Noninvasive coronary flow reserve evaluation of coronary stenosis detected by multislice computed tomography: a value added proposition?

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Short implants in maxillary and mandibular rehabilitations: interim results (6 to 42 months) of a prospective study

The aim of this single-cohort study was to evaluate clinical survival and success of partial rehabilitation supported by reduced-length implants in maxilla and mandible. Data from 53 short implants placed in 41 patients are presented. Before surgery mean residual bone height was 6.21 ± 1.05 mm in the upper jaw and 10.73 ± 1.63 mm in the mandible. None of the implants failed, and the cumulative survival rate was 100% at 1 year after prosthetic loading. Mean peri-implant bone loss was 0.69 ± 0.24 mm for maxillary implants and 0.73 ± 0.23 mm for mandibular implants, and there was no significant difference between the 2 jaws. No complications were recorded. Despite the limitations of this study concerning study design and sample size, short implants may be considered effective in supporting partial rehabilitation in both maxilla and mandible. More well-designed studies with a larger sample size and longer follow-up are needed to validate the use of short implants.

Morphometric analysis of the infraorbital groove, canal, and foramen on three-dimensional reconstruction of computed tomography scans

PURPOSE

This study aimed to investigate the anatomy of the infraorbital foramen (IOF), infraorbital canal (IOC), and infraorbital groove (IOG) with regard to surgical and invasive procedures using three-dimensional reconstruction of CT scans.

METHODS

The CT scans of 100 patients were evaluated retrospectively. The morphology of the IOF, IOC, and IOG as well as their relationships to different anatomic landmarks was assessed in a three-dimensional model.

RESULTS

The mean length of the IOC and IOG and the angle of the IOC relative to IOG were 11.7 ± 1.9, 16.7 ± 2.4 mm, and 145.5° ± 8.5°, respectively. The mean angles of the IOC relative to vertical and horizontal planes were 13.2° ± 6.4° and 46.7° ± 7.6°, respectively. In the relationships between the IOF and different anatomic landmarks, the mean distances from the IOF to supraorbital notch/foramen, facial midline, and infraorbital rim were 5.6 ± 3.1 mm laterally, 26.5 ± 1.9 mm laterally, and 9.6 ± 1.7 mm inferiorly, respectively. The mean distance from the IOF to anterior nasal spine (ANS) was 35.0 ± 2.6 mm, and the mean angle of the axis that passed the IOF and ANS relative to horizontal plane was 28.8° ± 4.1°. In addition, the mean soft tissue thickness overlying the IOF was 11.4 ± 1.9 mm.

CONCLUSIONS

These results provide detailed knowledge of the anatomical characteristics and clinical importance of the IOF. Such knowledge is of paramount importance for surgeons when performing maxillofacial surgery and regional block anesthesia.

Morphologic features of the mandibular ramus associated with increased surgical time and blood loss in sagittal split-ramus osteotomy

PURPOSE

To determine whether specific morphologic features of the mandibular ramus can predict increased surgical time and blood loss in sagittal split-ramus osteotomy (SSRO).

MATERIALS AND METHODS

The clinical and morphologic features of the mandibular ramus, obtained from computed tomographic images (n=50), were analyzed to predict the surgical time, the time required for ablation of the medial mandibular ramus, and the time required for sectioning of the mandible in performing a modified Obwegeser SSRO.

RESULTS

Significant factors associated with surgical time were an anterior border of the ramus at least 10.5 mm wide, a maximal length of the thickened ramus of at least 8.5 mm, and a distance from the mandibular incisor to the posterior border of the mandible of at least 97.5 mm. There were significant differences in blood loss between the 2 axial aspects of the medial ramus.

CONCLUSIONS

The greater protrusion of the medial oblique ridge, thickened ramus, and longer distance from the mandibular incisors to the posterior border of the mandible may increase the surgical time and blood loss in patients undergoing classic SSRO. When planning or performing an SSRO, the morphologic features obtained from computed tomographic images may help surgeons gain a better understanding of the potential difficulties when the surgical site involves the medial aspect of the ascending ramus of the mandible.

Raman spectroscopy demonstrates Amifostine induced preservation of bone mineralization patterns in the irradiated murine mandible

PURPOSE

Adjuvant radiotherapy in the management of head and neck cancer remains severely debilitating. Fortunately, newly developed agents aimed at decreasing radiation-induced damage have shown great promise. Amifostine (AMF) is a compound, which confers radio-protection to the exposed normal tissues, such as bone. Our intent is to utilize Raman spectroscopy to demonstrate how AMF preserves the mineral composition of the murine mandible following human equivalent radiation.

METHODS

Sprague Dawley rats were randomized into 3 experimental groups: control (n=5), XRT (n=5), and AMF-XRT (n=5). Both XRT and AMF groups underwent bioequivalent radiation of 70Gy in 5 fractions to the left hemimandible. AMF-XRT received Amifostine prior to radiation. Fifty-six days post-radiation, the hemimandibles were harvested, and Raman spectra were taken in the region of interest spanning 2mm behind the last molar. Bone mineral and matrix-specific Raman bands were analyzed using one-way ANOVA, with statistical significance at p<0.05.

RESULTS

The full-width at half-maximum of the primary phosphate band (FWHM) and the ratio of carbonate/phosphate intensities demonstrated significant differences between AMF-XRT versus XRT (p<0.01) and XRT versus control (p<0.01). There was no difference between AMF-XRT and control (p>0.05) in both Raman metrics. Computer-aided spectral subtraction further confirmed these results where AMF-XRT was spectrally similar to the control. Interestingly, the collagen cross-link ratio did not differ between XRT and AMF-XRT (p<0.01) but was significantly different from the control (p<0.01).

