Safety and efficacy of peptide receptor radionuclide therapy in neuroendocrine tumors: A single center experience

Peptide receptor radionucleotide therapy (PRRT) with 177Lu-dotatate is widely used for the treatment of patients with neuroendocrine tumors (NETs). We analyzed data from 104 patients with NETs treated with 177Lu -dotatate at a US academic center between December 2017 and October 2020 to better understand patterns of long-term efficacy, safety, and toxicity in the real-world setting. 177Lu-dotatate (200 mCi) was administered every eight weeks for four doses. The most common sites of primary disease were small intestine NETs (n = 49, 47%), pancreatic NETs (n = 32, 31%), and lung NETs (n = 7, 7%). Twenty-seven percent had Ki-67 <3%, 49% had Ki-67 between 3-20%, and 13.5% had Ki-67 >20%. The cohort had been pretreated with a median of two prior lines of treatment. Forty percent had received prior liver-directed treatment. Seventy-four percent of patients completed all four doses of treatment. The objective response rate was 18%. The median time-to-treatment failure/death was significantly longer for small-bowel NETs when compared to pancreatic NETs (37.3 months vs. 13.2 months, p = 0.001). In a multivariate model, Ki-67, primary site, and liver tumor burden ≥50% were found to independently predict time-to-treatment failure/death. Around 40% of patients experienced adverse events of ≥grade 3 severity. Treatment-related adverse events leading to discontinuation of therapy happened in 10% of patients. Preexisting mesenteric/peritoneal disease was present in 33 patients; seven of these patients developed bowel-related toxicities including two grade 5 events. We also report two cases of delayed-onset minimal change nephrotic syndrome, which occurred 14 and 27 months after the last dose of PRRT. Lastly, we describe six patients who developed rapid tumor progression in the liver leading to terminal liver failure within 7.3 months from the start of PRRT, and identify potential risk factors associated with this occurrence, which will need further study.

Comparison of clinical performance of obturating materials in pulpectomies: A randomized clinical trial

BACKGROUND

Chemomechanical debridement is insufficient to disinfect all bacteria from the root canals of primary teeth, and obturation of canals with an appropriate material thus acquires excellent importance and remains a critical step in the ultimate success of pulpectomy.

AIM

The aim of the study was to compare and evaluate Endoflas, Metapex, and a mixture of calcium hydroxide (CH) and zinc oxide (ZnO) as obturating materials (OMs) in primary mandibular second molars.

MATERIALS AND METHODS

Seventy-five mandibular second primary molars requiring pulpectomies were identified in children aged 4-8 years. They were randomly allocated to the three treatment groups according to the type of OM received using the block randomization technique. After the completion of chemomechanical debridement, the canals were filled with Endoflas, Metapex, and CH-ZnO mixture, respectively. The intergroup clinical and radiographic comparison was made based on Coll and Sadrian criteria to decipher their clinical performance at 1, 3, and 6 months.

RESULTS

No statistically significant differences between the groups were observed at any evaluation time interval (P > 0.05). At 6 months, the clinical success rates were 95.2% in Endoflas, 96% in Metapex, and 95.8% in the CH and ZnO mixture groups, respectively. The materials, however, behaved differently in different clinical situations.

CONCLUSION

Based on the observations, all three OMs showed similar clinical success in maintaining tooth functioning, but their use can be restricted to indications. However, prospective studies with longer follow-ups with more stringent eligibility criteria are required to reach more definitive conclusions.

Deep Learning Models for Classification of Deciduous and Permanent Teeth From Digital Panoramic Images

INTRODUCTION

Dental radiographs are essential in the diagnostic process in dentistry. They serve various purposes, including determining age, analyzing patterns of tooth eruption/shedding, and treatment planning and prognosis. The emergence of digital radiography technology has piqued interest in using artificial intelligence systems to assist and guide dental professionals. These cutting-edge technologies assist in streamlining decision-making processes by enabling entity classification and localization tasks. With the integration of artificial Intelligence algorithms tailored for pediatric dentistry applications and utilizing automated tools, there is an optimistic outlook on improving diagnostic capabilities while reducing stress and fatigue among clinicians.

METHODOLOGY

The dataset comprised 620 images (mixed dentition: 314, permanent dentition: 306). Panoramic radiographs taken were within the age range of 4-16 years. The classification of deciduous and permanent teeth involved training CNN-based models using different architectures such as Resnet, AlexNet, and EfficientNet, among others. A ratio of 70:15:15 was utilized for training, validation, and testing, respectively.

RESULT AND CONCLUSION

The findings indicated that among the models proposed, EfficientNetB0 and EfficientNetB3 exhibited superior performance. Both EfficientNetB0 and EfficientNetB3 achieved an accuracy rate, precision, recall, and F1 scores of 98% in classifying teeth as either deciduous or permanent. This implies that these models were highly accurate in identifying patterns/features within the dataset used for evaluation.

Coronary Artery and Peripheral Vascular Disease in a Patient with Poorly Differentiated Thyroid Cancer Treated with the Tyrosine Kinase Inhibitor Lenvatinib

A subset of patients with differentiated thyroid carcinoma develop radioiodine refractory (RAIR) incurable disease, which typically has a poor prognosis. The multitargeted tyrosine kinase inhibitor lenvatinib has demonstrated significant improvements in progression-free survival in RAIR thyroid cancers compared to placebos. However, in the phase III SELECT trial of the drug in thyroid cancer, 5.4% of patients on lenvatinib experienced arterial thromboembolic events, with 2.7% experiencing severe grade ≥3 toxicities associated with arterial vascular events. This case study reports a patient with metastatic poorly differentiated follicular thyroid cancer who developed significant obstructive coronary artery disease following initiation of lenvatinib treatment, despite no predisposing cardiovascular risk factors apart from a remote smoking history. The possibility of developing coronary or peripheral artery disease should be considered in patients who are on targeted therapies, such as lenvatinib, even in the absence of traditional cardiovascular risk factors. In addition, baseline cardiac risk assessment and early treatment should be pursued to minimize interruptions to potentially lifesaving cancer therapy.

