Management of a patient with a failed transmandibular implant

The Transmandibular Implant System (TMI) had been developed in order to provide a patient with a severely resorbed mandible with a stable and retensive implant-supported overdenture. Failure of the transmucosal posts may necessitate removal of the transmandibular implant in total and treatment with an implant-supported prosthesis. The purpose of this paper is to describe overcoming failure of a transmandibular implant without removal and synchronous placement of endosseous dental implants in the interforaminal region, providing an implant-retained overdenture to the patient.

CLINICAL RELEVANCE

Transmandibular implants are rarely used nowadays and management of a failed transmandibular implant is reported even less often. Where bone height is adequate, dental implants may be placed in the anterior mandible, even when the failed transmandibular implant is not completely removed.

Detection and quantitation of E. faecalis by real-time PCR (qPCR), reverse transcription-PCR (RT-PCR), and cultivation during endodontic treatment

Enterococcus faecalis is frequently recovered from refractory endodontic infections and has been implicated in endodontic treatment failures. This study compared real-time quantitative PCR (qPCR) assay to cultivation for E. faecalis detection and quantitation during endodontic treatment. A reverse-transcription PCR (RT-PCR) assay was also developed to detect the bacterium clinically in the viable but nonculturable (VBNC) state. Intra-canal samples (n = 87) were collected upon access, post-instrumentation/irrigation and postcalcium hydroxide treatment from 15 primary and 14 refractory infections involving 29 single-rooted teeth, and analyzed by the three methods. The bacterium was up to three times more prevalent in refractory than primary infections at each collection step. Overall, qPCR detected significantly more E. faecalis-positive teeth and samples than cultivation (p < 0.001). VBNC E. faecalis was detected by RT-PCR in four samples that were negative by cultivation. These findings support qPCR and RT-PCR as more sensitive methods than cultivation for detecting E. faecalis in endodontic infections.

Male revision rhinoplasty: pearls and surgical techniques

Male revision rhinoplasty surgery is the most difficult and challenging procedure that facial plastic surgeons perform because males usually have thick nasal skin, which is more difficult to re-support and project the nasal tip, and often have high or unrealistic expectations. The primary etiology for the need for male revision rhinoplasty is a primary rhinoplasty with aggressive lower lateral cartilage reduction that causes tip ptosis and loss of projection. The goal to an aesthetically pleasing revision rhinoplasty is to re-create adequate tip projection and an intact strong tripod complex. Following tip reconstruction, the height and width of the dorsum should be set. For male revision nasal surgery, a clear and thorough knowledge of nasal anatomy, function, and surgical techniques is paramount. Having an extensive preoperative discussion including expectations, outcomes, and a detailed list of potential complications with the patient can prevent physician-patient mis-communication. Prior to surgery, review the examination, previous operative summary, photographs, nasal analysis sheet, problem list, and plan and then proceed with the surgical treatment.

Hemorrhage in the Floor of the Mouth After Second-Stage Surgery: Case Report

Placement of dental implants in the interforaminal region of the mandible is generally considered a routine, simple, and safe procedure. However, severe bleeding and hematoma in the floor of the mouth have been reported as a rare but potentially fatal complication related to the placement of an implant in this region. The following report describes a case of life-threatening hemorrhage in the floor of the mouth after second-stage surgery to place the healing abutment. The implants were forced to match with the prosthesis in a severely atrophic upper jaw, resulting in a perforation of the lingual cortex and mucosa of the floor of the mouth. Clinicians who place implants should be knowledgeable in the treatment of such a serious complication.

Intentional Replantation: A Case Report

Nonsurgical retreatment and surgical endodontics are not always viable solutions to endodontic disease. Access for retreatment may be limited by posts. Surgical endodontics may be limited by anatomical features including bone thickness and nerve and sinus proximity. Anatomical limitations and complex restorations may prevent implant placement. Intentional replantation is considered by many as a procedure of last resort when nonsurgical or surgical endodontics is contra-indicated. The treatment described demonstrates intentional replantation as a procedure to be considered when endodontic procedures or a dental implant are not possible.

Repeated distraction osteogenesis for excessive vertical alveolar augmentation: a case report

In this article, a procedure involving 2-stage alveolar distraction osteogenesis using eccentric distraction devices for the augmentation of resorbed transplanted iliac bone following mandibular tumor resection is presented. A 6-month consolidation period was allowed between the first and second distractions, and endosseous implants were placed 4 months after the second distraction. Computerized tomographic images obtained before the implantation revealed that, 10 months after the first distraction, the bone generated still showed lower density compared with the basal bone, but the bone from both distractions showed enough maturity for implantation. It may be concluded that 2-stage alveolar distraction osteogenesis can be a useful and safe procedure for excessive alveolar lengthening if a sufficiently long consolidation period is allowed.

Representative drug susceptibility patterns for guiding design of retreatment regimens for MDR-TB

BACKGROUND

There is no gold standard on how national tuberculosis programs should design retreatment regimens. Often drug susceptibility testing (DST) is not available for all patients, and representative DST patterns in patient populations are used to guide therapy.

OBJECTIVES

To examine DST patterns in different patient populations based on previous treatment and to estimate the number of effective anti-tuberculosis agents in several retreatment regimens.

METHODS

We reviewed DST results from patients treated with individualized regimens in Peru between January 1998 and July 2004. We stratified patients into four groups based on previous treatment exposure from Group 1 who had failed only one regimen to Group 4 who had failed three regimens. We compared resistance frequencies across the four groups. In Groups 1 and 3, the number of likely effective agents under six possible retreatment regimen scenarios was estimated.

RESULTS

Resistance to second-line drugs was significantly higher in groups with more previous courses of treatment. A few retreatment regimens could be identified that would allow at least 80% of patients to receive at least four likely effective drugs.