CONCLUSION

Our novel findings demonstrate that AMF prophylaxis maintains and protects bone mineral quality in the setting of radiation. Raman spectroscopy is an emerging and exceptionally attractive clinical translational technology to investigate and monitor both the destructive effects of radiation and the therapeutic remediation of AMF on the structural, physical and chemical qualities of bone.

Coronary microvascular function in patients with Cushing's syndrome

The aim of the study was to evaluate patients with Cushing's syndrome the coronary flow reserve (CFR), an index of coronary microvascular function. Fifteen newly diagnosed patients with Cushing's syndrome (1 male/14 females; mean age 45 ± 11 years), were selected for having no clinical evidence of ischemic heart disease. Twelve patients had pituitary-dependent Cushing's disease and three had an adrenal adenoma. Fifteen subjects matched for age, sex, and major cardiovascular risk factors were used as controls. Coronary flow velocity in the left anterior descending coronary artery was investigated by transthoracic Doppler echocardiography at rest and during adenosine infusion. CFR was obtained as the ratio hyperemic/resting diastolic flow velocity. A reduced coronary reserve (hyperemic/resting ratio ≤ 2.5) was found in 5/15 Cushing patients and 4/15 controls. In all patients with abnormal CFR, epicardial coronary stenosis was excluded by multi-slice computed tomographic coronary angiography. CFR was inversely related to urinary cortisol in patients with endogenous hypercortisolism (Spearman's rho = -0.57, P = 0.03), while no correlation was found in controls. Coronary microvascular function, as assessed by CFR, is pathologically reduced in a considerable number of patients with Cushing's syndrome without clinical symptoms of ischemic heart disease and in the absence of epicardial coronary artery lesions, as well as in controls matched for cardiovascular risk factors. The presence of comorbidities can explain this early coronary abnormality in both patients and controls. Whether urinary cortisol may be a predictor of coronary microvascular function in the setting of patients with Cushing's syndrome, needs further investigation.

Prognostic impact of coronary microcirculation abnormalities in systemic sclerosis: a prospective study to evaluate the role of non-invasive tests

Introduction

Microcirculation dysfunction is a typical feature of systemic sclerosis (SSc) and represents the earliest abnormality of primary myocardial involvement. We assessed coronary microcirculation status by combining two functional tests in SSc patients and estimating its impact on disease outcome.

Methods

Forty-one SSc patients, asymptomatic for coronary artery disease, were tested for coronary flow velocity reserve (CFR) by transthoracic-echo-Doppler with adenosine infusion (A-TTE) and for left ventricular wall motion abnormalities (WMA) by dobutamine stress echocardiography (DSE). Myocardial multi-detector computed tomography (MDCT) enabled the presence of epicardial stenosis, which could interfere with the accuracy of the tests, to be excluded. Patient survival rate was assessed over a 6.7- ± 3.5-year follow-up.

Results

Nineteen out of 41 (46%) SSc patients had a reduced CFR (≤2.5) and in 16/41 (39%) a WMA was observed during DSE. Furthermore, 13/41 (32%) patients showed pathological CFR and WMA. An inverse correlation between wall motion score index (WMSI) during DSE and CFR value (r = -0.57, P <0.0001) was observed; in addition, CFR was significantly reduced (2.21 ± 0.38) in patients with WMA as compared to those without (2.94 ± 0.60) (P <0.0001). In 12 patients with abnormal DSE, MDCT was used to exclude macrovasculopathy. During a 6.7- ± 3.5-year follow-up seven patients with abnormal coronary functional tests died of disease-related causes, compared to only one patient with normal tests.

Conclusions

A-TTE and DSE tests are useful tools to detect non-invasively pre-clinical microcirculation abnormalities in SSc patients; moreover, abnormal CFR and WMA might be related to a worse disease outcome suggesting a prognostic value of these tests, similar to other myocardial diseases.

Location of the supraorbital and infraorbital foramen with references to the soft tissue landmarks in a Chinese population

The purpose of the current study was to determine the supraorbital foramen (SOF) and infraorbital foramen (IOF) based on soft tissue landmarks, to facilitate prediction of the location of this structure during facial surgery. Forty-two hemispheres of 21 adult cadavers (16 men and 5 women; aged 30-75 years) were dissected to expose the SOF and IOF. The locations of the SOF and IOF were evaluated with direct and photographic measurements. The data gained were analyzed by statistical method. The SOF localized 23.11 ± 2.35 mm superior and 9.48 ± 3.06 mm lateral to the angulus oculi medialis (AOM). The vertical angle from AOM to SOF was 68.3 (SD, 6.44) degrees. The SOF localized 24.81 (SD, 3.39) mm inferior and 10.89 (SD, 2.78) mm lateral to the AOM on the front view. The vertical angle from AOM to IOF was 66.5 (SD, 5.18) degrees. The SOF localized 11.22 (SD, 2.01) mm inferior and 6.09 (SD, 2.32) mm lateral to the ala of the nose (AL) on the front view. The vertical angle from AL to IOF was 61.7 (SD, 7.61) degrees. These results were a little different from the results of some other populations. We found the IOFs located on the point of one-fifth proportion distant to the ALs along the vertical direction distance from AL to SOF, whereas the AOMs located on the point of three-fifths proportion distant from the AL. Our results may provide more detailed information to predict the location of the SOFs and IOFs and help to prevent nerve or vessel damage.

Temporomandibular joint disorders in children

A child's difficulty in verbalizing the precise location and nature of facial pain and jaw dysfunction often results in a nondefinitive history, increasing the importance of the dentist's awareness of the early signs and symptoms of temporomandibular joint disorders (TMD). A focused examination of the masticatory musculature, the temporomandibular joints, and associated capsular and ligamentous structures can reveal if a patient's symptoms are TMD in origin. An accurate differential diagnosis enables timely referral to appropriate health care providers and minimizes the use of diagnostic imaging.

