Oral self-inflicted accidental trauma in patients with neurological disorders: a case report of dental management in infants with cerebellar hypoplasia

Self-inflicted oral injuries, accidental or otherwise, can cause major consequences. Measures need to be taken to protect individuals from chronic self-injurious behaviour; however, there are no official guidelines on the subject. The purpose of this article is to show the case of a 1-year-old patient with neurological disorders who, following the eruption of deciduous teeth, had self-inflicted a traumatic ulcer on his tongue and lower lip. Following a multidisciplinary approach involving several operating units of our hospital to make a diagnosis, an oral device was designed to completely cover the dental elements to prevent recurrence of the trauma and to prevent further worsening of the injuries already caused. The purpose of this work is to demonstrate that although the surgical approach, such as extraction of the dental elements, may be the quickest solution in situations similar to the one presented, the high biological cost and irreversibility of the result lead to seeking alternatives and more conservative solutions such as the one described.

Cephalometric changes of pushing splints 3 compared to rapid maxillary expansion and facemask therapy on the airway space in class III growing patients: A randomized clinical trial

BACKGROUND

Early orthopaedic treatment with rapid maxillary expansion (RME) associated with facemask (FM) has been shown to be effective in correcting Class III malocclusions in children. Treatment with pushing splints 3 (PS3) has shown to correct skeletal discrepancies in Class III growing patients. However, the effects of orthopaedic treatment on the upper airways in children with Class III malocclusion is controversial.

OBJECTIVES

The aim of this study was to evaluate the cephalometric changes in the airways of PS3 compared to the RME/FM protocol.

MATERIALS AND METHODS

In this study, 48 patients with Class III malocclusion (age range 5.5-8.5 years old) were selected for this study, and 24 were treated with PS3 appliance and 24 with RME/FM therapy. Lateral cephalograms before (T0) and at the end of the treatment (T1) were analysed to compare pharyngeal spaces. Paired and unpaired t tests were used for data analysis (P < .05).

RESULTS

A total of 41 patients (21 patients for the PS3 group, 11 males and 10 females, mean age 7.0 ± 1.2 years; 20 patients for the RME/FM group, 10 males and 10 females, mean age 7.2 ± 1.3 years) were included. The results showed a statistically significant (P < .05) increase in the nasopharyngeal space after both therapies. However, the effects were similar considering that there were no differences between groups for the assessed variables at T0-T1.

CONCLUSIONS

Early treatment of Class III malocclusion with PS3 does not induce a statistically significant increase in the sagittal airway space compared to RME/FM. The absence of untreated group could not define the role of growth in the increase of space.

Behavioral Modifications in Children after Repeated Sedation with Nitrous Oxide for Dental Treatment: A Retrospective Study

Sedation with nitrous oxide (N₂O) has been widely used as a viable alternative to general anesthesia to perform dental treatments in uncooperative or anxious children. The purpose of this retrospective study is to assess if repeated sedations with N₂O can improve collaboration of uncooperative children. The medical records of 650 children, aged between 3 and 14 years, who underwent at least two sedations, were consulted. Differences in the Venham score during the first sedation and subsequent sedations were collected. After removal incomplete records, 577 children's records (309 males and 268 females) were analyzed. The Venham score decreased both during each sedation and with repeated sedations (p < 0.01 for both comparisons). In particular, a significant reduction of the Venham score was observed at the first contact with the dentist, with a mean score ranging from 1.56 ± 1.46 to 1.16 ± 1.37, comparing the first and the second sedation, and from 1.65 ± 1.43 to 1.06 ± 1.30, comparing the first with the third sedation (p < 0.01). The reduction in the Venham score was recorded in both healthy and physically impaired patients, and it was significantly greater in older children than in younger children (p < 0.01). In conclusion, uncooperative children with or without physical impairments can be successfully treated with N₂O sedation in order to increase their confidence in dental procedures.

"Multidisciplinary management of post- infective osteoarthritis and secondary condylar resorption of temporomandibular joint: a case report in a 9 years-old female patient and a review of literature"

Background

Osteoarthritis and condylar resorption of temporomandibular joint (TMJ) has rarely been reported in children as consequence of otologic disease. We describe the management of a case in a 9-year-old female as long-term complication of an otomastoiditis and review the literature currently available on this topic.

Case presentation

A nine-years-old female patient referred to Emergency Room of Bambino Gesù Children’s Research Hospital, IRCCS (Rome,Italy) for an acute pain in the left preauricular area and reduced mandibular movements. In the medical history an otomastoiditis and periorbital cellulitis was reported at the age of six with complete remission of symptoms after antibiotic treatment. No recent history of facial trauma and no previous orthodontic treatment were reported. She was referred to a pediatric dentist that conducted a clinical examination according to the Diagnostic Criteria of Temporomandibular Disorders (DC/TMD) and was diagnosed with bilateral myalgia of the masticatory muscles and arthralgia at the level of the left TMJ. Then, a complete diagnostic path was performed that included multidisciplinary examinations by a rheumatologist, infectious disease specialist, ear nose and throat (ENT) doctor, a maxillofacial surgeon and a medical imaging specialist. Differential diagnosis included juvenile idiopathic arthritis, idiopathic condylar resorption, trauma, degenerative joint disease, neurological disease. Finally, unilateral post-infective osteoarthritis of the left TMJ with resorption of mandibular condyle was diagnosed. The patient went through a pharmacological therapy with paracetamol associated to counselling, jaw exercises and occlusal bite plate. After 1 month, the patient showed significant reduction of orofacial pain and functional recovery that was confirmed also one-year post-treatment. The novelty of this clinical case lies in the accurate description of the multidisciplinary approach with clinical examination, the differential diagnosis process and the management of TMD with conservative treatment in a growing patient.

Conclusions

Septic arthritis of temporomandibular joint and condylar resorption were described as complications of acute otitis media and/or otomastoiditis in children. We evidenced the importance of long-term follow-up in children with acute media otitis or otomastoiditis due to the onset of TMJ diseases. Furthermore, in the multidisciplinary management of orofacial pain the role of pediatric dentist is crucial for the diagnostic and therapeutic pathway to avoid serious impairment of mandibular function.