CONCLUSION

Because it is associated with resistance frequencies, previous treatment exposure can serve to guide the design of non-individualized MDR-TB regimens.

Endodontic re-treatment or implants: a contemporary conundrum

In recent years, dental implants have become a common alternative in dental care. Of course, not all patients present with clear-cut treatment needs. Treatment planning an endodontically treated tooth that may require re-treatment vs extracting that same tooth and placing an implant may be one such conundrum. Given the disparity between the implant and endodontic re-treatment literature and the relative paucity of data-based results for indications and contraindications of endosseous root-form implants vs endodontic re-treatment, treatment planning can become a complex task. This article presents a few criteria to consider when treatment planning endodontic re-treatment vs extraction and subsequent implant placement. Because treatment planning can become such a complex issue, using all the varied resources of the dental team is imperative.

[Optimization of the method of treatment of chronic viral hepatitis C with pegylated interferon-alfa and ribavirin]

Despite of significant progress in the treatment of chronic hepatitis C after introduction of combination therapy with pegylated form of interferon-a with ribavirin, still overall response rate in HCV genotype-1 infected has been modest. Several teams has been working on modification of therapeutic methods. Optimization of the results is realized by individualization of therapy taking under consideration some known virological and host features. The main trends are following: settlement of optimal period of treatment of infected with HCV genotype-1, applying interferon-induction therapy for non-responders and relapsers at the course of previous treatment, as well as prolongation of therapy-period, and ribavirin-dose increasing. Very important is also looking for optimal predictive-viral parameters in early course of disease.

Effectiveness of rotary and hand files in gutta-percha and sealer removal using chloroform or chlorhexidine gel

The purpose of this study was to assess in vitro the efficacy of nickel-titanium K³ rotary files and hand files for removal of gutta-percha and sealer from obturated root canals using either chloroform or chlorhexidine as solvents. Sixty extracted single-rooted bovine teeth with straight, large canals were prepared, obtured and randomly assigned to 3 groups (n=20). The teeth were stored at 37ºC for 1 month and then the gutta-percha and sealer were removed using different techniques, as follows. Group I: size 3 Gates-Glidden drills plus size 30 hand K-files and Hedström files and chloroform; Group II: K³ NiTi rotary files and chloroform; and Group III: K³ NiTi rotary files and 2% chlorhexidine gel. Radiographs were taken and scanned and the images were digitized. The total area of the canal and the area with remaining obturation material were measured in millimeters using a computed image analysis system (ImageLab). Data were analyzed statistically by one-way ANOVA and Tukey test at 5% significance level. The groups differed statistically (p<0.05) with respect to the average percentage of remaining gutta-percha and sealer, presenting the following sequence of effectiveness (from most to least effective): Group I (15.48%), Group II (28.42%) and Group III (35.96%). The findings of this study showed that, despite the technique used for removal of filling material, none of the retreated canals were completely free of gutta-percha and sealer remnants. The use of stainless steel hand files resulted in a lesser amount of filling debris than the use of nickel-titanium rotary instruments.

Successful retreatment with infliximab in patients with prior severe infusion reactions

Infusion of the antitumor necrosis factor-alpha chimeric monoclonal antibody infliximab can be associated with the development of severe infusion reactions (IR) during retreatment. We present the case of two rheumatoid arthritis patients with a history of severe acute IR to infliximab who subsequently underwent successful infusion using a prophylactic treatment with a combination of H1 and H2 receptor blockers, hydrocortisone, and diphenhydramine.

"Taking in the Waist": Adjusting the Size of a Stented Fontan Fenestration

Early spontaneous closure of a fenestration following Fontan palliation may complicate the postoperative management of such patients. The creation of a fenestration in the catheterization laboratory with an intravascular stent may improve these patients' hemodynamic status. The aim of this study is to present a new technique to reduce the diameter of stented Fontan fenestrations in those patients in whom the stent diameter is functionally made too large.

Treatment Planning Dilemmas Resulting From Failed Root Canal Cases

Endodontics is one of the least forgiving branches of dentistry in terms of treatment success or failure. As a result, re-treatment has become a significant part of today's endodontic practice. In the past, it was felt that surgical treatment with root-end filling would result in the highest degree of success. It has been subsequently demonstrated that microorganisms remaining in the root canal system after treatment were the main aetiological factor in post-treatment disease. Hence, non-surgical orthograde re-treatment has become the treatment of choice. While most authors support this method of re-treatment, some feel the surgical approach is still the best, and others advocate a combination of treatments. While treatment planning may appear to be straightforward, there are many grey areas in actual practice. This paper attempts to show a number of situations where the treatment planning may not be black and white.

Rebuilding core foundations for existing crowns using a custom-made template

This article describes a simple procedure for reproducing the internal contours of existing crowns to rebuild composite core foundations for endodontically treated abutment teeth. In the event of core fracture or recurrent caries under a crown, problems may be encountered when constructing a new dowel and core to retrofit an existing crown to the newly fabricated core. The procedure described in this article involves the use of a custom-made template and plastic foil to fabricate new composite core foundations for existing crowns.

Long-term efficacy and safety of etanercept after readministration in patients with active ankylosing spondylitis

OBJECTIVES

Treatment of ankylosing spondylitis (AS) with the tumour necrosis factor alpha (TNF-alpha) receptor fusion protein etanercept has shown efficacy in patients with active disease in randomized controlled trials (RCTs) for limited periods. The objective of the study was to assess the long-term efficacy and safety of etanercept over 1 yr, including discontinuation and readministration.

METHODS

In this 54-week open observational study, 26 AS patients received 25 mg etanercept subcutaneously twice weekly after several months of discontinuation following a 6-month RCT with the same agent. All patients who developed high disease activity after cessation of etanercept, defined as a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) > or = 4 and pain > or = 4 on a numerical rating scale, entered the study. Standard assessment tools, such as the Bath Ankylosing Spondylitis functional index (BASFI), were used. An intention-to-treat (ITT) and a completer analysis were performed. The results were compared with the baseline values of the open study.