Identifying a safe zone for midface augmentation using anatomic landmarks for the infraorbital foramen

BACKGROUND

Midface augmentation is commonly used to improve the appearance of concave faces and to achieve balance in the facial contour. It can also be an adjunct to orthognathic or reconstructive surgery. However, an inherent risk of midface augmentation is injury to the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity, including loss of sensation to the midface, nasal sidewall, upper lip, and lower eyelid.

OBJECTIVES

The authors identify a safe zone of dissection in the midface for subperiosteal placement of infraorbital, paranasal, malar, and submalar implants, which avoids injury to the infraorbital nerve.

METHODS

Given the popularity of transconjuctival and intraoral access to the midface skeleton, the authors identified relevant bony and dental landmarks from radiographic images and measured distances between the IOF and these landmarks. Forty-four computed tomography scans of adult hemifaces were used to accurately locate the IOF in relation to the anatomic landmarks.

RESULTS

Most often, the IOF's location correlated with the second premolar on a vertical axis. The average distance between the IOF and the infraorbital rim, piriform aperture, tip of the second premolar cusps, and lateral orbital rim was approximately 8.61, 17.43, 41.81, and 25.93 mm (respectively) in men and 8.25, 15.69, 37.33, and 24.21 mm (respectively) in women.

CONCLUSIONS

A safe zone of dissection for midface augmentation has been identified, which differs from previous findings. Awareness of this zone may help clinicians locate the IOF and avoid injury to the nerve.

The versatility of lower eyelid blepharoplasty incision: In open reduction and fixation of zygomatic complex injuries

INTRODUCTION

A ZYGOMATIC COMPLEX FRACTURE INCLUDES DISRUPTION OF THE FOUR ARTICULATING SUTURES: zygomaticofrontal, zygomaticotemporal, zygomaticomaxillary and zygomaticosphenoidal sutures. All zygomatic complex fractures involve the orbital floor and therefore an understanding of orbital anatomic features is essential for those treating these injuries.

AIMS AND OBJECTIVES

To analyze the efficacy and shortcomings of this approach. To evaluate the adequacy, role of tarsorrhaphy, difficulties, role of steroid in postoperative edema control in lower lid blepharoplasty approach.

MATERIALS AND METHODS

A total number of six patients were included in this study and all the patients were treated surgically under general anesthesia. All the patients were approached through lower eyelid blepharoplasty incision. The first skin crease in the lower eyelid region is selected for this incision.

RESULTS

All patients were administered with steroid injection. Frost sutures were placed in four cases and tarsorrhaphy was done in two patients. Three cases encountered immediate mild edema and immediate scar formation. Late scar was present only in two patients with a follow up of three months.

CONCLUSION

Lower eyelid blepharoplasty incision is an excellent, non complicated, simple procedure in the management of fractures in the infraorbital region, orbital floor, which occurs as a part of zygomatic complex fractures.

A preauricular long-corniform approach for open reduction and internal fixation of mandibular condylar fractures

INTRODUCTION

We report functional and clinical outcomes following use of a preauricular long-corniform incision for open reduction and internal fixation (ORIF) of mandibular condylar fractures.

MATERIALS AND METHODS

Patients with mandibular condylar fractures who underwent ORIF via a 120° preauricular long-corniform incision were included in the study. A total of 78 patients (100 condyles) were included. Follow-up occurred 10 days and 1-6 months after surgery, and included assessments of clinical, functional outcome, complications, and bone fusion.

RESULTS

There were 38 high neck, 26 low base, and 35 diacapitular condylar fractures. All measures of functional outcome significantly improved over time after surgery regardless of fracture type (all P < 0.001). The vast majority of patients in all fracture type groups had good occlusion (≥ 88.5%), no pain (≥ 89.5%), and anatomical reduction 10 days after surgery (≥ 81.6%). Fracture healing was complete in all patients after 6 months. There were no long-term complications and all patients were satisfied with their postoperative appearance.

CONCLUSIONS

Our findings suggest that a preauricular long-corniform incision provides a good visual field during surgery, and allows for effective ORIF of mandibular high neck, low base, and diacapitular condylar fractures, with positive outcomes and minimal postoperative complications.

Patterns and etiology of maxillofacial fractures in Riyadh City, Saudi Arabia

OBJECTIVE

The aim of the present study was to study the etiologies and patterns of maxillofacial fractures in patients treated in Riyadh City, Saudi Arabia, between 2007 and 2011.

PATIENTS AND METHODS

Data were obtained through a retrospective review of 237 patients admitted to the King Saud Medical City Dental Department with a diagnosis of maxillofacial trauma. After excluding patient files with incomplete or unclear records, and cases in which computed tomography showed no evidence of fracture, the files of 200 patients with a diagnosis of maxillofacial fracture were included in the study. For each case, patient's sex and age, pattern of facial fractures, and cause of injury were recorded on a data sheet. The data were transferred to an SPSS (ver. 16.0; SPSS Inc., Chicago, IL, USA) spreadsheet for statistical analysis. The chi-square test was used to test the association between two categorical variables or factors (age group, cause) with p value set at p<0.05, and t-test value at <0.05 and independent.

RESULTS

Motor vehicle accidents were the most common cause of maxillofacial fractures in most age groups, especially in males. Within the study sample, mandibular fractures were significantly more common than middle-third facial fractures (56.4% vs. 43.6%; p=0.006). Among mandibular fractures, parasymphyseal fractures were most common (47%), followed by condylar fractures (35.3%). Most (77.2%) middle-third facial fractures involved the zygomatic complex, and the incidence of such fractures differed significantly between male and female patients. p=0.72, not significant.