Cross Sectional Study on the Association between Dental Caries and Life Habits in School Age Italian Children

Dental caries is still a major public health issue and influences the overall health of children. The risk factors for caries include biological, socio-behavioral, and environmental factors. Our aim is to assess the association between dental caries and the life habits of children and their parents. A cross-sectional study was conducted in Rome (Italy) among primary school children aged 5 to 11. Parents completed the anamnestic questionnaire, and a dental clinical examination was performed on 333 children. Caries prevalence was 38.7% overall, 47% in males and 31.9% in females. The association between bottle night-time feeding and caries was statistically significant (43.2%; p = 0.013). Usage of a honeyed pacifier was also significantly associated with the presence of caries (72.7%; p = 0.027). Finally, higher caries prevalence was found among male children (47% vs. 31.9%; p = 0.005). The present study shows that the percentage of caries is still high in the paediatric population, and caries prevalence is associated with life habits. Our results highlight the importance of oral health education programs at primary school that involve teachers and parents to contribute to improving lifestyles.

Association between upper airway obstruction and malocclusion in mouth-breathing children

Objectives

To evaluate the association between upper airway obstruction and occlusal anomalies in mouth-breathing children.

Methods

356 mouth-breathing children were evaluated by ENT physicians and specialists in orthodontics. ENT examination included nasal endoscopy to assess the adenoidal hypertrophy, tonsillar grading and presence of nasal septum deviation. Clinical orthodontic examination was performed to record occlusal variables. Univariate and multivariable logistic regression were performed to study the association between registered variables.

Results

221 patients (mean age ± sd = 6.2 ± 2.5 years) met inclusion criteria. 81.4% of children presented malocclusion. A significant association between tonsillar grade 2 and the presence of malocclusion, Class II relation and increased overjet was shown. Tonsillar grade 4 showed a significant association with the presence of malocclusion and increased overjet. Adenoidal hypertrophy and nasal septum deviation did not show any association with occlusal findings.

Conclusions

A high frequency of orthodontic problems was seen in mouth-breathing children. Our results suggested that severe tonsillar hypertrophy may determine presence of malocclusion and increased overjet. On the other hand, the association between mild tonsillar hypertrophy and many occlusal anomalies in mouth-breathers suggest an important role of malocclusion in the onset of oral breathing in children.

Long-term assessment of clinical outcomes and disease progression in patients with corrected Tetralogy of Fallot

OBJECTIVE

Understanding changes of right ventricular (RV) geometry and function in repaired Tetralogy of Fallot (rToF) patients can improve decision-making for pulmonary valve replacement. Therefore, we aimed to assess the magnitude and clinical correlations of RV changes in rToF patients.

PATIENTS AND METHODS

Clinical and MRI data of rToF patients who underwent repeated cardiac magnetic resonance imaging (MRI) at two centers between December 2003 and September 2020 were analyzed together with anatomical factors, including RV outflow tract obstruction, pulmonary artery branch stenosis, and tricuspid regurgitation. Adverse cardiac events and/or NYHA class worsening were documented and correlated with MRI changes. QRS length was reported at each MRI.

RESULTS

Two-hundred-and-nineteen rToF patients (53% males, aged 20.2 ± 10.1 years) were enrolled. An increase of ventricular dimensions, except LVEDVi, and worsening of right and left ejection fractions were found over an average period of 5 years of follow-up. These changes were statistically significant but within 10% of the initial value. No significant changes were reported on a year-to-year basis, except in a small group of patients (6%) in whom no predictive factors were identified. Despite similar RV dimensions at the first examination, younger patients had a higher RV ejection fraction and a different annual rate of change of ventricular dimensions compared to older ones. Patients with arrhythmias (20%) were more frequently older and had larger RV dimensions but showed no significant correlations with MRI changes/years.

CONCLUSIONS

 Changes in RV dimensions and function occur rarely and very slowly in rToF patients. A small percentage of patients experience a significant worsening in a short time interval without any recognized risk factors. Arrhythmias appear to occur in a small percentage of cases in the late follow-up.

Balloon dilation and rapid maxillary expansion: a novel combination treatment for congenital nasal pyriform aperture stenosis in an infant

Background

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare condition that may occur alone or as part of a multi-formative syndrome. Management remains difficult. There is no specific treatment protocol. Traditional surgery would be anachronistic; a non-invasive or minimally invasive therapeutic option is required. However, the rarity of the disease and the infantile context render randomised clinical trials difficult.

Case presentation

We present the case of a one-month-old Caucasian boy with CNPAS. He presented to the Emergency Department of the Bambino Gesù Pediatric Hospital with nasal obstruction, noisy breathing, feeding difficulties, and suspected sleep apnoea. During hospitalisation, he underwent overnight pulse oximetry, airway endoscopy, and maxillofacial computed tomography (CT); the final diagnosis was CNPAS with moderate obstructive sleep apnoea syndrome. We successfully treated the patient using an innovative strategy that involved collaboration between ear-nose-and-throat surgeons and orthodontists.

Conclusions

A combination of minimally invasive balloon surgery and placement of a palatal device may successfully treat CNPAS; it may also treat other types of nasal bone stenosis. Future studies may allow the development of practice consensus treatment strategies.

Linguistic adaptation and psychometric evaluation of Italian version of children's sleep habits questionnaire

Background

The Children’s Sleep Habits Questionnaire (CSHQ) is a parent-report questionnaire used to examine sleep behavior in children. Linguistic adaptation of CSHQ into several languages and/or psychometric analysis of reliability have been published.

Main text

Our aim was to translate the original 33-items CSHQ from English to Italian and to examine its reliability for use in 4–10 years-old children of Italy. After translation and back-translation procedure of the original CSHQ, the Italian CSHQ (CSHQ-IT) was administered to 69 mothers of healthy children. Reliability of CSHQ-IT was examined by the internal consistency of the scale (using the Cronbach’s alpha coefficient), and by the test-retest analysis obtained by asking mothers who had completed the CSHQ-IT at baseline to re-complete it after a two-week interval (measured with the Lin’s Concordance Correlation Coefficient, CCC). The CSHQ-IT showed adequate internal consistency (Cronbach’s alpha = 0.81 for the total scale). The total CSHQ-IT score showed a strong correlation in retests (CCC 0.87; 95% Confidence Interval, 0.80; 0.92).

Conclusion

CSHQ-IT is a valuable tool for evaluating sleep behavior in children 4–10 years-old in Italy. Future research should be implemented to provide definitive validity of CSHQ-IT in children with sleep-disordered breathing.