'PartBreCon' study. A UK multicentre retrospective cohort study to assess outcomes following PARTial BREast reCONstruction with chest wall perforator flaps

BACKGROUND

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes.

METHODS

STROBE-compliant protocol ascertained CWPF outcomes between March 2011-March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis.

RESULTS

Across 15 centres, 507 patients with median age (54 years, IQR; 48-62), body mass index (25.4 kg/m2, IQR; 22.5-29), tumour size (26 mm, IQR; 18-35), and specimen weight (62 g, IQR; 40-92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11-39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%).

CONCLUSIONS

This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes.

Central Odontogenic Fibroma of the Mandible in a 9-year-old Child: A Case Report with 24-month Follow-up

Background

Central odontogenic fibroma (COF) is a rarely benign tumor with an incidence of only 0.1% among all odontogenic tumors, which commonly involve the mandible.

Case description

A 9-year-old child reported with asymptomatic bony expansion of the mandible, showing an unilocular radiolucency on an orthopantomogram. The tumor was managed surgically by enucleation, and the surgical stent was placed, which was later modified as a removable functional space maintainer. The patient was followed up for 24 months with the complete healing of periapical radiolucency and the eruption of displaced permanent tooth to the proper position.

Conclusion

This case report discusses the importance of the dentist in assessing and diagnosing COF, especially in the pediatric age group.

Visual learning strategies for oral health promotion and treatment interventions in children and adolescents with hearing impairment - A systematic review

AIM

People with hearing impairment (HI) prefer visual learning strategies in daily activities owing to their reliance on vision. The aim of this systematic review is to evaluate the effectiveness of visual learning as a communication strategy in improving oral hygiene and dental care of children and adolescents with HI.

METHODS AND RESULTS

Four electronic databases were searched and complemented by hand searching for original intervention studies published till December 2021. Eligible studies were screened, data was extracted as per priori data collection form and analyzed by thematic content analysis. The quality of studies was assessed as per the validated tools appropriate for study designs including ROB2, ROBINS-I, and NIH quality assessment tool. Out of 4159 records identified and 1302 duplicates removed, 24 original studies were identified and the visual learning strategies were classified into sign language, visual aids with or without sign language, customized educational demonstrations and the interim role of training the teachers. These strategies helped in improving oral hygiene status, oral health-related knowledge and attitude as well as dental anxiety during treatment. Participants were found to be satisfied with these strategies, however, significant heterogeneity in the included studies precluded meaningful meta-analysis. ROB2 and ROBINS were rated as high and serious in all included trials, respectively, and NIH Quality Assessment Tool for Pre-Post Studies With No Control as fair in five studies and poor in three.

CONCLUSION

Our findings emphasize the significance of visual learning, however, long-term rigorously designed trials are needed to better understand effective and patient-centered communication methods for people with HI.

Choroidal Thickness in Patients with Unilateral Amblyopia and Comparison between Anisometropic and Strabismic Amblyopia: A Prospective Cross-Sectional Study

Aims and Objectives

To determine the choroidal thickness (mainly subfoveal) using spectral domain optical coherence tomography (SD-OCT) in amblyopic eyes and to compare it with the choroidal thickness (CT) of healthy fellow eyes.

Materials and Methods

In this prospective study, 140 eyes of 70 patients (aged 5-40 years) with strabismic and anisometropic amblyopia were examined using enhanced depth imaging (EDI) mode in SD-OCT. The CT was measured directly below the fovea and six other locations: 500 μ, 1000 μ, and 1500 μ from fovea in both nasal and temporal quadrants.

Results

The mean age of the patients was 22.5 ± 11.2 years. The mean Best Corrected Visual Acuity (BCVA) in the amblyopic eyes was 0.87 ± 0.47 logMAR and 0 ± 0.02 logMAR in control eyes. The average subfoveal CT was 341.73 ± 60.39 μm in the amblyopic eyes and 314.77 ± 48.12 μm in the fellow eyes. Subgroup analysis showed that the patients with anisometropic amblyopia had a significantly thicker choroid as compared to the fellow healthy eyes (P = 0.00), whereas in strabismic amblyopic eyes, this difference was not significantly significant (P = 0.064).

Conclusion

Significant choroidal thickening was observed in subjects with amblyopia, which may contribute to the amblyopia pathogenesis and this could be used as a diagnostic parameter for amblyopia. These changes were more pronounced in patients with anisometropic amblyopia than strabismic amblyopia.

An International Investigation of Molar Incisor Hypomineralisation (iMIH) and Its Association with Dental Anomalies: Development of a Protocol

BACKGROUND

Molar incisor hypomineralisation (MIH) is a common disorder of tooth development, which has recently been found to be associated with a higher prevalence of hypodontia. The aim of this international multicentre study is to determine the association between MIH and other developmental anomalies in different populations.

METHODS

Investigators were trained and calibrated for the assessment of MIH and dental anomalies and ethical approvals obtained in each participating country. The study aimed to recruit 584 children with MIH and 584 children without MIH. Patients aged 7-16 years who attend specialist clinics will be invited to participate. Children will undergo a clinical examination to determine the presence and severity of MIH, using an established index. The presence of any other anomalies, affecting tooth number, morphology, or position, will be documented. Panoramic radiographs will be assessed for dental anomalies and the presence of third permanent molars. Statistical analysis, using a chi squared test and regression analysis, will be performed to determine any differences in dental anomaly prevalence between the MIH and non-MIH group and to determine any association between dental anomalies and patient characteristics.

CONCLUSION

This large-scale study has the potential to improve understanding about MIH with benefits for patient management.