CONCLUSION

Males were more prone to maxillofacial fractures, perhaps as a result of the conservative nature of Saudi society, as the rules of Saudi Arabia do not allow the females to drive. Motor vehicle accidents were the most common cause of maxillofacial fractures in patients aged 10-29 years, indicating the high demand for the application of stricter traffic rules to reduce the rate of such accidents.

Coronary flow reserve as a link between diastolic and systolic function and exercise capacity in heart failure

AIMS

In heart failure, a reduced exercise capacity is the prevailing symptom and an important prognostic marker of future outcome. The purpose of the study was to assess the relation of coronary flow reserve (CFR) to diastolic and systolic function in heart failure and to determine which are the limiting factors for exercise capacity.

METHODS AND RESULTS

Forty-seven patients with left ventricular ejection fraction (LVEF) <35 [median LVEF 31 (inter-quartile range 26-34)] underwent cardiorespiratory exercise test with measurement of VO2 peak, a dual X-ray absorptiometry scan for body composition, and a full echocardiography with measurement of LVEF using the biplane Simpson model, mitral inflow velocities, and pulsed wave tissue Doppler. Peak coronary flow velocity (CFV) was measured in the LAD, using pulsed-wave Doppler. CFR was calculated as the ratio between peak CFV at rest and during 2 min of adenosine stress. Fat-free-mass-adjusted VO2 peak correlated significantly with CFR (r = 0.48, P = 0.002), E/e' (r = -0.35, P = 0.02), and s' (r = 0.45, P = 0.001) but not with LVEF (r = 0.23, P = 0.11). CFR correlated significantly with E/e' (r = -0.46, P = 0.003) and s' (r = 0.36, P = 0.02), but not with LVEF (r = 0.18, P = 0.26). When adjusting for CFR in a multivariable linear model, s' but not E/e' remained independently associated with VO2 peak.

CONCLUSION

In this group of heart failure patients, VO2 peak was correlated with CFR, E/e', and s' but not with traditional measures of systolic function. CFR remained associated with VO2 peak independently of diastolic and systolic function and is likely to be a limiting factor in functional capacity of heart failure patients.

Maxillary sinus unilateral aplasia as an incidental finding following cone-beam computed (volumetric) tomography

This paper presents a case of maxillary sinus unilateral aplasia, an uncommon condition in adults, diagnosed as an incidental finding during cone-beam computed tomography (CBCT) examination for an endodontic case analysis. The patient was referred to a specialist endodontic practice for management of an upper right central incisor tooth. A CBCT scan was performed. The images of the left maxillary sinus showed a total lack of pneumatisation, prompting the diagnosis of aplasia. The patient's otolaryngologist was made aware of the findings. Clinical evaluation of volumetric images should be performed by an adequately trained dentist or radiologist so the maximum amount of information is gathered for the patient. This requires a systematic approach to ensure that no relevant information is missed and should include the paranasal sinuses and other surrounding structures as incidental findings can be observed during CBCT analysis.

The additive diagnostic role of coronary flow reserve in noninvasive evaluation of coronary stenosis on left descending artery previously detected by multislice computed tomography

PURPOSE

Multislice computed coronary angiography (MSCT) provides valuable morphological information about coronary artery disease, but precise quantification of coronary stenosis remains difficult. Transthoracic color Doppler echocardiography (TDE) gives a new insight into the functional significance of coronary luminal narrowing. We have tried to assess the additive value of coronary flow reserve (CFR) determined by TDE over MSCT in prediction of a significant stenosis on the left anterior descending artery (LAD) using the invasive coronary angiography (ICA) as a reference method.

METHODS

This prospective study included 63 patients in stable cardiac status with previously detected atherosclerotic lesions on LAD by MSCT. CFR assessment by TDE with adenosine infusion was obtained to all patients (feasibility was 96.92%). CFR was determined as ratio between the peak diastolic flow velocity during adenosine infusion and at basal condition, a cutoff value indicating significant stenosis was <2. ICA was preformed to all patients 24-48 hours after CFR.

RESULTS

MSCT had sensitivity of 86.36%, specificity 53.66%, positive predictive value 50.00%, negative predictive value 88.00%, and diagnostic accuracy of 65.07% in detection of significant LAD stenosis. CFR had sensitivity 81.81%, specificity 97.06%, positive predictive value 94.74%, negative predictive value 89.19%, and diagnostic accuracy of 91.07%. When the results of both methods were agreed diagnostic accuracy was improved to 92.72%.

CONCLUSION

Additional assessment of CFR by TDE increase diagnostic accuracy of MSCT angiography in detection of significant coronary artery lesions.

Massively enlarged styloid process presenting as a submandibular mass

A 47-year-old man is investigated in the ear, nose and throat department for a 6-month history of left submandibular swelling and pain. He underwent several investigations, before a large styloid process was found on CT imaging of the neck. The patient underwent surgical excision of the enlarged styloid process and stylohyoid ligament. He recovered well with no long-term complications and his symptoms were fully resolved.

Mesenchymal stem cells show radioresistance in vivo

Irradiation impacts on the viability and differentiation capacity of tissue-borne mesenchymal stem cells (MSC), which play a pivotal role in bone regeneration. As a consequence of radiotherapy, bones may develop osteoradionecrosis. When irradiating human bone-derived MSC in vitro with increasing doses, the cells’ self-renewal capabilities were greatly reduced. Mitotically stalled cells were still capable of differentiating into osteoblasts and pre-adipocytes. As a large animal model comparable to the clinical situation, pig mandibles were subjected to fractionized radiation of 2 χ 9 Gy within 1 week. This treatment mimics that of a standardized clinical treatment regimen of head and neck cancer patients irradiated 30 χ 2 Gy. In the pig model, fractures which had been irradiated, showed delayed osseous healing. When isolating MSC at different time points post-irradiation, no significant changes regarding proliferation capacity and osteogenic differentiation potential became apparent. Therefore, pig mandibles were irradiated with a single dose of either 9 or 18 Gy in vivo, and MSC were isolated immediately afterwards. No significant differences between the untreated and 9 Gy irradiated bone with respect to proliferation and osteogenic differentiation were unveiled. Yet, cells isolated from 18 Gy irradiated specimens exhibited a reduced osteogenic differentiation capacity, and during the first 2 weeks proliferation rates were greatly diminished. Thereafter, cells recovered and showed normal proliferation behaviour. These findings imply that MSC can effectively cope with irradiation up to high doses in vivo. This finding should thus be implemented in future therapeutic concepts to protect regenerating tissue from radiation consequences.