RESULTS

Out of the initial 30 patients, 26 (87%) were eligible for the open extension study after a mean of about 27 weeks. At week 54, 23/26 patients (88%) were still on treatment with etanercept. The ITT analysis showed that 58% (95% confidence interval 39-74%) of the patients achieved a 50% improvement of BASDAI at week 54. According to the Assessments in Ankylosing Spondylitis working group criteria, 8/26 patients (31%) were in partial remission at week 54. Function, metrology and quality of life improved significantly. Only one patient had a serious adverse event that resulted in discontinuation.

CONCLUSIONS

This study shows that treatment with etanercept is efficacious and safe after readministration over 1 yr in patients with active AS not taking DMARDs or steroids.

Management of endodontic failures: case selection and treatment modalities

General dentists should realize that endodontic failures can be retreated successfully, avoiding tooth loss. Retreatment of endodontic failure and initial root canal therapy share similar biologic principles and treatment objectives. The criteria for successful root canal therapy are important factors that must be understood before teeth are retreated. This article demonstrates three retreatment modalities for managing endodontic failures as an alternative to tooth extraction.

[Retreatment strategies for the patients with HCV infection]

Despite recent advances in the treatment of chronic hepatitis C, especially introduction of combined therapy with pegylated interferons with ribavirin, significant number of patients fails to achieve sustained virologic response. Such patients may be divided into relapsers and non-responders.. Pegylated interferon-based retherapy appear to induce sustained response in 40-68% of relapsers and only in 11% of non responders. New therapeutic approaches are needed for treatment of these group of patients. Current retreatment strategies includes administration of pegylated interferon and ribavirin, maintenance therapy with pegylated interferon for prevention of liver fibrosis and daily administration of consensus interferon and ribavirin. In the work the initial results of 3 clinical investigation (HALT-C, EPIC 3 and COPILOT) are presented, in which beneficial efficacy of pegylated interferon in non responders was observed.

Results of a Retrospective Multicenter Trial of the Viatorr Expanded Polytetrafluoroethylene– covered Stent-Graft for Transjugular Intrahepatic Portosystemic Shunt Creation

PURPOSE

To report the results of a multicenter experience with the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt (TIPS) creation in which patency and clinical outcome were evaluated.

MATERIALS AND METHODS

One hundred consecutive patients with portal hypertension, with a mean age of 52 years (range, 22-86 years), underwent implantation of the Viatorr TIPS stent-graft at one of three hospital centers. The indications for TIPS creation were variceal bleeding (n = 81) and refractory ascites (n = 19). Twenty patients had Child-Pugh class A disease, 46 had class B disease, and 34 had class C disease. Eighty-seven patients underwent de novo TIPS placements, with 13 treated for recurrent TIPS stenosis. Sixty-two patients were available for follow-up portal venography and portosystemic pressure gradient (PSG) measurement commencing 6 months after Viatorr stent-graft placement.

RESULTS

The technical success rate was 100%. TIPS creation resulted in an immediate decrease in mean PSG (+/-SD) from 21 mm Hg +/- 6 to 7 mm Hg +/- 3. Acute repeat intervention (within 30 days) was required for portal vein thrombosis (n = 1), continued bleeding (n = 3), and encephalopathy (n = 1). The all-cause 30-day mortality rate was 12%. Two patients developed acute severe refractory encephalopathy, which led to death in one case. New or worsening encephalopathy was identified in 14% of patients. The incidence of recurrent bleeding was 8%. The cumulative survival rate at 1 year was 65%. Sixty-two patients available for venographic follow-up had a mean PSG of 9 mm Hg +/- 5 at a mean interval of 343 days (range, 56-967 days). There were four stent-graft occlusions (6%) and seven hemodynamically significant stenoses (11%), four within the stent-graft and three in the non-stent-implanted hepatic vein. The primary patency rate at 1 year by Kaplan-Meier analysis was 84%.

CONCLUSIONS

This retrospective multicenter experience with the Viatorr stent-graft confirms the preliminary findings of other investigators of good technical results and improved patency compared with bare stents. Early mortality and symptomatic recurrence rates are low by historical standards. The theoretical increase in TIPS-related encephalopathy was not demonstrated. Longer-term follow-up will be required to determine whether the additional cost of the Viatorr stent-graft will be offset by reduced surveillance and repeat intervention.

Treatment of recurrent and advanced stage squamous cell carcinoma of the head and neck

Despite advances in our ability to safely treat patients with recurrent cancer of the upper aerodigestive tract, outcomes for retreatment are generally poor and the first chance to cure these patients remains the best chance. Thorough knowledge of the outlook and options for patients with recurrent disease is also of significance in choosing therapy for patients with newly diagnosed disease. This is especially true for newly diagnosed patients making the choice between surgery and nonsurgical ("organ-sparing") options, who need to know the outlook for salvage surgery, should they recur after radiation with or without concomitant chemotherapy. Salvage surgery is generally the best option for previously irradiated patients who are faced with resectable, recurrent disease. Unfortunately, the results of surgical salvage are generally poor for patients with advanced stage recurrence and for those who recur after treatment of advanced disease. The site of initial and recurrent disease is important. Surgical salvage is most effective for patients with recurrent laryngeal cancer, least effective for recurrent cancer of the pharynx, and is intermediate for recurrence in the oral cavity. Patients choosing nonsurgical treatment for newly diagnosed cancer of the pharynx cannot rely on salvage surgery in the event of recurrence. Reirraditation for patients who have failed initial treatment that included radiation therapy has been used at a number of institutions with some success. Experience using reirradiation with or without concomitant chemotherapy continues to evolve. Palliative chemotherapy is an option for most patients, but response rates are generally poor and of short duration, after failure of initial treatment that includes radiation therapy. The best approach for many patients and families who face advanced recurrent disease is honest but compassionate communication and supportive care with the help of a hospice organization.