Dental and Periodontal Care at the Bedside Using a Portable Dental Unit in Hospitalized Special Needs Patients: The Experience of an Italian Pediatric Hospital

Patients with special needs (SNPs) include individuals who are disabled due to physical limitations, medical complications, developmental problems, and cognitive impairments. SNPs may be at an increased risk of oral diseases throughout their lifetime. These patients have difficulties in accessing traditional dental studios or clinics. Moreover, orodental problems may cause local and generalized infections, leading to worrisome complications when not properly treated. In this paper, we describe the preliminary experience of treating dental problems in a series of nine hospitalized patients with special needs. This innovative protocol at the Bambino Gesù Children's Hospital (Rome, Italy) provides an introduction to a portable dental unit in order to perform oral care for hospitalized patients at the bedside. A multidisciplinary team composed of pediatric dentists, dental hygienists, nursing staff, and the patient's case manager was involved in the operative protocol. The SNPs described were affected by congenital heart or oncohematological diseases and neurodisabilities, and they were all hospitalized for different reasons: Open heart surgery, chemotherapy, organ transplantation, and rehabilitation. The oral evaluation was mandatory for ruling out or treating problems that could cause complications. Dental extractions, caries and fracture fillings, sealing, and oral hygiene procedures were performed at the bedside of the patients in the reference unit of their pediatric hospital. The results of this protocol confirm the feasibility of dental procedures at patients' bedside with portable dental units, encourage implementation of their use, and may represent an actionable model for oral care management in hospitalized SNPs.

Cephalometric effects of Pushing Splints 3 compared with rapid maxillary expansion and facemask therapy in Class III malocclusion children: a randomized controlled trial

Background

Pushing Splints 3 (PS3) device was recently introduced for the treatment of Class III malocclusion in children.

Objectives

To assess the effect on the sagittal maxillary position (SNA, primary outcome) of PS3 therapy compared with rapid maxillary expansion and facemask therapy (RME/FM) and to compare skeletal and dento-alveolar effects in growing Class III patients.

Trial design

This trial was a single-centre randomized controlled trial with two groups randomly allocated in a 1:1 ratio of equal size by sealed-envelope randomization, conducted at the Dentistry Unit of Bambino Gesù Children’s Hospital, IRCCS (Rome, Italy).

Methods

A total of 48 patients with Class III malocclusion were included in the study and randomly allocated to the two groups: PS3 therapy and RME/FM therapy. Only the RME/FM group underwent palatal expansion, and both groups were instructed to wear the appliances 14 hours/day. Pre- (T0) and post-treatment (T1) cephalograms were taken. An independent sample t-test and regression analysis were used to analyse the data (P value <0.05). Researchers involved in statistics and tracings were blinded to the treatment allocation.

Results

A total of 42 patients (21 for each group) completed the study. The maxillary sagittal position improved similarly in both groups (SNA = 0.4°; P = 0.547). A statistically significant decrease of SNPg angle (−1.6°; P < 0.001) and increase of ANPg angle (1.4°; P = 0.018) were found in the RME/FM group compared with PS3 group. CoGoMe angle significantly decreased in RME/FM group compared with PS3 group (−1.7°; P = 0.042). The regression analysis showed an association between SN/MP angle at T0 and the differences between T1 and T0 of SNPg (B = 0.13; P = 0.005) and SN/MP (B = −0.19; P = 0.034). Only three patients (PS3 = 2; RME/FM = 1) had breakages of the devices.

Limitations

Results are limited to short-term effects.

Conclusion

RME/FM therapy and PS3 are both effective therapies for the early correction of Class III malocclusion. The PS3 controlled better mandibular divergency reducing the clockwise rotation in patients with higher mandibular inclination.

Registration

This study was not registered in a clinical trial registry.

Neonatal teeth: Importance of histological findings in management update

BACKGROUND

Presence of teeth in a newborn represents a rare finding and a disturbance of biological chronology of teeth. The aim of this paper is to report two cases with neonatal teeth histologically examined.

CASE REPORT

In this paper two cases of patients with neonatal teeth are reported and histological examinations of three extracted teeth are described. We report an exceptional finding in one of the neonatal teeth microscopically examined: a massive inflammatory infiltration in the pulp tissue similar to that in pulpitis.

RESULTS

The management of natal and neonatal teeth usually includes the extraction in case of ulceration on the tongue or severe tooth mobility to prevent accidental inhalation or feeding disturbances. The presence of an inflammatory infiltration of pulp tissue in one of teeth histologically examined suggests to review the indications for extraction considered to date.

CONCLUSION

The management of natal and neonatal teeth should consider the presence of an inflammatory infiltration of pulp tissue. An anamnestic interview is advisable in ordert to deeply investigate about possible behaviours of the child due to pain or discomfort.

MaNGA: a novel multi-niche multi-objective genetic algorithm for QSAR modelling

SUMMARY

Quantitative structure-activity relationship (QSAR) modelling is currently used in multiple fields to relate structural properties of compounds to their biological activities. This technique is also used for drug design purposes with the aim of predicting parameters that determine drug behaviour. To this end, a sophisticated process, involving various analytical steps concatenated in series, is employed to identify and fine-tune the optimal set of predictors from a large dataset of molecular descriptors (MDs). The search of the optimal model requires to optimize multiple objectives at the same time, as the aim is to obtain the minimal set of features that maximizes the goodness of fit and the applicability domain (AD). Hence, a multi-objective optimization strategy, improving multiple parameters in parallel, can be applied. Here we propose a new multi-niche multi-objective genetic algorithm that simultaneously enables stable feature selection as well as obtaining robust and validated regression models with maximized AD. We benchmarked our method on two simulated datasets. Moreover, we analyzed an aquatic acute toxicity dataset and compared the performances of single- and multi-objective fitness functions on different regression models. Our results show that our multi-objective algorithm is a valid alternative to classical QSAR modelling strategy, for continuous response values, since it automatically finds the model with the best compromise between statistical robustness, predictive performance, widest AD, and the smallest number of MDs.

AVAILABILITY AND IMPLEMENTATION

The python implementation of MaNGA is available at https://github.com/Greco-Lab/MaNGA.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Short-term effects of the Sander bite-jumping appliance on the pharyngeal airways in subjects with skeletal Class II malocclusion: A retrospective case-control study

BACKGROUND

Skeletal Class II subjects present often a retruded mandible that might increase the probability of breathing disorders.

OBJECTIVE

To evaluate the effects of functional treatment by means of the Sander bite-jumping appliance (BJA) on the upper airways of growing subjects.