Prediction of long-term ischemic events by noninvasively assessed coronary flow reserve

BACKGROUND

Coronary flow reserve (CFR) by adenosine echocardiography in left anterior descending (LAD) or posterior descending coronary arteries may predict clinical outcome.

METHODS

We used models accounting (Cox's model) or not (logistic regression and neural network) for time to event and either considered (forced models) or not (stepwise logistic regression and neural network models) all among 21 covariates to predict 1-year composite events after LAD CFR.

RESULTS

There were 553 consecutive patients with coronary artery disease (CAD): 89 patients had also posterior descending CFR. During 1-year follow-up 328 patients were event-free, 35 had composite ischemic events and 190 underwent short-term revascularization. LAD and posterior descending CFR (respectively, 1.53 ± 0.83, N = 225 and 1.84 ± 0.80, N = 42) were significantly (P < 0.0001) lower in patients with events (or with revascularization following CFR measurement) than in those without (respectively, 3.13 ± 0.84, N = 328, and 2.53 ± 0.72, N = 47). Using LAD CFR as a continuous covariate, by both forced Cox's and logistic regression, coefficients (t values, respectively, -14.11 and -10.19) were significant (both P < 0.00001) to predict outcome. Global predictive accuracies by neural network, adopting a receiver operating characteristic areas under the curve (ROC) assessment, were excellent (>0.91) and the role of LAD CFR among predictors was overwhelming. Other indices of myocardial ischemia and the presence of coronary stenoses or previous infarction did not modify the multivariable predictive role of LAD CFR. When patients with revascularization were discounted, the LAD CFR predictive role was the same.

CONCLUSIONS

Thus, adenosine echocardiography-based LAD CFR predicts 1-year composite ischemic events in patients with CAD, independent of the multivariable model adopted. Posterior descending CFR also has a role.

Global trends in maxillofacial fractures

Background The etiology, demographics, fracture site in facial injury patients have been reported worldwide. However, few studies have attempted to identify changes in maxillofacial fractures over time periods and between countries. The statistics are vastly different due to variations in social, environmental, and cultural factors. Methods Data were collected from departmental records between 1996 and 2006 for patients treated at Christchurch Hospital for facial fractures. Variables examined included incidence, demographics, site of fracture, and treatment methods. Results A total of 2563 patients presented during the study period, 1158 patients in the first half and 1404 patients in the second half. Male-to-female ratio was 4:1 in both periods and males in 16- to 30-year group accounted for about half of all patients. Interpersonal violence was the most common cause of injuries, and there was a decrease in injuries caused by motor vehicle accidents. Approximately half of all patients required hospitalization and surgery, and the most common method of treatment was open reduction and internal fixation. Conclusion Maxillofacial fracture is a common injury in young males following interpersonal violence in New Zealand. Studies in other countries and over different time periods yield interesting differences in the etiology, demographics, and fractures patterns. These are due to environmental, societal, cultural, and legislative differences.

Patterns of paediatric facial fractures in a hospital of São Paulo, Brazil: a retrospective study of 3 years

The objective of this study is to analyze patterns of facial fractures in children treated at the Service of Oral and Maxillofacial Surgery of the Vila Penteado General Hospital (HGVP), in São Paulo, Brazil, in a period of 3 years. Between May 2008 and April 2011 the authors reviewed 110 records of patients under 12 years old with facial fractures. The following parameters were evaluated: age and sex distribution, aetiology of trauma, incidence and type of fractures, monthly distribution and treatment modality. Male-to-female ratio was 1.8:1, and the mean age was 8.13. The majority of the involved patients were aged between 6 and 12 years. The most prevalent cause was fall (58%) and nasal fractures were the most common type of fracture (69%). Monthly distribution was similar in all seasons. Of 110 patients, 69 (62%) were treated conservatively. The incidence of facial fractures in the area of study is high. The high incidence of nasal fractures should be a warning to maxillofacial surgeons, so that they are not overlooked. Safety programs should be installed in Brazil to increase public awareness and to decrease morbidity resulting from paediatric trauma.

Relationship Between Brachial Artery Flow-Mediated Dilation, Carotid Artery Intima-Media Thickness and Coronary Flow Reserve in Patients With Coronary Artery Disease

Background

The aim of this study was to assess the relationship between brachial artery flow mediated dilation (FMD), carotid artery intima-media thickness (IMT) and coronary flow reserve (CFR) in patients with coronary artery disease (CAD).

Methods

Fifty patients with coronary artery disease, except left anterior descending artery (LAD), who showed no cardiac symptoms and 45 control subjects underwent assessment of brachial artery FMD, carotid artery intima-media thickness by high-resolution ultrasound. In addition, transthoracic second harmonic Doppler echocardiography was used to measure CFR.

Results

All of the parameters were found to be correlated with each other. CFR correlated with brachial artery FMD (r = 0.232, P < 0.05) and with carotid IMT (r = -0.403, P < 0.001). Carotid IMT correlated with brachial artery FMD (r = -0.211, P < 0.05).