Postoperative pain after endodontic retreatment: Single- versus two-visit treatment

OBJECTIVE

The purpose of this clinical study was to determine the effect of 1- or 2-visit root canal treatment on the postoperative pain in the retreatment cases.

STUDY DESIGN

Two hundred eighteen cases that required retreatment were included in the study. Obturated and unfilled canal space and the status of periapical tissues were evaluated according to the PAI index. The patients were subcategorized in regard to the presence or the absence of preoperative pain. Approximately half of each category was treated in 1 appointment. After removing the previous root canal obturation materials and biomechanic preparation of root canals, the teeth in the 1-visit group were obturated at the first appointment by using AH 26 sealer and laterally compacted gutta-percha, and those in the 2-visit group were medicated with calcium hydroxide-chlorhexidine combination and then closed with a temporary filling material. One week after the initial appointment, patients were asked about the occurrence of postoperative pain. The level of discomfort was rated as no pain, mild pain, moderate pain, or severe pain (flare-up). Data were statistically analyzed using the chi-squared and Fischer exact tests.

RESULTS

Eight patients from the 1-visit group and 2 patients from the 2-visit group had flare-ups. There was a statistical difference between the groups (P <.05). Two-visit root canal treatment was more effective in completely eliminating pain than 1-visit treatment of previously symptomatic teeth (P <.05).

CONCLUSIONS

Two-visit endodontic treatment with intracanal medication was found to be effective in reducing postoperative pain of previously symptomatic teeth and decreased the number of flare-ups in all retreatment cases.

Transhepatic embolization of a recanalized congenital hepatic arterioportal fistula with NBCA and coils

Congenital hepatic arterioportal fistula is a treatable cause of portal hypertension. Transarterial embolization is a widely accepted endovascular treatment approach. Here, a case of a recanalized congenital hepatic arterioportal fistula after prior transarterial coil embolization that was successfully treated with percutaneous transhepatic embolization with coils and N-butyl 2-cyanoacrylate is reported. The percutaneous transhepatic approach can be an effective alternative for patients with recanalized hepatic arterioportal fistula who have undergone prior transarterial coil embolization, and N-butyl 2-cyanoacrylate can be used as an embolic material in addition to metallic coils to achieve quick and total occlusion.

A technique to re-establish dose distributions for previously treated brain cancer patients in external beam radiotherapy

Tumor recurrences or new tumors may develop after irradiation of local lesion(s) in the brain, and additional radiotherapy treatments are often needed for previously treated patients. It is critical to re-establish the dose distributions delivered during the previous treatment in the current patient geometry, so that the previous dose distributions can be accurately taken into consideration in the design of the current treatment plan. The difficulty in re-establishing the previous treatment dose distributions in the current patient geometry arises from the fact that the patient position at the time of reirradiation is different from that at the previous treatment session. Simple re-entry of the previous isocenter coordinates, gantry, and couch and collimator angles into the new treatment plan would result in incorrect beam orientations relative to the new patient anatomy, and therefore incorrect display of the previous dose distributions on the current patient anatomy. To address this issue, a method has been developed so that the previous dose distributions can be accurately re-established in the framework of the current brain treatment. The method involves 3 matrix transformations: (1) transformation of beams from machine coordinate system to patient coordinate system in the previous treatment; (2) transformation of beams from patient coordinate system in the previous treatment to patient coordinate system in the current treatment; and (3) transformation of beams from patient coordinate system in the current treatment to machine coordinate system. The transformation matrices used in the second transformation are determined by registration using a mutual information-based algorithm with which the old and new computed tomography (CT) scan sets are registered automatically without human interpretation. A series of transformation matrices are derived to calculate the isocenter coordinates, the gantry, couch, and collimator angles of the beams for the previous treatment in the current patient geometry, and the previous dose distributions are re-established on the current CT images. The method has been proven to be successful and robust.

Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure

PURPOSE

To compare the outcomes of embolotherapy and surgery as salvage therapy after therapeutic endoscopy failure in the treatment of upper gastrointestinal peptic ulcer bleeding.

MATERIALS AND METHODS

Retrospective analysis of 70 cases of refractory peptic upper gastrointestinal hemorrhage was performed. Thirty-one cases were managed with embolotherapy and 39 were managed surgically. Demographic variables, underlying conditions, clinical findings, endoscopic treatment, transfusion requirements before and after alternative therapeutic approach, length of hospital stay, and outcomes including recurrent bleeding, need for surgery after initial alternative treatment, and in-hospital death were recorded.

RESULTS

Patients who received embolotherapy were older (75.2 years +/- 10.9 vs 63.3 years +/- 14.5; P <.001) and had greater incidences of heart disease (67.7% vs 20.5%; P <.001) and previous anticoagulation treatment (25.8% vs 5.1%; P =.018). There were no differences in the rest of the pretreatment variables. No differences were found between the embolotherapy and surgery groups in the incidence of recurrent bleeding (29% vs 23.1%), need for additional surgery (16.1% vs 30.8%), or death (25.8% vs 20.5).

CONCLUSIONS

The lack of differences between these two treatment alternatives, despite the more advanced age and greater prevalence of heart disease in the embolotherapy group, provides support for future prospective randomized studies aimed to evaluate the role of embolotherapy in the management of refractory peptic ulcer bleeding.

The operating microscope and ultrasonics; a perfect marriage

Ultrasonic instruments for endodontic, endo-restorative, and microrestorative procedures are underutilized by restorative dentists. These ultrasonic instruments are useful with traditional visualization (unaided vision or loupes). However, their true worth can best be appreciated in conjunction with microscopic visualization. It is imperative that the reader understand that some of the utilizations described in this article are not recommended unless accompanied by the operating microscope and some level of training.