METHODS

Thirty-four subjects (21 males, 13 females; mean age 11.1 ± 1.2 years) with skeletal Class II malocclusion due to mandibular retrusion were treated with the Sander BJA (BJA group). The control group consisted of thirty-four untreated subjects with skeletal Class II malocclusion (25 males, 9 females; 10.4 ± 1.2 years; CTR group). The effect of the Sander BJA appliance on the airway dimensions was evaluated by comparing lateral cephalograms recorded before (T0) and after (T1) the period of observation/treatment. Within- and between-group comparisons were statistically evaluated according to the distribution of the data (P < .05).

RESULTS

The oropharyngeal region (ph_pph) increased in the BJA group (1.8 ± 3.2; P = .001) but the difference respect to the CTR group was not statistically significant (0.73 ± 4.0; P = .314; P = .077). The tongue height (th) increased in the BJA group (2.8 ± 3.7; P < .001), and this increase was statistically significant respect to the CTR group (0.6 ± 4.7; P = .461; P = .038). In the BJA, the Ans_Pns_P angle showed a statistically significant decrease (-3.8 ± 7.8; P = .007) compared to the CTR group (-0.1 ± 5.4; P = .705; P = .026).

CONCLUSIONS

The airway dimensions increased for both control subjects and Class II patients treated with Sander BJA due to physiological growth. The Sander BJA induced a statistically significant change in the tongue and soft palate position, but the clinically relevant of these changes is questionable.

P1336 Sometimes the heart could appear different if seen under a magnetic resonance scanner: misdiagnosed cases of isolated left ventricle apical hypoplasia and double chambered left ventricle

Introduction

Congenital heart diseases (CHD) are detected in 1% of children, often usually the first year of life; however, many defects are diagnosed later or remain undiagnosed. Both congenital and acquired disorders could affect the left ventricle (LV). First-line assessment includes echocardiography; nonetheless, because of intrinsic or technical limitations and artefacts, further investigation may be required. Cardiac Magnetic Resonance (CMR) is capable of providing anatomical and functional information without many of limitations and drawbacks of echocardiography. We describe CMR findings of misdiagnosed cases of two rare congenital LV abnormalities: isolated LV apical hypoplasia (ILVAH) and double-chambered LV (DCLV).

Case report 1 (image A,B,D)

An 18 yrs girl diagnosed with dilated cardiomyopathy (DCM) was submitted to our CMR Lab for a functional assessment. After birth, deep Q waves in the inferior leads were noted on the ecg, and an echocardiographic examination showed a dilated and hypokinetic LV. At 1 year of age, she underwent cardiac catheterization that excluded coronary arteries anomalies and confirmed a reduced LV systolic function. A diagnosis of idiopathic DCM was formulated and she was initiated with anticongestive therapy. During the follow-up she felt well with normal exercise tolerance, longitudinal echocardiography did not show any substantial modification over the years. In 2018, a CMR study was performed. Surprisingly, the cardiac apex was formed exclusively by the right ventricle, wrapped around the LV. The LV appeared spherical and truncated inferiorly, and the apical portion was missing; LV volumes and ejection fraction were normal; regional akinesia and subendocardial late gadolinium enhancement (LGE) were evident at the inferior wall. These findings were consistent of ILVAH.

Case Report 2 (image C,E,F)

A 24 yrs old boy with prenatal diagnosis of LV diverticulum came to our observation for a CMR study. He was asymptomatic, particularly, no palpitations or syncope were referred, nor arrhythmias were detected during the follow-up; exercise tolerance was normal. CMR showed a coarse muscle band in the LV cavity, extending from the apex to the posterior papillary muscle, thus delimiting a contractile accessory chamber. LV volumes and global systolic function were normal. The LV accessory chamber presented a normal structured free lateral wall with a normal systolic thikening, except at the apical infero-lateral segment where it appeared thinned and akinetic and showed LGE with a subendocardial pattern. These findings were consistent of DCLV.

Conclusions

the LV could be affected by many diseases with different etiological, clinical and morphological features. Compared to other imaging diagnostic modalities, CMR allows better definition of LV morphology, function and tissue characterization, becoming essential for LV abnormalities diagnosis and follow-up.

Abstract P1336 Figure.

Correlation between cephalometric variables and obstructive sleep apnoea severity in children

AIM

Alterations in craniofacial growth have been associated with obstructive sleep apnoea in children. The main objectives of this study were to analyse the correlation between cephalometric variables and Obstructive Apnea/Hypopnea Index (OAHI) in order to investigate if craniofacial features may influence the severity of obstructive sleep apnoea and to study the correlation between upper nasopharyngeal width and maxillomandibular skeletal discrepancy in sagittal and vertical plane.

MATERIALS AND METHODS

Study Design: Correlations between cephalometric variables and obstructive sleep apnoea/hypopnea index and between upper airways space and maxillomandibular skeletal discrepancy were investigated. Forty-seven children with obstructive sleep apnoea diagnosed by overnight sleep study (polysomnography) underwent a lateral radiograph, orthodontic and ear-nose-throat examinations. Cephalometric analysis according to Kirjavainen has been performed to define skeletal and upper airways variables.

STATISTICS

Spearman's correlation analysis was performed between OAHI and all cephalometric variables. Pearson's correlation analysis was performed between cephalometric variables of upper airway space and cephalometric variables related to maxillomandibular discrepancy. Chi-square test was used to compare occlusal features with adenoidal and tonsillar hypertrophy. Kruskal-Wallis rank test was used to compare OAHI with occlusal variables and adenotonsillar hypertrophy.

RESULTS

The results show a positive correlation between OAHI and maxillomandibular discrepancy measured by ANB angle (rho=0.32; p=0.023). A significant correlation was found between upper nasopharyngeal width and vertical maxillomandibular skeletal discrepancy: 1) ad1-PNS were correlated to Mandibular Plane/Sella- Nasion angle (r=-0.36; p=0.012), Palatal Plane/Mandibular Plane angle (r=-0.39; p=0.007), and Posterior-Anterior Facial Height % (r=0.29; p=0.045); 2) ad2-PNS was correlated to Palatal Plane/Mandibular Plane angle (r=-0.39; p=0.007). No statistically significant differences were found in non-parametric tests between OAHI and occlusal variables or adenoidal and tonsillar hypertrophy.

CONCLUSIONS

The present study shows a significant correlation between maxillomandibular discrepancy and the severity of OSA. Moreover, the reduction of nasopharyngeal width was correlated to maxillomandibular hyperdivergent growth pattern. These results support the presence of a correlation between sleep-disordered breathing and craniofacial features even if the cause-effect relation is still unclear. Based on these evidences, we suggest the importance of orthodontic evaluation in the management of paediatric OSA.