A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids

OBJECTIVE/INTRODUCTION

Ketamine is an opioid-alternative used for analgesia in the prehospital setting. There are knowledge gaps regarding its use during emergency medical services (EMS) encounters for pediatric patients. Our objective was to compare pain reduction, adverse events, and prehospital deaths between ketamine and opioids when used for analgesia administered by any route among pediatric patients.

METHODS

This was a retrospective review of 9-1-1 EMS records of injured pediatric patients (≤17 years of age) who received ketamine or opioids for analgesia using the ESO Data Collaborative (calendar years 2019-2020). We excluded interfacility transfers, patients receiving both medications, those with EMS clinician impressions indicating behavioral disorders, and those who received medication to facilitate advanced airway placement. EMS narrative review was performed to confirm ketamine use was for analgesia and to identify any unplanned airway placements. We assessed pain score reduction (0-10 ordinal scale) and clinician-documented patient response (improved, unchanged, worsened, unknown). Adverse events were defined as change in vital signs (GCS, SBP, RR, SpO2), bag valve mask ventilation alone, or death. Descriptive statistics were calculated to compare outcomes between groups.

RESULTS

Overall, 9,223 patients were included, 190 (2.1%) received ketamine and 9,033 (97.9%) received opioids. Mean age in years was 12.8 [SD 4.0] for ketamine and 12.7 [SD 4.0] for opioids. Patients in both groups experienced pain reduction, and more patients receiving ketamine had EMS clinician reported improvement (93.2% vs. 87.9%, p = 0.03). Ketamine was associated with a greater average reduction in pain score than opioids (mean difference: -4.4 [SD 3.5], and -3.1 [SD 2.8], p < 0.001). Adverse events were rare with few patients receiving ventilatory support following the use of ketamine or opioids, (0, [SD 0.0%] vs. 6 [SD 0.1%], p = 1). There were no unplanned airway placements or prehospital deaths identified.

CONCLUSION

We identified similar high rates of pain reduction and rare adverse events among pediatric patients who received ketamine or opioids. A greater pain reduction was noted among patients administered ketamine. Intubation as a result of medication administration did not occur and need for ventilatory assistance was rare.

A Phase II Clinical Trial of Nivolumab and Temozolomide for Neuroendocrine Neoplasms

PURPOSE

Treatment options are limited in patients with metastatic neuroendocrine neoplasms (NEN). We present the results for a phase II trial of combination nivolumab and temozolomide in patients with advanced NEN along with results of immune changes in peripheral blood.

PATIENTS AND METHODS

NCT03728361 is a nonrandomized, phase II study of nivolumab and temozolomide in patients with NEN. The primary endpoint was response rate using RECIST 1.1. Secondary endpoints included progression-free survival (PFS), overall survival (OS), and safety. Immune profiling was performed by mass cytometry to evaluate the effect on peripheral blood immune cell subsets.

RESULTS

Among all 28 patients with NEN, the confirmed response rate was 9/28 [32.1%, 95% confidence interval (CI): 15.9-52.4]. Of 11 patients with lung NEN, the response rate was 64% (n = 7); there was a significant difference in responses by primary tumor location (lung vs. others, P = 0.020). The median PFS was 8.8 months (95% CI: 3.9-11.1 months), and median OS was 32.3 months (95% CI: 20.7-not reached months). Exploratory blood immune cell profiling revealed an increase in circulating CD8+ T cells (27.9% ± 13.4% vs. 31.7% ± 14.6%, P = 0.03) and a decrease in CD4+ T cells (59.6% ± 13.1% vs. 56.5% ± 13.0%, P = 0.001) after 2 weeks of treatment. LAG-3-expressing total T cells were lower in patients experiencing a partial response (0.18% ± 0.24% vs. 0.83% ± 0.55%, P = 0.028). Myeloid-derived suppressor cell levels increased during the study and did not correlate with response.

CONCLUSIONS

Combination nivolumab and temozolomide demonstrated promising activity in NEN. See related commentary by Velez and Garon, p. 691.

Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies

INTRODUCTION

Ketamine is an emerging alternative sedation agent for prehospital management of agitation, yet research is limited regarding its use for children. Our objective was to compare the effectiveness and safety of ketamine and benzodiazepines when used for emergent prehospital sedation of pediatric patients with behavioral emergencies.

METHODS

We performed a retrospective review of 9-1-1 EMS records from the 2019-2020 ESO Data Collaborative research datasets. We included patients ≤18 years of age who received ketamine or benzodiazepines for EMS primary and secondary impressions indicating behavioral conditions. We excluded patients with first Glasgow Coma Scale (GCS) scores ≤8, those receiving ketamine or benzodiazepines prior to EMS arrival, those receiving both ketamine and benzodiazepines, and interfacility transfers. Effectiveness outcomes included general clinician assessment of improvement, decrease in GCS, and administration of a subsequent sedative. Safety outcomes included mortality; advanced airway placement; ventilatory assistance without advanced airway placement; or marked sedation (GCS ≤8). Chi-square and t-tests were used to compare the ketamine and benzodiazepines groups.

RESULTS

Of 57,970 pediatric patients with behavioral complaints and GCS scores >8, 1,539 received ketamine (13.3%, n = 205) or a benzodiazepine (86.7%, n = 1,334). Most patients were ≥12 years old (89.2%, n = 1,372), predominantly Caucasian (48.3%, n = 744), and were equally distributed by sex (49.7% male, n = 765). First treatment with ketamine was associated with a greater likelihood of improvement (88.8% vs 70.5%, p < 0.001) and a greater average GCS reduction compared to treatment with benzodiazepines (-2.5 [SD:4.0] vs -0.3 [SD:1.7], p < 0.001). Fewer patients who received ketamine received subsequent medication compared to those who received benzodiazepines (12.2% vs 27.0%, p < 0.001). Marked sedation was more frequent with ketamine than benzodiazepines (28.8% vs 2.9%, p < 0.001). Provision of ventilatory support (1.5% vs 0.5%, p = 0.14) and advanced airway placement (1.0% vs 0.2%, p = 0.09) were similar between ketamine and benzodiazepine groups. No prehospital deaths were reported.