Asystole during successive electroconvulsive therapy sessions: a report of two cases

Intense vagal discharge often follows stimulus application during electroconvulsive therapy (ECT). Related periods of asystole during ECT have been reported sporadically in psychiatric journals, but to date not in the anesthesia literature. We report here two cases of prolonged asystole that occurred in our facility in spite of the fact that published suggestions for its prevention were followed. With careful monitoring of these patients--including echocardiography for one patient--we document the onset of asystole at the exact time of ECT stimulus application. With these data, we discuss why asystole is likely to result from a direct central pathway rather than via a baroreceptor reflex, and discuss a neuroanatomic pathway potentially responsible for our findings. We also demonstrate that high-dose atropine (0.8 mg) can effectively prevent most cases of asystole in susceptible patients, and that administration of esmolol following cessation of seizures effectively reduces the elevated heart rate without causing asystole or bradycardia.

Effectiveness of tirofiban for failed thrombolysis during acute myocardial infarction

The clinical outcome of 48 consective patients with myocardial infarction who received tirofiban for unsuccessful thrombolysis was compared with that of 48 patients matched for age, gender, and infarct location who did not receive rescue treatment. Those who received tirofiban had more successful reperfusions, and there were few bleeding complications.

Twenty-four vs. forty-eight weeks of re-therapy with interferon alpha 2b and ribavirin in interferon alpha monotherapy relapsers with chronic hepatitis C

BACKGROUND/AIM

Roughly 50% of patients with chronic hepatitis C, who relapsed after a previous monotherapy with interferon alpha, will respond in a sustained fashion to 24 weeks of re-therapy with the combination of interferon alpha plus ribavirin. Whether prolonging treatment duration to 48 weeks will further increase sustained response rates remains ill defined. In this randomised controlled pilot trial we compared the efficacy and tolerability of a 24 week with that of a 48 week course of combination therapy with interferon alpha and ribavirin in interferon monotherapy relapsers with chronic hepatitis C.

METHODS

Interferon alpha monotherapy relapsers with chronic hepatitis C were randomised to receive interferon alpha 2b (3 x 3 MIU sc weekly) and oral ribavirin (1000/1200 mg po daily) for either 24 weeks or 48 weeks. Virological response was evaluated by HCV RNA PCR at week 10 (initial response), at the end of treatment (end of- treatment response) and at the end of 24 weeks follow-up (sustained response). Only patients with negative HCV RNA at week 10 continued treatment. Adverse events were recorded at regular intervals.

RESULTS

Thirty-seven patients were enrolled, 19 (6 females, median age 43) in the 24 week and 18 (5 females, median age 40) in the 48 week treatment arm. Baseline characteristics were similar in both groups. At treatment week 10, 12/19 (63%) in the 24 week group and 14/18 (78%) patients in the 48 week group had lost HCV RNA in serum (p = 0.33). All initial responders remained HCV RNA negative throughout the treatment period. Sustained response rates were 10/19 (53%) in the 24 week group and 13/18 (72%) in the 48 week group (p = 0.31). Three patients discontinued treatment early (two due to moderate adverse events, one due to non-compliance). Dose modifications were necessary in 9 patients, 4 in the 24 week and 5 in the 48 week group for anaemia, neutropenia, nausea and depression, respectively.

CONCLUSION

Prolonging interferon / ribavirin combination therapy in interferon alpha monotherapy relapsers with chronic hepatitis C from 24 to 48 weeks may increase sustained response rates. Larger controlled trials using pegylated interferon alpha and ribavirin in relapsers with chronic hepatitis C seem warranted.

In-stent restenosis

The decrease in restenosis rates compared with conventional angioplasty, stable angiographic results with a subsequent decreased need for urgent or emergency coronary bypass graft surgery, and reliable treatment of acute or threatened closure resulting from conventional angioplasty have all made stents the treatment of choice for many patients undergoing percutaneous intervention. In-stent restenosis (ISR), however, has become a significant problem. Neointimal hyperplasia with vascular smooth muscle cells is even more exaggerated with stent placement than with conventional angioplasty. In addition, failure to deploy the stent optimally at the time of the initial placement may result in increased restenosis. Symptoms of ISR typically occur within 6 to 9 months following intervention, and range from asymptomatic angiographic narrowing, or even occlusion, to recurrent angina/ischemia or myocardial infarction. Evaluation is by repeat angiography. Treatment with balloon angioplasty is effective for focal in-stent restenotic lesions; for other lesions excimer laser, rotational atherectomy, and directional coronary atherectomy are associated with excellent initial outcome, but long-term outcome of these procedures is unclear. Brachytherapy with both gamma and beta sources has been found to result in improved outcome with less angiographic restenosis and decreased target vessel revascularization. Late thrombosis has been documented in up to 10% of patients treated with vascular gamma brachytherapy, and increased stenosis at the edges of the treated segment is also seen. Prolonged dual antiplatelet therapy and avoidance of a new stent has been shown to reduce late thrombosis in patients treated with vascular brachytherapy.

Late results of percutaneous balloon mitral commissurotomy in patients with restenosis after surgical commissurotomy compared to patients with 'de-novo' stenosis

BACKGROUND AND AIMS OF THE STUDY

The outcome of percutaneous balloon mitral commissurotomy (BMC) has been reported as poor in patients with prior surgical commissurotomy. The study aim was to evaluate immediate and long-term follow up results of BMC in patients with restenosis after surgical commissurotomy compared to patients with 'de-novo' mitral stenosis.

METHODS

Between October 1988 and September 1999, a total of 1,027 patients underwent BMC. Of these patients, 169 (16.5%) were examined at 17+/-7 years (range: 2-33 years) after surgical commissurotomy (group 1), and 858 (83.5%) had de-novo mitral stenosis (group 2).