Conclusion

Transthoracic CFR correlated with well-established noninvasive predictors of atherosclerosis and we suggest that it can be used as a surrogate for coronary atherosclerosis.

Open versus closed reduction: diacapitular fractures of the mandibular condyle

PURPOSE

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of diacapitular fractures (DFs) of the mandibular condyle.

METHODS

An electronic search in PubMed was undertaken in March 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies reporting clinical series of DFs, including both animal and human studies, without date or language restrictions.

RESULTS

The search strategy initially yielded 108 references. Twenty-eight studies were identified without repetition within the selection criteria. Additional hand-searching of the reference lists of selected studies yielded three additional papers.

CONCLUSIONS

The current indications for open reduction and internal fixation (ORIF) of DFs described in the literature are: (a) fractures affecting the lateral condyle with reduction of mandibular height; (b) fractures in which the proximal fragment dislocates laterally out of the glenoid fossa, which cannot be reduced by closed or open treatment of another part of the mandibular fracture. The indications for conservative treatment are: (a) fractures that do not shorten the condylar height (a fracture with displacement of the medial parts of the condyle); (b) undisplaced fractures; (c) comminution of the condylar head, when the bony fragments are too small for stable fixation; and (d) fractures in children. As the temporomandibular joint disk plays an important role as a barrier preventing ankylosis, it is important to reposition the disk (if displaced/dislocated) during the surgical treatment of DFs. The lateral pterygoid muscle should never be stripped from the medially displaced fragment because its desinsertion disrupts circulation to the medial bony fragment, and also because this muscle helps to restore the muscle function after surgery. ORIF of selected DFs improves prognosis by anatomical bone and soft tissue recovery when combined with physical therapy. If conducted properly, surgical treatment of DFs is a safe and predictable procedure and yields good results.

Open versus closed reduction: mandibular condylar fractures in children

PURPOSE

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of mandibular condylar fractures (MCFs) in children.

METHODS

An electronic search in PubMed was undertaken in May 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies published in English or German from the last 20 years (from 1992 onwards) reporting clinical series of MCFs in children and adolescents until the age of 18.

RESULTS

The search strategy initially identified 542 studies. The references from 1992 onwards totaled 339 articles. Twenty-seven studies were identified without repetition within the selection criteria. Additional hand-searching yielded two additional papers.

CONCLUSIONS

Pediatric MCFs require thoughtful consideration in management to avoid significant growth disturbance. Early treatment is indicated in order to improve the chances for favorable development. Long-term follow-up is required, in order to properly treat late complications that may appear. Coronal computed tomography is helpful in substantiating the correct final diagnosis. Many studies show that conservative treatment (CTR) has satisfactory long-term outcome of jaw function, occlusion, and facial esthetics, despite a high frequency of radiological aberrations. Surgery before puberty should be reserved for exceptional cases such as missile injuries, in cases with extensive dislocation and lack of contact between the fragments, in cases with multiple midfacial fractures, in which the mandible has to serve as a guide to reposition the midfacial bones, and in cases which the dislocation of the fractured stump creates a functional impediment that cannot be resolved by CTR. As the craniofacial skeleton becomes more adult-like in its form at about 12 years of age, the decreased remodeling capacity in the adolescents may occasionally result in abnormally shaped condylar heads or shortened ramus heights that may lead to persistent malocclusion. Thus, the indication of open reduction and internal fixation increases with age.

Changing characteristics of facial fractures treated at a regional, level 1 trauma center, from 2005 to 2010: an assessment of patient demographics, referral patterns, etiology of injury, anatomic location, and clinical outcomes

INTRODUCTION

Despite improvements in automotive safety, motor vehicle collision (MVC)-related facial fractures remain common and represent preventable injuries. This study examines the changing characteristics of facial fractures treated at a regional, level I trauma center, from 2005 to 2010.

METHODS

We identified all patients with facial fractures admitted to our hospital, from 2005 to 2010, by querying the North Carolina Trauma Registry, using International Classification of Diseases, Ninth Revision codes. Prospectively collected data, sorted by year, were descriptively analyzed for demographics, referral patterns, etiology, anatomic location, and clinical outcomes.

RESULTS

Number of patients with facial fractures increased from 201 per year to 263 per year (total n = 1508). Although transport distances remained constant at ∼85 miles, standard deviation increased from 37 to 68 miles. Transport time increased from 87 to 119 minutes. Referrals came from 28 surrounding counties in 2005 and 43 counties in 2010. Regarding etiology, MVCs decreased from 40% to 27%, all-terrain vehicle crashes decreased from 6% to 2%, falls increased from 8% to 19%, and bicycle accidents increased from 3% to 6%. Regarding anatomic location, frontal sinus fractures increased from 8% to 37%, zygomaticomaxillary fractures increased from 9% to 18%, nasoethmoid fractures decreased from 12% to 6%, orbital floor fractures decreased from 6% to 3%, and mandible fractures decreased from 28% to 18%. Single-site fractures increased from 75% to 90%. Length of intensive care unit and hospital stay remained stable at 3 and 7 days, respectively.

CONCLUSIONS

Despite a decrease in MVC-related facial fractures, the overall increase in facial fractures referred to our trauma center is due to a growing number of patient transfers from rural hospitals, where a paucity of qualified surgeons may exist.

Insulin resistance and exercise tolerance in heart failure patients: linkage to coronary flow reserve and peripheral vascular function

Background

Insulin resistance has been linked to exercise intolerance in heart failure patients. The aim of this study was to assess the potential role of coronary flow reserve (CFR), endothelial function and arterial stiffness in explaining this linkage.