CONCLUSION

In this pediatric cohort, prehospital sedation with ketamine was associated with greater patient improvement, less subsequent sedative administration, and greater sedation compared to benzodiazepines. Though we identified low rates of adverse events in both groups, ketamine was associated with more instances of marked sedation, which bears further study.

Validity of CHA2DS2-VASc score in patients with malignancies

Introduction

Anticoagulation for patients with atrial fibrillation/flutter (AF) after risk stratification based on CHA2DS2-VASc score (congestive heart failure, hypertension, age group, Diabetes Mellitus, prior stroke, transient ischemic attack or thromboembolism, prior heart attack, peripheral artery disease or aortic plaque and patient's gender) has been the gold standard practice to prevent cerebrovascular accidents (CVA).

Purpose

Since patients with malignancies are at increased risk of thrombophilia, we tried to study if cancer patients with atrial fibrillation are at increased risk for CVA beyond what should be expected based on their comorbidities.

Methods

We used the Nationwide Readmissions Database (NRD) database for the years 2016–2019. First, we extracted all cases with a diagnosis of atrial fibrillation/flutter. Exclusion criteria included patients younger than 18-year-old. We studied the comorbidities and calculated CHA2DS2-VASc score. Then, we compared the risk for admission with an acute CVA in patients with and without any diagnosis of malignancies (solid cancer, leukemia, lymphoma or metastatic disease). Patients with carcinoma in situ were considered non-cancer patients. Corrected logistic regression and Chi-square tests using survey procedures in SAS 8.1 were applied to accommodate for complex sampling (Rao-Scott design).

Results

We identified 1,748,619 weighted admissions with AF equally distributed across the years. 5% were patients with malignancies. The mean age was 74-year-old for cancer patients and 71-year-old for non-cancer patients with quite equal gender distribution (43–49% were female). Patients with a diagnosis of cancer has high inpatient mortality (13%). Every additional point in CHA2DS2-VASc score was associated with increased odds of admission with CVA. Having a diagnosis of cancer was not associated with increased odds of admission with CVA (odd ratio for 95% confidence interval 1.0 [0.95–1.1]). Patients with history of VTE (assuming they are on anticoagulation) or who are on chronic anticoagulation have lower risk of admission with acute CVA if they have AF.

Conclusions

Although malignancies is associated with hypercoagulable status including higher risk for stroke, deep venous thrombosis and pulmonary embolism, our cross-sectional study indicates that CHA2DS2-VASc score is still a reliable tool for risk stratification in patients with atrial fibrillation. More longitudinal studies are needed.

Funding Acknowledgement

Type of funding sources: None.

Clinical Profile, Neuroimaging Characteristics, and Surgical Outcomes of Patients With Acute Acquired Non-accommodative Comitant Esotropia

PURPOSE

To report the clinical presentations, neuroimaging findings, and surgical outcomes in patients with acute acquired non-accommodative comitant esotropia (AACE).

METHODS

A retrospective review of records of all patients diagnosed as having AACE between January 2011 and December 2019 across three tertiary eye care centers was done. Cases with AACE onset after age 1 year were included. Patients were divided into two groups based on age of onset of esotropia: childhood (16 years or younger) and adult (older than 16 years). Surgical success was defined as postoperative horizontal deviation of 8 prism diopters (PD) or less at the last follow-up visit.

RESULTS

A total of 338 patients (220 males and 119 females; mean age at presentation: 12.60 ± 9.8 years) met the study criteria. The mean age at onset of esotropia in the childhood and adult onset groups was 3.61 ± 1.1 and 26.6 ± 8.7 years, respectively. There were significantly more individuals with myopia (30%) in the adult onset group compared to the childhood onset group (6%) (P = .004). Thirty-seven (16%) had positive neuroimaging findings (16.4% adult onset vs 9.4% childhood onset). A total of 148 (44%) patients underwent surgery for esotropia, and the overall success rate was 73%. Mean preoperative esotropia was comparable in either group (P = .20), but surgical success was better in the adult onset group (75.6% vs 66.3% in the childhood onset group). Mean duration of follow-up postoperatively was 13.6 ± 12 months.

CONCLUSIONS

Two-thirds of the patients had childhood onset of AACE. Intracranial pathology was found in 1 of 6 patients. Surgical success was better in the adult onset group, which was not influenced by preoperative esotropia, neuroimaging findings, or refractive status, but was dependent on age at onset of esotropia and duration between onset and intervention. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

Prehospital Ketamine Use in Pediatrics

Introduction: Information regarding prehospital ketamine use in the pediatric population is limited as existing literature focuses primarily on critical care and air transport. Our objective was to describe patient characteristics among pediatric EMS patients who received ketamine. Secondarily, we assessed effectiveness, deviation from recommended dosing, and adverse outcomes of pediatric EMS patients who received ketamine.Methods: We conducted a retrospective data review of records from the ESO Data Collaborative for all 9-1-1 transports of pediatric patients (≤ 18 years of age) who received ketamine from 2019-2020. We categorized EMS primary impressions as a proxy for medication indication. We defined effectiveness as paramedic-identified clinical improvement, and pain relief as decrease in pain score ≥2 points between initial and final recording. Descriptive statistics were used to summarize clinical characteristics. Non-parametric Wilcoxon signed-rank test was used to assess change in pain score.Results: Out of 422,968 ground-ambulance pediatric patients, 1,291 received ketamine. They were predominately male (842, 65.2%), teenagers (median age 16, IQR: 13-17), Caucasian (810, 62.7%), and from urban areas (1,041, 80.6%). The most common EMS impressions were related to injuries (810, 62.7%) and behavior disorders (281, 21.8%). Only 980/1,291 (75.9%) had weights and identifiable routes recorded. Most patients (960, 74.4%) received single doses of ketamine, with EMS clinicians reporting improvement in 855 (89.1%) of 960 patients. Among non-behavioral emergency patients, 727/1,010 (72.0%) had pain scores recorded. Pain scores decreased significantly from a median of 8 (IQR: 4-10) to 2 (IQR: 0-6) (p < 0.001) with 59% (429) of 727 patients reporting pain score reductions of 2 or more points. Desaturation (<90% SpO₂) events were noted to be minimal (1.8%). A small number (28, 2.2%) received positive pressure ventilation without advanced airway placement. No prehospital deaths were documented.Conclusion: In this large review of pediatric prehospital ketamine use, ketamine was primarily used for analgesia, but was frequently used for other indications. Most patients were observed to improve after ketamine use, with most injured patients reporting decreases in pain scores. We observed few significant adverse events related to ketamine use in this population.