RESULTS

Group 1 patients were older than group 2 patients (49.4+/-9.3 versus 47.3+/-9.6 years; p <0.05), and atrial fibrillation was seen more often in group 1 (53.9% versus 32.4%; p <0.005). Before BMC, mitral valve area (MVA) was similar in both groups (1.18+/-0.27 and 1.15+/-0.26 cm2 in groups 1 and 2 respectively; p = NS); following BMC, MVA was 1.82+/-0.3 and 1.93+/-0.40 cm2 respectively (p <0.05). Four patients (2.4%) from group 1, and 24 (2.8%) from group 2 required mitral valve replacement due to severe regurgitation (p = NS). Annual clinical and echocardiographic evaluation was completed for 950 patients (mean follow up 56.2+/-31.1 months (range: 12-132 months). Cardiac events defined as death, valve surgery or repeat BMC occurred in 16.0% of patients in group 1, and in 9.6% of those in group 2. At follow up of three, five and 10 years, actuarial event-free survival was 85.7+/-2.9%, 79.8+/-3.8% and 65.2+/-7.5% respectively in group 1, and 93.4+/-0.9%, 90.1+/-1.1% and 72.7+/-3.9% respectively in group 2 (log rank test, p = 0.02). Multivariate analysis showed MVA <1.5 cm2 after BMC, mitral regurgitation grade >2/4, Wilkins score >8, and mean transmitral gradient and left atrial mean pressure post BMC to be independent predictors of an adverse event occurring during follow up.

CONCLUSION

BMC in patients with restenosis after surgical commissurotomy is an effective method of treatment, and may help to avoid valve surgery in most patients.

Retreatment with dose-dense weekly cisplatin after previous cisplatin chemotherapy is not complicated by significant neuro-toxicity

Cisplatin induces a cumulative dose-dependent axonal sensory neuropathy. With a cumulative dose over 600 mg/m2, a significant percentage of patients will develop a moderate or severe neuropathy. We retreated patients with progressive or recurrent ovarian cancer after previous platinum-containing chemotherapy with weekly 50-70 mg/m2 cisplatin for six cycles. This group was prospectively followed for the development of neuropathy. Patients received six weekly cycles of either 50 or 70 mg/m2 cisplatin, combined with oral etoposide. Responding patients continued treatment with daily oral etoposide for nine months. Neurological toxicity was assessed with a sensory sum score, the sensory neuropathy common toxicity criteria (CTC) and quantitated sensory analysis of the vibration perception threshold (VPT). Neurological assessment was scheduled at baseline, after three cycles, at the end of cisplatin chemotherapy and at 3 monthly intervals until 1 year after the discontinuation of chemotherapy. The first evaluation carried out in the interval of 1-4 months after the end of weekly cisplatin therapy was taken as the principle evaluation for neurotoxicity because during this time interval the nadir of cisplatin neurotoxicity is to be expected. Of 89 patients evaluated for neurological toxicity, 80 patients were fully evaluable. Forty-nine had received prior cisplatin (median cumulative dosage 450 mg/m2); the others had received prior treatment with carboplatin. Cisplatin pretreated patients had slightly higher neuropathy scores at the start of weekly cisplatin. Almost all cisplatin pretreated patients received six cycles of cisplatin, 29 at 50 mg/m2 and 20 at 70 mg/m2 per cycle. Despite treatment up to an overall cumulative dose of 750-900 mg/m2 cisplatin, only 1 patient discontinued treatment due to neurotoxicity. One other patient developed a grade 3 neuropathy during follow-up. Only a marginal increase of neuropathic signs and symptoms were observed in all the other patients. In multiple regression analysis, the increase in VPT or the sensory sum score was not related to prior treatment (cisplatin or carboplatin). Patients with mild signs of neuropathy after prior treatment with cisplatin to a cumulative dose level of 400-450 mg/m2 can be retreated with weekly cisplatin to a cumulative dose of 420 mg/m2 (overall cumulative dose up to 800-900 mg/m2) with only a minimal risk of significant neurotoxicity.

[Excimer retreatment for undercorrection or regression after laser in situ keratomileusis]

OBJECTIVE

To evaluate the results of excimer retreatment for undercorrection or regression after laser in situ keratomileusis (LASIK).

METHODS

Eight-eight eyes received retreatment for undercorrection or regression after first LASIK (FLASIK) in 2 149 eyes in our photorefractive keratotectomy (PRK)/LASIK center from March, 1996 to July, 1999. They were divided into 2 groups according to their degrees of pre-FLASIK myopia spherical equivalents. Group I was </= 10.00 diopters (D) (41 eyes); group II was > 10.00 D (47 eyes). We analyzed the factors of FLASIK which led to the re-LASIK (RLASIK), and observed the mean spherical equivalents (MSE), the ratio within +/- 1.00 D of emmetropia, the uncorrected visual acuity (UCVA), the best corrected visual acuity (BCVA) and the complication after RLASIK for at least 1 year follow-up study.

RESULTS

The retreatment ratio was 4.1% among the 2 149 eyes. In group II, the ratio was 2.3 times that of the group I. In the comparison with other eyes, the eyes received RLAISK had no difference in sex, laterality and age (P > 0.05). Over 50.0% had pre-FLASIK diopters >/= 10.00 D, and 73.9% had astigmatism correction in FLASIK. After RLASIK, no undercorrection or regression occurred in group I, but there was undercorrection in group II. The ratio within +/- 1.00 D of emmetropia after 1 year was 68.3% in group I and 51.1% in group II. The UCVA above 0.5 was over 90.0% in all eyes. Eight eyes (9.0%) lost two or more lines of BCVA. The serious complication after RLASIK was keratoconus of 3 eyes in group II.