Methods

39 patients with LVEF < 35% (median LV ejection fraction (LVEF) 31 (interquartile range (IQ) 26–34), 23/39 of ischemic origin) underwent echocardiography with measurement of CFR. Peak coronary flow velocity (CFV) was measured in the LAD and coronary flow reserve was calculated as the ratio between CFV at rest and during a 2 minutes adenosine infusion. All patients performed a maximal symptom limited exercise test with measurement of peak oxygen uptake (VO₂peak), digital measurement of endothelial function and arterial stiffness (augmentation index), dual X-ray absorptiometry scan (DEXA) for body composition and insulin sensitivity by a 2 hr hyperinsulinemic (40 mU/min/m²) isoglycemic clamp.

Results

Fat free mass adjusted insulin sensitivity was significantly correlated to VO₂peak (r = 0.43, p = 0.007). Median CFR was 1.77 (IQ 1.26-2.42) and was correlated to insulin sensitivity (r 0.43, p = 0.008). CFR (r = 0.48, p = 0.002), and arterial stiffness (r = −0.35, p = 0.04) were correlated to VO₂peak whereas endothelial function and LVEF were not (all p > 0.15). In multivariable linear regression adjusting for age, CFR remained independently associated with VO2peak (standardized coefficient (SC) 1.98, p = 0.05) whereas insulin sensitivity (SC 1.75, p = 0.09) and arterial stiffness (SC −1.17, p = 0.29) were no longer associated with VO2peak.

Conclusions

The study confirms that insulin resistance is associated with exercise intolerance in heart failure patients and suggests that this is partly through reduced CFR. This is the first study to our knowledge that shows an association between CFR and exercise capacity in heart failure patients and links the relationship between insulin resistance and exercise capacity to CFR.

The convergence of radiation and immunogenic cell death signaling pathways

Ionizing radiation (IR) triggers programmed cell death in tumor cells through a variety of highly regulated processes. Radiation-induced tumor cell death has been studied extensively in vitro and is widely attributed to multiple distinct mechanisms, including apoptosis, necrosis, mitotic catastrophe (MC), autophagy, and senescence, which may occur concurrently. When considering tumor cell death in the context of an organism, an emerging body of evidence suggests there is a reciprocal relationship in which radiation stimulates the immune system, which in turn contributes to tumor cell kill. As a result, traditional measurements of radiation-induced tumor cell death, in vitro, fail to represent the extent of clinically observed responses, including reductions in loco-regional failure rates and improvements in metastases free and overall survival. Hence, understanding the immunological responses to the type of radiation-induced cell death is critical. In this review, the mechanisms of radiation-induced tumor cell death are described, with particular focus on immunogenic cell death (ICD). Strategies combining radiotherapy with specific chemotherapies or immunotherapies capable of inducing a repertoire of cancer specific immunogens might potentiate tumor control not only by enhancing cell kill but also through the induction of a successful anti-tumor vaccination that improves patient survival.

Ultrafast Doppler imaging of blood flow dynamics in the myocardium

Imaging intramyocardial vascular flows in real-time could strongly help to achieve better diagnostic of cardiovascular diseases. To date, no standard imaging modality allows describing accurately myocardial blood flow dynamics with good spatial and temporal resolution. We recently introduced a novel ultrasonic Doppler imaging technique based on compounded plane waves transmissions at ultrafast frame rate. The high sensitivity of this ultrafast Doppler technique permits to image the intramyocardial blood flow and its dynamics. A dedicated demodulation-filtering process is implemented to compensate for the large tissue velocity of the myocardium during the cardiac cycle. A signed power Doppler processing provides the discrimination between arterial and venous flows. Experiments were performed in vivo in a large animal open chest model ( N = 5 sheep) using a conventional ultrasonic probe placed at the surface of the heart. Results show the capability of the technique to image intramyocardial vascular flows in normal physiological conditions with good spatial (200 μm) and temporal resolution (10 ms). Flow dynamics over the cardiac cycle were investigated and the imaging method demonstrated a phase opposition of flow waveforms between arterial and venous flows. Finally, ultrafast Doppler combined with tissue motion compensation was found able to reveal vascular flow disruption in ischemic regions during occlusion of the main diagonal coronary artery.

Endoscopy-assisted transoral resection of the styloid process in Eagle's syndrome. Case report

Eagle's syndrome is often associated with elongated styloid process or ossified stylohyoid or stylomandibular ligament. Patients with this syndrome present with recurrent cervicofacial pain. Surgical removal of the elongated styloid process is a standard treatment and can be accomplished through either a transoral or extraoral approach. Both approaches have advantages and disadvantages, and the best surgical approach remains controversial. In our case, the elongated styloid process was removed by transoral approach assisted by endoscopy. Endoscopy provides clear surgical view thus lessen the chance of neurovascular injury and other intraoperative complications. Endoscopy-assisted transoral resection is an optional alternative surgical procedure for Eagle's syndrome.

Myofibroblasts and their resistance to apoptosis: a possible mechanism of osteoradionecrosis

Osteoradionecrosis (ORN) in the head and neck area is the most devastating long-term complication of radiotherapy, with slow progression and inability to heal spontaneously. ORN can lead to intolerable pain, fractures, and sequestration of devitalized bone and fistulae, making oral feeding impossible and causing facial deformation. In spite of its notorious reputation over at least 90 years, the precise pathogenesis of ORN has not been fully clarified, which has led to obstacles in the management of the disease. Several theories about its pathogenesis have been formulated, and radiation-induced fibrosis is the newest one. According to this theory, ORN is essentially a type of fibrosis induced by radiotherapy, and antifibrosis therapy has been shown to be effective in its treatment. We assumed that ORN, like fibrosis in other organs, is the result of a process of fibrogenesis in which myofibroblasts are the key effector cells. The uninterrupted accumulation of myofibroblasts and consequent persistent excess production of collagenous extracellular matrix and tensile force result in loss of normal function and ultimately radiation-induced fibrosis. During this process, myofibroblasts may be protected from apoptosis by acquiring an immune-privileged capacity, which allows continuous matrix synthesis. If this hypothesis proves to be correct, it would enable better understanding of the cellular and molecular mechanisms underlying the pathogenesis and progression of ORN, and would help improve our ability to prevent occurrence of ORN, give an earlier diagnosis, and treat it more effectively.