Prevalence of malocclusion in children with obstructive sleep apnoea

OBJECTIVES

To describe the prevalence of malocclusions in 2- to 10-year-old children suffering from obstructive sleep apnoea (OSA) and to evaluate the association between occlusal variables and OSA.

SETTING AND SAMPLE POPULATION

A total of 2101 consecutive patients referred to an otorhinolaryngology unit were considered for the study. One hundred and fifty-six children (range 2-10 years) with suspected OSA were selected for a sleep study. The final sample consisted of 139 children suffering from OSA and a control group of 137 children.

MATERIALS AND METHODS

All patients included in the study underwent a clinical orthodontic examination to record the following occlusal variables: primary canine relationship, presence of a posterior crossbite, overjet and overbite. Odds ratios and 95% confidence intervals, comparing the demographic characteristics and dental parameters in OSA vs non-OSA children, were computed. Multivariable logistic regression models were developed to compare independent variables associated with OSA to non-OSA children.

RESULTS

The prevalence of malocclusions in children with OSA was 89.9% compared to 60.6% in the control group (P < 0.001). Factors independently associated with OSA compared to the control group were posterior crossbite (OR = 3.38; 95%CI:1.73-6.58), reduced overbite (OR = 2.43; 95%CI:1.15-5.15.), increased overbite (OR = 2.19; 95%CI:1.12-4.28) and increased overjet (OR = 4.25; 95%CI:1.90-9.48).

CONCLUSIONS

This study showed a high prevalence of malocclusion in children with OSA compared to the control group. The posterior crossbite and deviations in overjet and overbite were significantly associated with OSA. The presence of these occlusal features shows the importance of an orthodontic evaluation in screening for paediatric OSA.

Multidisciplinary approach to the treatment of double bilateral upper permanent incisors in a young boy

BACKGROUND

A double tooth is a rare developmental anomaly referring to the fusion of two adjacent tooth buds or the gemination of a single bud.

CASE REPORT

This case report describes the multidisciplinary approach to an 11-year-old patient with two double upper permanent incisors. The clinical intraoral examination showed a mixed dentition with bilateral double maxillary central incisors, molar Class I malocclusion and palatal ectopy of two lateral upper incisors. Computed tomography of the upper dental arch revealed the presence of double central incisors with two distinct roots. The clinical choice consisted of an innovative treatment including surgical, endodontic, orthodontic and restorative treatments. This management protocol produced good aesthetic, healthy and functional results that were stable also two years post-treatment.

The Menkes and Wilson disease genes counteract in copper toxicosis in Labrador retrievers: a new canine model for copper-metabolism disorders

The deleterious effects of a disrupted copper metabolism are illustrated by hereditary diseases caused by mutations in the genes coding for the copper transporters ATP7A and ATP7B. Menkes disease, involving ATP7A, is a fatal neurodegenerative disorder of copper deficiency. Mutations in ATP7B lead to Wilson disease, which is characterized by a predominantly hepatic copper accumulation. The low incidence and the phenotypic variability of human copper toxicosis hamper identification of causal genes or modifier genes involved in the disease pathogenesis. The Labrador retriever was recently characterized as a new canine model for copper toxicosis. Purebred dogs have reduced genetic variability, which facilitates identification of genes involved in complex heritable traits that might influence phenotype in both humans and dogs. We performed a genome-wide association study in 235 Labrador retrievers and identified two chromosome regions containing ATP7A and ATP7B that were associated with variation in hepatic copper levels. DNA sequence analysis identified missense mutations in each gene. The amino acid substitution ATP7B:p.Arg1453Gln was associated with copper accumulation, whereas the amino acid substitution ATP7A:p.Thr327Ile partly protected against copper accumulation. Confocal microscopy indicated that aberrant copper metabolism upon expression of the ATP7B variant occurred because of mis-localization of the protein in the endoplasmic reticulum. Dermal fibroblasts derived from ATP7A:p.Thr327Ile dogs showed copper accumulation and delayed excretion. We identified the Labrador retriever as the first natural, non-rodent model for ATP7B-associated copper toxicosis. Attenuation of copper accumulation by the ATP7A mutation sheds an interesting light on the interplay of copper transporters in body copper homeostasis and warrants a thorough investigation of ATP7A as a modifier gene in copper-metabolism disorders. The identification of two new functional variants in ATP7A and ATP7B contributes to the biological understanding of protein function, with relevance for future development of therapy.

Summary: Labrador retrievers with hereditary copper toxicosis are a useful new model for copper-metabolism disorders.

Evaluation of Distensibility and Stiffness of Ascending Aortic Aneurysm using Magnetic Resonance Imaging

INTRODUCTION

Magnetic resonance imaging emerging as a new tool for the diagnosis and evaluation of ascending aortic aneurysm. The aim of our study is to evaluate in vivo distensibility and pulse wave velocity of the aortic wall using functional magnetic resonance imaging technique.

METHODS

We enrolled 25 patients undergoing surgery for ascending aortic aneurysm and or aortic valve replacement for a period of 8 months. Preoperatively, all the patients underwent functional MRI study of the aorta. Aortic wall distensibility and pulse wave velocity of ascending aorta was evaluated.

RESULTS

Mean age of the patient was 66 years (66.68 ± 5.62 years) with 60% (15) male patients. More than fifty percentages of patients were smoker (52%), hypertensive (64%) and diabetic (56%). We have observed significant decrease of distensibilty in the patients with aortic diameter above 50 mm (p-0.0002). Furthermore, we have found a significant inverse correlation between aortic distensibility and pulse wave velocity (R= -0.650, R2= 0.42, p-0.0004). Similarly, we have found a significant inverse correlation between ascending aortic diameter and distensibility of the aorta (R= -0.785, R2= 0.61, p-0.00001). Statistically significant positive correlation was observed between aortic diameter and pulse wave velocity (R= 0.865, R2= 0.74, p-0.00001).

CONCLUSIONS

MRI measurement of aortic diameters, distensibility, and flow wave velocity is an easy, reliable and reproducible technique. Distensibility and pulse wave velocity define the elasticity of the aorta. We have observed that elasticity of aortic wall is decreased in ascending aorta aneurysm patients.

