compared with the reference population or with gestational age-matched controls at the time of first MPI evaluation. There were no consistent longitudinal patterns in MPI that would suggest its clinical utility. The mean ± SD gestational age at delivery was 34.6 ± 3.8 weeks and birth weight was 1.7 ± 0.6 kg, and the median neonatal hospital admission time was 27 days, confirming a pathological cohort. There were no significant correlations between left, right or delta-MPI and perinatal outcome, although there were significant correlations between UA, middle cerebral artery (MCA) and ductus venosus (DV) Doppler and perinatal outcome (birth weight, gestational age at birth and length of neonatal hospital stay). Exploratory subgroup comparisons (EFW < 3^rd vs 3^rd -10^th centile; early- vs late-onset; abnormal vs normal UA Doppler) found only minor differences in MPI, reaching statistical, but not clinical, significance, only in the EFW < 3^rd vs 3^rd -10^th centile comparison.

CONCLUSIONS

MPI did not demonstrate clinical utility in either triage or longitudinal follow-up of an SGA/FGR cohort presenting to fetal medicine services. Given that prior research suggesting its utility originates from single-center cohorts, while multicenter, large cohorts have suggested little utility or no additional utility if routine UA/MCA/DV Doppler is performed, publication bias may have affected previous reports. It seems unlikely that MPI has clinical utility in assessment and management of SGA/FGR fetuses. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Indications for delivery in pre-eclampsia

OBJECTIVE

Examine the frequency with which the most accepted indicators for delivery in pre-eclampsia are used in a population with predominantly late-onset (birth > 32 weeks) pre-eclampsia (PE).

METHODS

Retrospective cohort study using the St George Public Hospital (SGH) Hypertension in Pregnancy database. Demographic, pregnancy, and outcome details were extracted and verified by comparison with data collection sheets.

RESULTS

From 2001 to 2013, 908 women (970 babies) with PE were included, of which a subgroup of 303 women (33%) had clearly delineated delivery triggers available. This subgroup of women had similar demographic and outcome characteristics to the total PE population. In this group, the most common maternal trigger for delivery apart from gestational age 37+ weeks was difficult to control/severe hypertension (114 cases, 38%) and the most common fetal trigger intrauterine growth restriction (IUGR: 14 cases, 4%). 78 (35%) of term women had no specific delivery trigger other than gestation. A primary maternal trigger and/or associated complication was slightly more common in those delivering <37 weeks vs 37+ weeks (52 vs 38%, p = .03), while a fetal or combined maternal/fetal complication was over four times more common in preterm women (25 vs 6%, p < .001).

CONCLUSION

In our population of predominantly late-onset PE, maternal triggers for delivery (predominantly severe hypertension) far outweigh fetal triggers (predominantly IUGR). Fetal and mixed indicators for delivery were relatively more common in women delivering preterm, possibly reflecting the severity of placental dysfunction in this subgroup.