Contrast-enhanced sonography of malignant pediatric abdominal and pelvic solid tumors: preliminary safety and feasibility data

BACKGROUND

Little information exists regarding pediatric contrast-enhanced US.

OBJECTIVE

To assess the safety and feasibility of contrast-enhanced US of pediatric abdominal and pelvic tumors.

MATERIALS AND METHODS

This prospective study included eight boys and five girls (mean age, 10.8 years) with abdominal or pelvic tumors. Cohorts of three subjects underwent US with perflutren contrast agent at escalating dose levels. Neurological and funduscopic examination, electrocardiography and continuous pulse oximetry were performed before and after contrast administration. Three radiologists independently scored six imaging parameters on pre- and postcontrast sonography. Inter-reviewer agreement was measured by the Kappa statistic.

RESULTS

No neurological, retinal, electrocardiographical or pulse oximetry changes were attributable to the contrast agent. Two subjects reported minor, transient symptoms. Postcontrast US parameter scores improved slightly in 8 of 12 subjects. Postcontrast ultrasound inter-reviewer agreement improved slightly for detection of tumor margins (precontrast = 0.20, postcontrast = 0.26), local tumor invasion (precontrast = -0.01, postcontrast = 0.10) and adenopathy (precontrast = 0.35, postcontrast = 0.44).

CONCLUSIONS

Although our sample size is small, perflutren contrast agents appear to be safe and well tolerated in children. Contrast-enhanced sonography of pediatric abdominal and pelvic tumors is feasible, but larger studies are needed to define their safety and efficacy in children.

Eagle's syndrome: embryology, anatomy, and clinical management

BACKGROUND

Eagle's syndrome refers to a rare constellation of neuropathic and vascular occlusive symptoms caused by pathologic elongation or angulation of the styloid process and styloid chain. First described in 1652 by Italian surgeon Piertro Marchetti, the clinical syndrome was definitively outlined by Watt Eagle in the late 1940s and early 1950s.

METHODS

This article reviews how underlying embryologic and anatomic pathology predicts clinical symptomatology, diagnosis, and ultimately treatment of the syndrome.

RESULTS

The length and direction of the styloid process and styloid chain are highly variable. This variability leads to a wide range of relationships between the chain and the neurovascular elements of the neck, including cranial nerves 5, 7, 9, and 10 and the internal carotid artery. In the classic type of Eagle's syndrome, compressive cranial neuropathy most commonly leads to the sensation of a foreign body in the throat, odynophagia, and dysphagia. In the carotid type, compression over the internal carotid artery can cause pain in the parietal region of the skull or in the superior periorbital region, among other symptoms.

CONCLUSIONS

Careful recording of the history of the present illness and review of systems is crucial to the diagnosis of Eagle's syndrome. After the clinical examination, the optimal imaging modality for styloid process pathology is spiral CT of the neck and skull base. Surgical interventions are considered only after noninvasive therapies have failed, the two most common being intraoral and external resection of the styloid process.

Urban-rural differences in oral and maxillofacial trauma

The aim of this research was to assess oral and maxillofacial trauma in urban and rural populations of the same region. The data collected included age, gender, year and month of trauma occurrence, origin (rural and urban), cause of injury, and the type of oral and maxillofacial trauma. Records from 1121 patients with 790 instances of oral and maxillofacial trauma were evaluated. Statistical analysis was performed with the Statistical Package for Social Sciences (SPSS) version 17.0 software and involved descriptive statistics and Pearson's chi-squared test. Male patients were more prone to maxillofacial trauma (n = 537; 68%), and the patients were mostly from urban areas (n = 534; 67.6%). The male-to-female ratio was found to be 2.12:1 (urban zone, 1.72:1; rural zone, 3.49:1). The average age was 25.7 years (SD = 14.1). A traffic accident was the most common cause of oral and maxillofacial trauma (27%). The jaw (18%) was the most commonly fractured bone in the facial skeleton, followed by the zygoma (12.9%). Avulsion (8.5%) was the most common dental trauma. A significant statistical relationship was found between place of origin and gender (p < 0.001). Accidents involving animals were more frequent in rural areas (P < 0.001). Zygomatic fractures (p < 0.001), contusion (p = 0.003), and abrasion (p = 0.051) were the most common injuries among individuals from rural areas. Nasal fracture (p = 0.011) was the most frequent type of trauma in individuals from urban areas. According to these data, it seems reasonable to assume that specific preventive public policy for urban and rural areas must respect the differences of each region.

Recurrent angina after coronary angioplasty: mechanisms, diagnostic and therapeutic options

Recurrent angina in patients who underwent percutaneous coronary intervention is defined as recurrence of chest pain or chest discomfort. Careful assessment is recommended to differentiate between non-cardiac and cardiac causes. In the case of the latter, recurrent angina occurrence can be related to structural ('stretch pain', in-stent restenosis, in-stent thrombosis, incomplete revascularization, progression of coronary atherosclerosis) or functional (coronary micro-vascular dysfunction, epicardial coronary spasm) causes. Even though a complete diagnostic algorithm has not been validated, ECG exercise testing, stress imaging and invasive assessment of coronary blood flow and coronary vaso-motion (i.e. coronary flow reserve, provocation testing for coronary spasm) may be required. When repeated coronary revascularization is not indicated, therapeutic approaches should aim at targeting the underlying mechanism for the patient's symptoms using a variety of drugs currently available such as beta-blockers, calcium-channel blockers, ivabradine or ranolazine.