Efficacy of nivolumab and temozolomide in advanced neuroendocrine neoplasms (NENs) in a phase 2 clinical trial

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Background: Treatment options are limited in patients with metastatic NEN. Temozolomide (TEM) alone and in combination with capecitabine is active in NEN and has been shown to have immunomodulatory impact. Here we present the final results for the NEN cohort of a phase 2 trial of combination nivolumab and TEM in patients with advanced NEN along with observed peripheral immune changes. Methods: NCT03728361 is a non-randomized, two-cohort, open-label phase 2 trial of nivolumab and TEM in patients with metastatic NEN and small cell lung cancer. The NEN cohort enrolled patients with tumors of any WHO grade, location, and line of therapy; all patients had evidence of progression prior to study. Prior immunotherapy was not allowed. Treatment consisted of nivolumab 480 mg IV on day 1 and TEM 150 mg/m2 on days 1-5 of a 28-day cycle. The primary objective was efficacy measured as response rate (RR) by RECIST v1.1. Secondary objectives were progression free survival (PFS) and overall survival (OS), by the method of Kaplan–Meier. The translational objective was to analyze peripheral blood mononuclear cells (PBMCs) collected at screening (baseline) and on cycle 1, day 15 (C1D15) via mass cytometry. Results: The RR was 36% (n=10/28, 95% CI: 18.6%-55.9%), including 10 patients (36%) with PR, 16 (57%) with SD, and 2 (7%) with PD (Table). The disease control rate was 93%. Responses occurred across all WHO grades; 44% of patients with tumors with Ki-67 >20% had PR. There was a significant difference in ORR by primary tumor location (bronchial vs pancreas vs other, p=0.004). There was no significant difference in response by Ki-67% (p=0.872), or in patients treated as first line (31%) or beyond (40%, p=0.706). The median PFS was 8.9 months (95% CI: 3.9 – 11.1 months), and median OS was not reached (95% CI: 20.7 – NR months). Two immune related SAE’s occurred: myocarditis and diarrhea in one patient each; gr4 toxicities included neutropenia (10%) and thrombocytopenia (7%). Profiling of PBMCs revealed no correlation of baseline MDSC levels with clinical benefit, however significant changes within the T cell landscape, including a decrease in CD4+ T cells (59.6% ±13.08 vs. 56.5% ±13.01, p=0.001) and increase in CD8+ T cells (27.9% ±13.36 vs. 31.7% ±14.57, p=0.03) were observed. Conclusions: Combination nivolumab and TEM demonstrated promising efficacy in patients with NENs; median OS has not been reached. Clinical trial information: NCT03728361. [Table: see text]

Association of LAG-3 expression in circulating T cells and response to combination temozolomide (TMZ) and nivolumab (NIVO) in advanced neuroendocrine neoplasms (NENs): Results from an investigator-initiated phase 2 trial

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Background: LAG-3 is an immune checkpoint present on NK cells, activated T cells and myeloid cells that inhibit T cell responses. Recent evidence demonstrating the safety and efficacy of LAG-3 inhibition has increased interest in this pathway for the treatment of multiple malignancies but the role in NEN is unclear. We present results from correlative peripheral blood mass cytometry (CyTOF) performed in a phase 2 trial (NCT03728361) of the combination of NIVO and TMZ in pts with advanced NEN. Methods: Patients (pts) with progressive NEN of any grade or primary location and any line of therapy were eligible. Small cell lung cancer was excluded. Clinical results from NCT03728361 will be presented in a separate abstract. Study treatment consisted of NIVO 480 mg IV every 4 weeks and TMZ 150 mg/m2 for 5 consecutive days out of a 28-day cycle. Peripheral blood mononuclear cells (PBMCs) were available from 16 out of 28 patients at screening (baseline) and cycle 1, day 15 (C1D15) and analyzed via CyTOF. Antibody labelling was performed using a 37 marker Maxpar Direct Immune Profiling Assay (Fluidigm). Immune cell populations were compared using two sample t-tests between pts with partial response (PR) and non-partial response (non-PR). Results: At screening, no differences were observed in PD-1, TIM3, or KLRG1 positive T-cell populations between pts with PR or non-PR. Patients with a PR had a significantly lower % of LAG-3 expressing T cells (p=0.029). There was a trend towards a lower % CD8+LAG-3+ T cells in pts with PR (p=0.086). At C1D15: The % of CD8+ LAG-3+ T cells were significantly higher in PRs vs. non-PR (p = 0.015). In matched samples comparing T cell populations at screening to C1D15, LAG-3+ CD8+ T cells increased significantly in PRs when compared to non-PRs (p=0.021). Conclusions: The % of LAG-3+ T cell population at baseline associates with non-response to TMZ/NIVO in NENs. Among responders, there was a significant increase in CD8+ LAG-3+ T cells by Day 15 compared to baseline indicating a potential mechanism of immune escape and eventual resistance. Clinical trial information: NCT03728361. [Table: see text]

INFLUENCE OF THE DURATION OF DIABETES AND VIBRATION PERCEPTION THRESHOLD ON THE SEVERITY OF ERECTILE DYSFUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

BACKGROUND

Erectile dysfunction(ED) in men is a frequent under-reported complication of diabetes mellitus, which is becoming significant health problem worldwide.