CONCLUSIONS

The risk factors which lead to retreatment after FLASIK are high myopia with astigmatism before FLKSIK and the reaction to the operation. In this study, RLKSIK is safe, effective, predictable and accurate for </= -10.00 D correction in FLASIK. But, to prevent the occurrence of serious complication such as keratoconus, it is better not to perform RLASIK for > -10.00 D in FLASIK.

[Test your decision-making. When to do endodontic retreatment? Some therapeutic alternatives]

The aim of the present article was to propose examples of treatment alternatives for the management of 14 clinical cases. All these cases involved endodontically treated teeth and have been managed by the same practitioner. In this paper, the authors tried to show the variety of treatment alternatives as well as the complexity of the decision-making process and, not to consider that proposed alternatives were the most adequate.

[Test your decision-making. When to do endodontic retreatment? Results of a study]

The goals of this survey were to determine the most frequent therapeutic option and to evaluate the consensus among a sample of Belgian practitioners managing the same simulated cases of root treated teeth. On average, conservative options (nonsurgical retreatment 35.27% and no retreatment 29.61%) are the most selected alternatives. Surgical options and extraction respectively constitute 21.18% and 13% of the treatment propositions. As expected, the presence of radiographic and/or clinical signs resulted in a more aggressive attitude, but the presence of symptoms does not seem to be a valid reason for reintervention. The results of the study demonstrate considerable interindividual variations in clinical management of root treated teeth, regardless of personal factors, such as gender, years of experience and graduation institution. Even if a consensus appears within a group of professionals, it is not necessarily applied by a majority of practitioners; this contributes certainly to the explanation of the geographical or institutional variations noted in the medical practices.

Management of cutaneous verruciform xanthoma

Verruciform xanthoma is an uncommon mucocutaneous condition of uncertain cause that only occasionally affects the skin. The histopathology is distinctive for the presence of foamy histiocytes present within elongated dermal papillae. Although simple excision of intraoral lesions is reportedly curative, treatment of cutaneous lesions has not been previously reported. We describe a 62-year-old man with a large lesion of verruciform xanthoma affecting both inguinal folds. Immunohistochemical staining, reverse transcriptase polymerase chain reaction for human papilloma virus, and ultrastructural analysis were performed to investigate the pathogenesis of this lesion. The results of these studies support the theory that the source of lipid in dermal histiocytes is degenerating keratinocytes. Initial treatment with wire loop electrosection, pulsed dye (585 nm) laser, and x-ray therapy of this patient proved unsuccessful. Preliminary success has been achieved using wide surgical excision with primary closure.

Apical terminus location of root canal treatment procedures

The apical termination of root canal treatment is considered an important factor in treatment success. The exact impact of termination is somewhat uncertain; most publications on outcomes are based on retrospective findings. After vital pulpectomy, the best success rate has been reported when the procedures terminated 2 to 3 mm short of the radiographic apex. With pulpal necrosis, bacteria and their byproducts, as well as infected dentinal debris may remain in the most apical portion of the canal; these irritants may jeopardize apical healing. In these cases, better success was achieved when the procedures terminated at or within 2 mm of the radiographic apex (0 to 2 mm). When the therapeutic procedures were shorter than 2 mm from or past the radiographic apex, the success rate for infected canals was approximately 20% lower than that when the procedures terminated at 0 to 2 mm. Clinical determination of apical canal anatomy is difficult. An apical constriction is often absent. Based on biologic and clinical principles, instrumentation and obturation should not extend beyond the apical foramen.

[The treatment of intra-stent restenosis. The current situation and future outlook]

In-stent restenosis is an increasing problem due to the frequent use of coronary stent as a form of percutaneous revascularization. The global incidence is near to 28%, and it is well document that a neointimal hyperplasia is its principal mechanism. The most commonly related factors for its appearance are diabetes mellitus, a longer length of the original lesion, a smaller diameter of the reference vessel, the left anterior descending artery location and a smaller luminal diameter at the end of the procedure. Due to a different long term evolution in-stent restenosis has been classified as focal or diffuse, according to the length of the restenotic lesion (focal < 10 mm and diffuse > or = 10 mm). Some strategies have been proven for its treatment, but no randomized-controlled trials have been published comparing these different treatments. In focal in-stent restenosis the practice of a conventional balloon angioplasty is associated with high initial clinical success with a favourable long term evolution (target lesion revascularization between 11-15%). But on the contrary, in diffuse in-stent restenosis, in spite of a high initial success rate, an elevated target lesion revascularization has been detected at the follow-up (up to 43%). Other proved such as atherectomy or excimer laser are associated with a significant procedural non-Q-wave infarction (near to 9%) and a long term target lesion revascularization during follow-up (23-31%). The implantation of an additional stent has been performed with low procedural complications and with a long term target lesion revascularization near to 27%. Patients treated with intracoronary radiation as a complementary technique seem to have a better long term evolution than those having had the other strategies alone. In conclusion, in-stent-restenosis is a new and progressively more frequent problem, requiring complex treatment and of which as been established. Comparative controlled studies need to be performed in order to determine the best treatment for this new entity.

A randomized trial of elective stenting after balloon recanalization of chronic total occlusions

OBJECTIVES

The aim of this study was to assess the role of Wiktor stent implantation after recanalization of chronic total coronary occlusions with regard to the clinical and angiographic outcome after six months.

BACKGROUND

Beside the common use of stents in clinical practice, the number of stent indications proven by randomized trials is still limited.

METHODS

Eighty-five patients with a thrombolysis in myocardial infarction grade 0 chronic coronary occlusion were examined. After standard balloon angioplasty, the patients were randomly assigned to stent implantation, or percutaneous transluminal coronary angioplasty (PTCA) alone (no further intervention). Quantitative coronary angiography was performed at baseline and after six months.