Unexpected histopathologic result of a wide surgical excision of a bleeding lesion of the skin: a case of Merkel cell carcinoma of the leg

BACKGROUND

Merkel cell Carcinoma is a very rare primary cutaneous tumor that often looks like an innocuous and asymptomatic nodule or plaque of the skin, but with a very fast growing. It is also called neuroendocrine carcinoma of the skin or trabecular cancer. The main treatment is based on a local excision followed by radiotherapy or chemotherapy. The most common site of presentation of this lesion is head and neck (40-60%.) and it often occur in older men with immunological system dysfunction like HIV patients, cancer, severe infections and immunosuppression for transplantation.

METHODS

The authors report a case of a bleeding Merkel Cell Carcinoma of the right leg in a 83 years old man with HCV infection, chronic kidney disease and diabetes mellitus type 2 that required local excision.

RESULTS

Lesion was entirely removed and then patient was sent to oncologists. After two months from surgical excision, healing process is regular and without complications.

CONCLUSIONS

This type of tumor can be misdiagnosed and, if bleeding, it can represent a serious surgical emergency.

Effects of simultaneous palatal expansion and mandibular advancement in a child suffering from OSA

This clinical report describes a child suffering from obstructive sleep apnoea (OSA) and class II skeletal malocclusion with maxillary contraction and anterior open bite. He presented moderate obstructive sleep apnoea with large impact on quality of life of patient and parents. He was treated using an innovative orthodontic device (Sleep Apnea Twin Expander) to simultaneously carry out palatal expansion and mandibular advancement. After orthodontic therapy, the OSA-18 questionnaire demonstrated an improvement of the main respiratory symptoms, while cardiorespiratory sleep study revealed a reduction in obstructive sleep apnoea events. Post-treatment, clinical assessment and cephalometric analysis showed a reduction of sagittal maxillary discrepancy and an extension of upper airway space. In conclusion, this case report suggests that orthodontic treatment might be a valuable alternative treatment in children with obstructive sleep apnoea related to craniofacial anomalies.

A biased random-key genetic algorithm for data clustering

Cluster analysis aims at finding subsets (clusters) of a given set of entities, which are homogeneous and/or well separated. Starting from the 1990s, cluster analysis has been applied to several domains with numerous applications. It has emerged as one of the most exciting interdisciplinary fields, having benefited from concepts and theoretical results obtained by different scientific research communities, including genetics, biology, biochemistry, mathematics, and computer science. The last decade has brought several new algorithms, which are able to solve larger sized and real-world instances. We will give an overview of the main types of clustering and criteria for homogeneity or separation. Solution techniques are discussed, with special emphasis on the combinatorial optimization perspective, with the goal of providing conceptual insights and literature references to the broad community of clustering practitioners. A new biased random-key genetic algorithm is also described and compared with several efficient hybrid GRASP algorithms recently proposed to cluster biological data.

Oral parafunctions as risk factors for diagnostic TMD subgroups

The frequency of diurnal clenching and/or grinding and nail-biting habits was assessed in patients affected by temporomandibular disorders (TMDs) and in healthy controls in order to investigate the possible association between these oral parafunctions and different diagnostic subgroups of TMDs. The case group included 557 patients (127 men, mean age +/- SD = 34.5 +/- 15.4 years; 430 women, mean age +/- SD = 32.9 +/- 14.1 years) affected by myofascial pain or disc displacement or arthralgia/arthritis/arthrosis. The control group included 111 healthy subjects (55 men, mean age +/- SD = 37 +/- 15.2 years; 56 women, mean age +/- SD = 38.2 +/- 13.8 years). Multinomial logistic regression analysis was used to assess the association between oral parafunctions and TMDs, after adjusting for age and gender. Daytime clenching/grinding was a significant risk factor for myofascial pain (odds ratio (OR) = 4.9, 95% confidence interval (CI): 3.0-7.8) and for disc displacement (OR = 2.5, 95% CI: 1.4-4.3), nail biting was not associated to any of the subgroups investigated. Female gender was a significant risk factor for myofascial pain (OR = 3.8; 95% CI: 2.4-6.1), whereas the risk factor for developing disc displacement decreased with ageing. No association was found between gender, age and arthralgia/arthritis/arthrosis.

[Diaphragmatic rupture with intrathoracic hepatic dislocation. Two case report]

The authors show two cases of diaphragmatic rupture by blunt trauma with intra thoracic liver dislocation due to an accident on the street. The preoperative diagnosis has been based on the CT scan. The laparotomy, central for a patient and sub costal bilateral for the other one, gave the chance to repair the diaphragmatic defect directly and to deal with the associated lesions existing in both the casualties. No prosthetic material has been used and the reconstruction of the diaphragmatic defect has been conducted through a interrupted suture with non absorbable material. According to our experience the reparation of the diaphragmatic defect has always been conducted through a laparotomic approach and without using any prosthetic material. We repute that in these cases the laparotomic approach is the best one, which permits not only the reparation of the diaphragmatic defect but also the correct management of the related lesions which could be present. Usually we use a interrupted suture with non absorbable material for minor lesions and a continuous one, double layered if possible, for the major ones.

Amino-terminal fragment of pro-brain natriuretic hormone identifies functional impairment and right ventricular overload in operated tetralogy of Fallot patients

To evaluate the relationship between plasma concentration of amino-terminal fragment of pro-brain natriuretic peptide (NT-proBNP), functional capacity, and right ventricular overload in survivors of tetralogy of Fallot (TOF) repair, we prospectively studied 70 operated TOF patients (44 males, 21 +/- 1 years old; mean +/- SEM) who underwent, during the same day, echocardiography, cardiac magnetic resonance imaging, neurohormonal characterization (plasma NT-proBNP, catecholamines, plasma renin activity, and aldosterone assay), and cardiopulmonary exercise testing. Forty-eight age- and sex-matched healthy volunteers served as the control group. Compared to controls, maximal workload and peak oxygen consumption (VO2/kg) were lower in operated TOF patients (p < 0.001), whereas NT-proBNP concentration was elevated (p < 0.001). No difference was found among the other neurohormones. In operated TOF patients, NT-proBNP showed a significant positive correlation with right ventricular (RV) end systolic and end diastolic volumes and RV systolic pressure, and it showed a negative correlation with peak VO2/kg and RV ejection fraction. From multivariable analysis, NT-proBNP concentration was found to be an independent predictor of peak VO2/kg, RV end systolic volume, and RV systolic pressure. These results show an association among RV overload, decrease in functional capacity, and cardiac natriuretic peptide expression in operated TOF patients. NT-proBNP plasma assay may be a useful tool for diagnostic purposes and for decision making in this setting.