AIMS

The study aims to determine the prevalence and risk factors for development of ED in North Indian patients with type 2 diabetes mellitus.

METHODS

We used international index of erectile function (IIEF-5) for the assessment of ED in 796 patients with type 2 diabetes mellitus. We recorded the age, duration of diabetes, glycemic status, body mass index, diabetes medications, microvascular and macrovascular complications.

RESULTS

The mean age of patients in the study was 49.38 ± 9.52 years. The prevalence of ED in patients with type 2 diabetes mellitus was 79.4%. Logistic regression analysis revealed that age, body mass index, glycemic control, insulin therapy, retinopathy and nephropathy was not significantly associated with erectile dysfunction in patients with type 2 diabetes mellitus. Duration of diabetes (OR = 1.054, 95% CI 1.007 to 1.102, P=0.023) and vibration perception threshold (OR = 1.071, 95% CI 1.042 to 1.102, P=0.000) were identified as key risk factors for development of ED.

CONCLUSION

Duration of diabetes and peripheral neuropathy emerged as significant risk factors for development of severe erectile dysfunction.

Oral Health-related Quality of Life of Children with Early Childhood Caries before and after Receiving Complete Oral Rehabilitation under General Anesthesia

Introduction

Early childhood caries (ECC) significantly affects the quality of life of children due to recurrent pain, infection, and other associated problems.

Aim and objective

To assess the change in oral health-related quality of life of children aged <5 years undergoing complete oral rehabilitation under general anesthesia.

Materials and methods

A total of 50 healthy children affected with ECC were enrolled for the present study. Oral health-related quality of life (OHRQoL) of every child was assessed by interviewing the mothers using a prevalidated Early Childhood Oral Health Impact Scale (ECOHIS) questionnaire one day prior to the treatment appointment and comparing the scores with those at 1 and 3 months post-treatment to evaluate the changes in the OHRQoL, if any and assess the stability of the changes.

Results

The results revealed a statistically significant reduction in Ouality of Life (QoL) scores of all the domains and total ECOHIS scores between baseline and 1 month, and baseline and 3 months. Conclusion: The oral health-related quality of life showed a significant improvement after complete oral rehabilitation under general anesthesia and the improvement persisted beyond the immediate post-treatment period.

How to cite this article

Raghu R, Gauba K, Goyal A, et al. Oral Health-related Quality of Life of Children with Early Childhood Caries before and after Receiving Complete Oral Rehabilitation under General Anesthesia. Int J Clin Pediatr Dent 2021;14(S-2):S117–S123.

An evaluation of remineralised MIH using CPP-ACP and fluoride varnish: An in-situ and in-vitro study

BACKGROUND

Molar incisor hypomineralization (MIH) affected teeth have enamel with altered mineral content like decreased calcium and phosphorus and increased carbon content leading to porous enamel and subsequent post-eruptive breakdown.

AIM

An in situ study was conducted to evaluate and compare the effects of a Casein Phosphopeptide-Amorphous Calcium Phosphate (CPP-ACP)-based cream and fluoride varnish on the remineralization of MIH affected teeth.

METHODS

Enamel slabs were prepared from MIH affected teeth that had been extracted for various reasons and inserted in appliances of 30 participants who were undergoing interceptive orthodontic therapy. They were randomly divided into two groups using block randomization technique: Group A-daily single application of CPP-ACP cream (n = 15); Group B-professional application of fluoride varnishes every 3 months (n = 15). After 6 months of regular wear of the appliance, the enamel slabs were placed under Field Emission Scanning Microscope (FESEM) and Energy-Dispersive Spectroscopy (EDS) for evaluation of ultra structure and mineral content, respectively.

RESULTS

A significant increase in calcium and phosphorus content, and a decrease in carbon content was observed within the 6 months period, suggesting remineralization in both the groups. On comparing the Ca:P and Ca:C ratios, a significant increase in the Ca:C ratio was evident in the two groups. No significant difference was seen in the Ca:P ratio in the CPP-ACP group at six months. The inter-group comparison did not reveal any significant difference between the two groups either at baseline or at 6 months post-intervention.

CONCLUSION

Remineralization can be achieved in MIH affected teeth with the use of remineralizing agents.

Full coverage crowns for rehabilitation of MIH affected molars: 24 month randomized clinical trial

BACKGROUND

Teeth affected with severe molar incisor hypomineralization (MIH) require extensive restorations, which do not last for a long time and often require treatment in the form of onlays or full coverage restorations.

AIM

To evaluate and compare the clinical performance of zirconia, lithium disilicate, and cast metal crowns as full-coverage restorations on MIH-affected first permanent molars (FPMs).

METHODS

60 MIH affected FPMs requiring full-coverage crowns were identified in children aged 8-15 years and were randomly allocated to the three treatment groups according to the type of full coverage restoration received using block randomization technique. After an adequate removal of the MIH defect and restoration with composite resin, the tooth preparation was done followed by fabrication of crown and its cementation using resin cement. The intergroup comparison was done on the basis of USPHS criteria, gingival, plaque scores, patient and parents acceptance through a visual analog scale to decipher their clinical performance at 6, 12, 24 months.

RESULTS

After 24 months, the crowns showed similar clinical success in terms of the criterias used to compare their clinical performance. The retention, marginal adaptation, relief from hypersensitivity, proximal contact, gingival health with no statistically significant difference among the three groups.

CONCLUSION

Based on the observations, Lithium disilicate, Zirconia and full cast metal crowns showed similar clinical success in rehabilitation of First permanent molars with severe MIH over 24 months of evaluation. The clinical success is not influenced by the material of the restoration. However, prospective studies with a longer follow-up are required to reach a more definitive conclusion.