RESULTS

The minimal lumen diameter did not differ immediately after recanalization (stent group 1.61 +/- 0.30 mm vs. PTCA group 1.65 +/- 0.36 mm), and increased after stent implantation to 2.51 +/- 0.41 mm. After six months, the stent group still had a significantly greater lumen (1.57 +/- 0.59 vs. 1.06 +/- 0.90 mm; p < 0.01) and a significantly lower restenosis and reocclusion rate (32% and 3%) compared with the PTCA group (64% and 24%); restenosis analysis according to treatment was 72% (PTCA) versus 29% (stent, p < 0.01). Late loss was equal in both groups. At follow-up, the stent patients had a better angina class (p < 0.01), and fewer cardiac events (p < 0.03). A meta-analysis including this trial and three other controlled trials with the Palmaz-Schatz stent showed concordant results.

CONCLUSIONS

Stent implantation after reopening of a chronic total occlusion provides a better angiographic result, corresponding to a better clinical outcome with fewer recurrence of symptoms and reinterventions after six months.

Evidence-based dentistry: endodontic failure--how should it be managed?

OBJECTIVE

To review the evidence on the most appropriate management of failed endodontic treatment.

DATA SOURCES

Appropriate articles were selected from the international literature.

RESULTS

There was good evidence that conventional endodontic treatment is associated with a successful outcome in a significant proportion of cases. The results of surgical treatment are more difficult to interpret since account should be made of the status of the existing root filling. However, there is evidence of an increased success rate with a satisfactory orthograde root filling.

CONCLUSIONS

It is difficult to make direct comparisons from cited studies to advance a clear argument in support of one treatment modality. However, it is judged that a conventional endodontic retreatment approach is the most appropriate in the first instance, providing access to the root canal is possible. This does not preclude a subsequent surgical approach. Teeth that are permanently restored soon after retreatment are more successful than those which are not. There are significant challenges in setting up prospective research studies to directly address the problem of the failed root filing.

Efficacy, cleaning ability and safety of different devices for gutta-percha removal in root canal retreatment

The purpose of this study was to evaluate the efficacy, cleaning ability and safety of five different devices and techniques to remove gutta-percha root canal fillings. One hundred and twenty extracted single-rooted anterior and premolar teeth were enlarged to ISO size 35 and obturated with laterally condensed gutta-percha using AH 26 as the sealer. Removal of gutta-percha was performed with the following devices and techniques: (a) Gates-Glidden and Hedstrom files, (b) only Hedstrom files, (c) Hedstrom files and chloroform, (d) the Endotec and Hedstrom files, and (e) the XGP drill and Hedstrom files. The following data were recorded: time taken to reach the desired working length, time required for the removal of the gutta-percha, and the amount of material extruded apically. The teeth were split longitudinally and photographed. Cleanliness of the root canal walls was scored using the projected slides with a total magnification of approximately 70x. The fastest technique to reach the working length was using the XGP drill (e), followed by the Gates-Glidden drills (a), Hedstrom files and chloroform (c), and the Endotec device (d). The use of Hedstrom files (b) without any additional support proved to be most time-consuming. Differences were statistically significant (U-test, P > 0.05) between the rotary devices and the manual techniques. Time for complete removal of gutta-percha was again shortest with the XGP drills (e), followed by the Gates-Glidden burs (a), the Endotec device (d), Hedstrom files with chloroform (c), and Hedstrom files alone (b). The XGP burs and the Gates-Glidden drills worked significantly faster than the other techniques. The amount of debris and filling material extruded apically in most cases did not exceed 0.1 mg. No significant differences could be detected between the groups (U-test, P > 0.05). Root canal cleanliness proved best following the use of Hedstrom files without additional support (b) and the Gates-Glidden drills (a), followed by Hedstrom files in combination with chloroform (c), the XGP-gutta-percha remover (e), and the Endotec device (d). When using the XGP two instrument fractures occurred in the apical parts of the root canals preventing further instrumentation to the apical foramen. When using the Gates-Glidden burs four instrument fractures occurred, but all fragments could be removed with forceps immediately. The results suggest that the XGP gutta-percha remover and the Gates-Glidden drills are efficient and time saving devices to remove gutta-percha but include a certain risk of instrument breakage and may leave some filling material inside the root canal. The best root canal cleanliness was achieved with Hedstrom files alone which, on the other hand, were shown to be the most time-consuming.

The role of hyperfractionated re-irradiation in metastatic brain disease: a single institutional trial

Progression of brain metastases after brain irradiation has prompted several studies on retreatment of the brain. Increased durations of survival and improved quality of life have been reported. Fifteen patients with previously treated brain metastases were entered into this pilot study between May 1990 and January 1994. All patients had neurologic and/or radiologic evidence of progression of brain metastases. The lung was the primary site in 60% of cases. The remaining 40% had breast, ovarian, and skin primaries. The median interval between the first treatment and retreatment was 10 months. All patients received whole-brain irradiation with or without a boost for their initial treatment course. Doses ranged from 3,000 to 5,500 cGy for initial treatments (median, 3,000). Retreatment consisted of limited fields with a median side equivalent square of 8.8 cm. Patients were retreated with a median dose of 3,000 cGy (range, 600-3,000 cGy). A median cumulative dose of 6,000 cGy was achieved. Retreatment consisted of twice-daily fractions (150 cGy/fraction). Retreatment was tolerated without serious complications. Of the 15 patients treated, nine (60%) experienced improvement, and five (27%) had stabilization of neurologic function and/or radiographic parameters. Median survival was 3.2 months; two of the reirradiated patients survived > or = 9 months. In conclusion, reirradiation is a viable option in patients with recurrent metastatic lesions of the brain, and the use of a limited retreatment volume makes this a well-tolerated, low-morbidity treatment that leads to clinical benefits and, in some instances, enhanced survival. The influence of hyperfractionation on the outcome needs to be investigated further in large series.