On some optimization problems in molecular biology

In the last two decades, the study of gene structure and function and molecular genetics have become some of the most prominent sub-fields of molecular biology. Computational molecular biology has emerged as one of the most exciting interdisciplinary fields, riding on the success of the ongoing Human Genome Project, which culminated in the 2001 announcement of the complete sequencing of the human genome. The field has currently benefited from concepts and theoretical results obtained by different scientific research communities, including genetics, biochemistry, and computer science. It is only in the past few years that it has been shown that a large number of molecular biology problems can be formulated as combinatorial optimization problems, including sequence alignment problems, genome rearrangement problems, string selection and comparison problems, and protein structure prediction and recognition. This paper provides a detailed description of some among the most interesting molecular biology problems that can be formulated as combinatorial optimization problems and proposes a new heuristic to find improved solutions for a particular class of them, known as the far from most string problem.

Tetralogy of fallot with left heart hypoplasia, total anomalous pulmonary venous return, and right lung hypoplasia: role of magnetic resonance imaging

We report a rare case of tetralogy of Fallot with total anomalous pulmonary venous return, left heart hypoplasia, right lung hypoplasia, and left ocular-mandibular synchinesia (Marcus-Gunn phenomenon), correctly diagnosed by cardiovascular magnetic resonance imaging and successfully operated by modified Glenn anastomosis.

[Primary anastomosis in the neoplastic colonic obstruction]

The authors report their own experience on the treatment of large bowel obstruction caused by a neoplastic stenosis. During a 36-month period 110 operations for emergency large bowel obstructions were performed: 59 (53.6%) underwent primary anastomosis without colostomy (28 right colectomy, 16 left colectomy, 9 sub-total and 6 total colectomy). Total group post-operative mortality was 2.9% as a result of cardio-pulmonary complications. Morbidity was 19.8%, included a 3% of anastomotic leak underwent surgical treatment. Our results suggest that resection and primary anastomosis can be performed with acceptable morbidity and mortality in a high proportion of cases of emergency large bowel obstructions.

[Abdominal lymphoma with abscess and thoracic perforation: en-bloc resection]

The authors compare a rare case of acute onset Gastric Lymphoma with that present in the literature. The patient, a white 67 year-old man, was admitted to hospital in severe general condition. On CT scan an opacity of the pleura and a subtotal collapse of the left lung associated with a mass infiltrating the diaphragm, the gastric fundus and pancreas were seen. After 48 hours from the admission an operation was performed. The abdominal mass infiltrating the stomach, the spleen and the left thorax was resected en-bloc by laparotomy. A Boulau drainage was inserted. The histology showed an high malignant, diffused, big cell lymphoma. The patient was discharged 23 days later after a regular postoperative course. Surgery can be necessary, sometime curative in gastric lymphomas while long term result and quality of life could be improved by chemotherapy.

Transcatheter closure of atrial septal defects with the STARFlex device: early results and follow-up

BACKGROUND

The STARFlex (SF) device is a CardioSEAL (CS) double-umbrella device that has been modified by the addition of a self-centering mechanism comprised of nitinol springs connected between the two umbrellas and a flexible core wire with a pin-pivoting connection. This paper compares the results of atrial septal defect (ASD) closure with CardioSEAL and STARFlex devices.

PATIENTS AND METHODS

Between December 1996 and March 2000, 117 patients underwent ASD closure with CardioSEAL (n = 79) and STARFlex (n = 38). The mean age (17 years), weight (49 kg), and ASD size (15 mm) were similar in the two groups. The procedures were performed under general anesthesia with both fluoroscopic and transesophageal echocardiographic monitoring.

IMMEDIATE RESULTS

The devices were successfully implanted in all patients. Ten patients had multiple ASDs. A single device was used in four patients (CardioSEAL in three, STARFlex in one), while a simultaneous placement of two CardioSEAL (one patient) or two STARFlex (five patients) were performed in six patients. The results are summarized as follows: [table: see text] Follow-Up Results: On follow-up clinical exam, electrocardiograms, chest X-rays, and echocardiograms were obtained at 1, 6, and 12 months. [table: see text] During follow-up there were no deaths, endocarditis, rhythm disturbances, or other complications. Arm fractures were observed almost exclusively with large CardioSEAL devices (40 mm, less frequently with 33 mm), and only in one 33-mm STARFlex device. There were no clinical complications related to fractures.

CONCLUSIONS

The STARFlex device seems to offer better results than the CardioSEAL, with significantly lower rates of residual shunts and arm fractures.

Lack of effects of recombinant human growth hormone in a child with a complex cardiovascular malformation and dilated cardiomyopathy

Recent studies have suggested the beneficial effects of GH treatment in patients with dilated cardiomyopathy. We have treated with recombinant human growth hormone (rhGH) a 6-year-old female with a complex congenital heart defect (severe tricuspid hypoplasia and malposition of the great arteries), who developed a progressive dilated cardiomyopathy of unknown etiology. rhGH treatment (0,1 U/kg/day, for 3 months) did not improve cardiac function, nor clinical symptoms, although we have no clear explanations for this. However, a trial with rhGH may be offered to children with dilated cardiomyopathy and waiting for heart transplantation.

Rapid reversal of dilated cardiomyopathy following removal of neuroblastoma

Reported is a child with dilated cardiomyopathy, in whom medical therapy resulted in a mild improvement of cardiac function. Metabolic studies suggested the presence of a catecholamine-secreting tumour; and an adrenal neuroblastoma was identified and surgically removed. Following surgery, there was progressive and complete normalization of cardiac function. Although very rare, neurogenic tumours may be involved in the development of a dilated cardiomyopathy in the infant and child.

Mechanical valves in the pulmonary position: a reappraisal

OBJECTIVES

To evaluate midterm results of mechanical valves in pulmonary position in patients with pulmonary regurgitation and right ventricular dysfunction as an alternative to bioprostheses.

PATIENTS

Mechanical valves (six tilting disc valves and two bileaflet valves) were implanted in eight patients previously operated on for tetralogy of Fallot (n = 7) and truncus arteriosus (n = 1), with severe right ventricular dysfunction caused by massive pulmonary regurgitation.

RESULTS

All patients survived prosthesis implantation and are currently well. At follow-up (3 months to 9 years), they do not show signs of valve failure, and right ventricular function has dramatically improved in all but one, who still shows moderate ventricular hypokinesia.