Label-free quantitative proteomics reveals molecular correlates of altered biomechanical properties in molar incisor hypomineralization (MIH): an in vitro study

PURPOSE

Molar-incisor hypomineralization (MIH) is a qualitative developmental defect of enamel that affects first permanent molars with or without affecting permanent incisors. We aimed to carry out a quantitative proteomics-based study to compare and evaluate proteins in sound and MIH-affected enamel.

MATERIALS AND METHODS

Ten blocks each of the MIH-affected enamel and sound enamel were processed and prepared for LC-MS/MS analysis. Label-free quantitation was carried out to evaluate the differentially expressed proteins in the two groups of samples.

RESULTS

A significant increase in the number of proteins in MIH-affected enamel (50.3 ± 29.6) was observed compared to the sound enamel (21.4 ± 3.2). While proteins like collagens, α1-anti-trypsin, kallikrein-4 (KLK4), matrix metalloprotease-20 (MMP-20), alpha-2-macroglobulin, and alpha-2-HS-glycoprotein were upregulated in sound enamel, there was over-expression of albumin, calcium-binding proteins, anti-thrombin III, and dentin sialophosphoprotein (DSPP), along with proteins implicated in stress response and inflammatory processes in MIH.

CONCLUSION

We propose that altered biomechanical properties of the enamel in MIH samples arise due to (i) down-regulation of proteins contributing to collagen biosynthesis and fibril formation; (ii) an overall imbalance in required levels of proteases (KLK4 and MMP-20) and anti-proteases (anti-thrombin-III which inhibits KLK-4), essential for optimal mineralization; (iii) very low levels of alpha-2-macroglobulin with important consequences in enamel mineralization and amelogenesis; and (iv) increased albumin in MIH, preventing proper growth of hydroxyapatite crystals. Increased inflammatory component was also seen in MIH; however, whether inflammation is a cause or consequence of the poor mineralization process needs to be assessed.

Impact of covid-19 pandemic on characteristics of dental emergencies and treatment services at tertiary care centre

To categorize and compare the dental emergencies along with status of health services received in the tertiary dental health care centre during the pre covid- 19 periods and period of the complete lockdown in COVID 19 pandemic. Methods: A retrospective cross-sectional observational survey was conducted. Four different groups period were studied on patients who visited for dental emergencies at tertiary care centre. April 14 to 13 May 2020 assigned and analyzed as a test period group or group IV. The control period group i.e. group III was 14 February 2020 to 17 March, pre lockdown COVID 19 month when there was no consideration of epidemic in India. Same as periods of group II and IV, group I and II from last year 2019 were also assigned and analyzed. The tertiary care centre provision of health services during this pandemic was also inquired and evaluated. The information was recorded regarding availability of health services like non-emergency dental treatments, emergency dental services, and online professional consultation. To compare four different time period of obtained data, Analysis of variance (ANOVA) and Chi square test were used. Results: The overall proportion and percentage of dental emergencies were raised. The reason for emergency visits to dental clinic were the main problem related with pulpal (46.0%) followed by abscess (16.6%), periapical lesions (15.0%), cellulitis (4.1%) or trauma (0.3%). In lockdown most of the dental emergencies 228(2 6 5) were endodontic related (86.1%) which managed mostly through '3A" approach (advise, analgesics and antibiotics) (60.1%) and remaining (26.0%) through extraction.

Salivary parameters and their correlation with neutrophil counts in children with acute lymphoblastic leukemia

BACKGROUND

Chemotherapy for Acute Lymphoblastic Leukemia (ALL) is known to render children immuno-deficient. A concomitant suppression of local defence mechanisms, such as saliva may further aggravate the adverse consequences of chemotherapy. The present study was conducted to evaluate alterations in salivary flow rate, pH and buffering capacity and to correlate these parameters with Absolute Neutrophil Counts (ANC).

METHODS

A cohort of 43 patients, aged 3-12 years were evaluated for the aforementioned parameters at baseline, post-induction and post-consolidation phases. Salivary collection was done and ANC was measured from routine haematological reports.

RESULTS

A decrease in the salivary parameters was observed at the end of Induction phase as compared to baseline, with a statistically significant decrease in unstimulated salivary flow rates (p < 0.01). Statistically significant positive correlations were found between ANC and salivary flow rate (p = 0.005), pH (p < 0.00) and buffering capacity (p < 0.00). On testing the significance of these correlations, all the values for these parameters were found to be statistically significant.

CONCLUSION

Salivary parameters showed derangements over the phases of chemotherapy, with maximum decrease at the end of induction phase. The positive correlations of salivary parameters with ANC of the subjects may be considered indicative of a concomitant immunological compromise in these children.

1191 The Use of CT Urography to Diagnose Upper Tract Urothelial Carcinomas (UTUC); Managing Surgical Resources During The COVID-19 Pandemic

Introduction

Upper tract urothelial carcinomas (UTUC) account for 5-10% of urothelial malignancies. Rapid diagnosis is essential as 60% are invasive at diagnosis and confer poor prognoses. European Association of Urology (EAU) guidelines recommend CT urography (CTU) for initial diagnosis and staging of UTUCs. Diagnostic ureteroscopy (URS) is used second line where diagnosis is unclear. The COVID-19 pandemic has limited theatre access and may delay diagnosis of suspected UTUC. Our aim was to evaluate specific CTU findings in predicting UTUC to aid prompt diagnosis and risk stratification in a tertiary centre.

Method

A retrospective analysis was performed on 122 patients who underwent CTU with diagnostic URS over two years from 2018-2019 for possible UTUC. Data including demographics, imaging and histology were collected from our electronic database.

Results

57 patients had confirmed UTUC, all had CT changes. CTU had an overall positive predictive value (PPV) of 45%. CT findings were divided into: hydronephrosis; filling defect/lesion; urothelial thickening; normal; or other. The PPV was highest for filling defects/lesions at 60%, hydronephrosis was 38%, urothelial thickening was 30%, and other was 33%. Of those with high-grade histology, 61% had evidence of filling defects/lesions and 24% had hydronephrosis.