CONCLUSION

After operative correction of congenital heart defects in selected patients who show severe dysfunction of the right ventricle caused by pulmonary regurgitation/stenosis, mechanical valves may represent an alternative to bioprosthetic valves. The selection of the valve type is still a matter of debate. However, according to literature data, complications seem to have occurred only in patients with bileaflet mechanical valves in the pulmonary position, whereas no thromboembolic episodes or valve failure is reported in subjects with tilting disc valves in the right ventricular outflow. Tilting disc valves might perform better in the right ventricular outflow than bileaflet valves.

Idiopathic right pulmonary artery aneurysm with pulmonary valve insufficiency

A case of idiopathic right pulmonary artery aneurysm with pulmonary valve insufficiency simulating a mediastinal teratoma occurred in an asymptomatic 13-year-old boy. The key to correct diagnosis was pulmonary angiography. The patient was successfully treated with surgery.

[The surgical treatment of fixed aortic subvalvular stenosis]

Over the past 5 years, 45 patients (11 adults and 33 children) have undergone operations for discrete and fixed subaortic stenosis. The resection of the subvalvular membrane or the fibromuscular collar was the procedure of choice. 28 patients underwent myectomy and/or myotomy. None patients died during operations. No significant symptoms and gradients remained after operation. We conclude that in the surgical management of fixed discrete subaortic stenosis myectomy and myotomy in addition to membranectomy produces better relief of the left ventricular outflow obstruction than do membranectomy alone.

[Percutaneous closure of interatrial defect using the buttoned double-disk prosthesis]

BACKGROUND

Surgical repair is the procedure of choice for atrial septal defect correction. Even though surgical mortality is low (< 1%), morbidity is significant (anesthesia, thoracotomy, cardiopulmonary bypass, longer hospitalization and intensive care unit monitoring). Transcatheter methods to occlude atrial septal defects have been in development during the last two decades. We report our experience in Italy with the Sideris buttoned double-disk device.

METHODS

From March 1992 to April 1993, 14 patients aged 20 months to 52 years, weight 10 to 82 kg, underwent transcatheter atrial septal defect occlusion with the Sideris buttoned device. The buttoned device is a miniaturized two disk device introduced through small venous sheaths (8-9 F). The diameter of atrial septal defects by echocardiography varied between 9 and 23 mm, while the balloon stretched diameter of the defects varied between 13 and 24 mm. The devices selected were 19 +/- 4 mm larger than the stretched diameter of the defect, but less than the total length of the septum (33-56 mm) by echo.

RESULTS

Pulmonary-to-systemic flow ratio varied between 1.5 to 4.0. Mean pulmonary artery pressure varied between 10 and 24 mmHg (mean value 17 +/- 3.5 mm Hg). The relationship between different atrial septal defect measurements (echo, shunt flow, stretched diameter) was statistically analysed: transthoracic echo diameter had a good correlation with the balloon stretched diameter (r = 0.63, p < 0.001). The atrial septal defect was occluded in 12 patients (86% success rate). There was one early "unbuttoning" which was surgically corrected with success. The other patient underwent surgical correction 3 months later because of unsuitability for transcatheter closure. Minimal residual shunt detected by color flow mapping at 1 month follow-up was seen in 4 patients (33%). No complications occurred in any of our patients.

CONCLUSIONS

This initial experience with the Sideris buttoned double-disk device demonstrated that transcatheter closure of atrial septal defect is feasible and effective. It can be accomplished through small introducing sheaths. Further clinical trials are justified. This method could become the procedure of choice for the correction of small ASDs.

Infundibular septal defect with severe aortic regurgitation: a new surgical approach

Aortic regurgitation associated with prolapse of an aortic cusp and an infundibular septal defect is caused by the lack of anatomical support for the aortic annulus by the conal septum. This fact is taken into consideration in the new surgical approach that we performed in 5 children 3 to 16 years of age with infundibular ventricular septal defect and severe aortic regurgitation. The ventricular septal defect is closed by a patch anchored to another patch through the prolapsed cusp. This second patch is pulled up with the prolapsed cusp and is then fixed in the aortic wall. In all 5 patients, all clinical signs of aortic insufficiency disappeared, and only minimal aortic regurgitation could be demonstrated by color Doppler mapping.

[Total anomalous pulmonary venous drainage: is a surgical correction possible on the sole basis of echocardiography?]

Between April '83 and August '89, 33 patients with total anomalous pulmonary venous drainage were studied at the department of Cardiology in Bergamo. There were 18 males and 15 females, aged between three days and 8 months (average: two months). In this study only cases of isolated total anomalous pulmonary venous drainage were taken into consideration. The patients underwent echocardiographic examination with ATL MK 600, Vingmed 700, ATL Ultramark 9 with 3.5; 5; 7.5; MHz transducers; in the last three years the echocardiographic examination was integrated by continuous and pulsed wave Doppler and, in the last year, by color Doppler. The morphologic diagnosis was routinely established by means of the sequential approach method. A common feature in all types of total anomalous pulmonary venous drainage was the impossibility of defining the connections of the pulmonary veins with the left atrium. Furthermore, patients had a volume overload of the right heart, and atrial septal defects of various sizes. The site of anomalous drainage of the pulmonary veins was assessed by means of multiple cuts from subcostal, precordial and suprasternal windows. The echocardiographic diagnosis was exact and complete in 29 cases (87.9%), and in four cases it was incomplete but basically correct (12.1%). The anatomical findings were confirmed during cardiac surgery in 32 cases and by autopsy in one case of supracardiac total anomalous pulmonary venous drainage in a critically ill patient, who died before surgery. Of the 32 patients who underwent surgical correction, 20 (62.5%) had only an echocardiographic diagnosis, which resulted correct in all cases. The majority of patients with isolated TAPVD can be confidently diagnosed by means of echocardiography, thus, avoiding preoperative catheterization.

Aortopulmonary window coexisting with tetralogy of Fallot: echocardiographic diagnosis

Aortopulmonary window coexisting with tetralogy of Fallot (TF) was prospectively diagnosed by two-dimensional (2D) echocardiography and Doppler in an 18-month-old boy; the diagnosis was confirmed by cardiac catheterization and angiocardiography. Surgical correction was performed, but the patient died in the operating room from right ventricular dysfunction. The autopsy showed an adequate surgical repair, but the histologic examination of the lungs demonstrated severe pulmonary vascular disease, which was presumed to be the cause of death.