Conclusions

A specific CTU finding of filling defect/lesion in combination with cytology can aid diagnosis and risk stratification of UTUC. This may enable us to reduce use of diagnostic URS, as well as associated risks of intravesical seeding, necessary in the COVID-19 pandemic. With other CTU findings of hydronephrosis or urothelial thickening, a diagnostic URS may be required.

1054 A Simple Intervention to Minimise the Incidence of The Forgotten Ureteric Stent: Updating the Surgical Discharge Summary

Introduction

Ureteric stents are routinely used in ureteric obstruction, however, have considerable morbidity with major complications, such as encrustation, obstruction, urosepsis, and renal failure if left in situ for longer than six months. Despite an electronic stent register, there are still multiple emergency admissions of complications from forgotten stents, as well as those presenting with significant stent symptoms. Often stents are inserted as an emergency procedure with minimal information given on their discharge summary. A discharge template was therefore introduced that could also serve as a patient information leaflet to help minimise the incidence of forgotten stents.

Method

A discharge template was designed based off the trust-endorsed and British Association of Urological Surgeons (BAUS) patient leaflet and distributed amongst the juniors. A total of 28 patients were interviewed via telephone questionnaires – 21 randomly selected pre-intervention and 7 post-intervention from a one-month scale either side of the intervention. The template included: information on stents, common stent symptoms, indications to seek healthcare advice, and contact details to use in the event they are lost to follow-up.

Results

Patients aware that stents should be changed within six months went from 52% to 100%. Awareness of stent symptoms and red-flag symptoms went from 52% to 91%, and 57% to 100% respectively. Those who felt they had sufficient information on the discharge letter to understand their stent increased from 52 to 89%.

Conclusions

Significant improvement in patient understanding of stents and therefore hopefully in appropriate health-seeking behaviour, patient rapport, safety, and improvement in stents removed within target.

Systematic content analysis of online information on herbal smoking products

BACKGROUND

Herbal smoking products (HSPs) are marketed as a safer alternative to tobacco. These are easily available at affordable prices in the online retail websites. This study aimed to analyze the HSP-related informational content available in the most popular online platforms.

METHODS

Google, Yahoo, Bing and YouTube online platforms were searched for HSP related content using appropriate keywords. First 50 search results were retrieved and screened for potential eligibility. The included web-pages were categorized as video and still records. From each included record, information regarding source, primary theme, health benefits/hazards and tone was abstracted. Additionally, video production quality, like ratio and video power index was also computed for each video record. All included records were subjected to descriptive statistics and Chi-square test, as appropriate. Level of significance was set at <0.05.

RESULTS

174 still and 94 video records were included. 35.6% of the included still records were sourced by manufacturers/suppliers while that of scientific origin was 12.1%. 83% of the video-records were posted by general public. About 90% of the included records had not mentioned anything regarding age restrictions. 67.8% of the still records and 87.2% of the video records promoted the use of HSPs.

CONCLUSIONS

The informational content presented online is huge, mostly posted by the general public without any scientific rationale and exclusively favors the use of HSPs. There is no age restriction as to who can access the information, making this content easily accessible to people of all ages. Such spread of information may mislead the public in adopting the smoking of these herbal products. Since HSPs may act as a potential gateway to tobacco smoking, there is an urgent need to regulate the content available online.

Reducing mortality in mucormycosis of the head and neck in diabetic patients: A CARE case series

INTRODUCTION

Rhinocerebral mucormycosis is extremely fatal, with mortality rates ranging from 85-93% despite the best treatment in immunocompromised patients. We emphasize the importance of early diagnosis, repeated debridement, and aggressive antifungal treatment to reduce mortality.

CASE SUMMARY

We report six cases (five male and one female), with a mean age of 51 years who were diagnosed to have mucormycosis from 2017 to 2019. All patients were diabetic. Intracranial involvement and orbital involvement were found in four cases. Facial nerve palsy was seen in two cases, one without any apparent otological involvement. Aggressive serial debridement and amphotericin B was started. Posaconazole was added subsequently to the treatment in two cases. One patient succumbed to the disease five months after discharge. The other five patients are on regular follow-up for a mean duration of 14 months at the end of which two had residual disease which was under control.

DISCUSSION

Repeated surgical debridement with an early aggressive and combination antifungal therapy can result in good outcomes even in advanced mucormycosis. Concurrent management of the underlying pathology, monitoring of liver and kidney functions, and therapeutic drug monitoring are useful to ensure smooth and effective treatment.

Modelling the impact of increase in sugar prices on dental caries in India

OBJECTIVES

This study aims to assess the impact of raising the price of sugar and/or sugar-sweetened beverages (SSBs) on caries incidence in the Indian population.

METHODS

A tooth-level decision-analytic model was developed to evaluate a change in caries increment after increasing the price of Sugar and SSBs. The transition of a tooth from a caries-free state to the state of tooth loss in both scenarios was modelled with the help of a Markov model for a time horizon of 63 years, ranging from 2021 to 2083 for the 12-year-old population cohort of India. A conceptual framework was designed to implicate the possible effects of an increase in sugar prices on the reduction of caries incidence. Health effects were estimated in terms of the number of carious lesions and tooth-loss in both the scenarios and modelled as a product of the dose-response relationship between sugar intake and caries incidence. The model was thus used to establish the number of caries lesions prevented, and tooth-loss avoided. Uncertainties in the parameters were assessed using probabilistic sensitivity analysis. The Monte Carlo method was used for simulating the results 999 times.

RESULTS

A 20% rise in the price of sugar is expected to result in the prevention of an average of 1.32 teeth in a lifetime of an individual and prevent 27.96 million tooth-loss incidents among the population cohort of India that will eventually lead to a saving of INR (₹) 3116.32 billion (US$ 42.69 billion) on account of dental caries treatment. Similarly, increasing-price of SSBs by 20% will lead to a 0.86% reduction in carious teeth incidence in an individual's lifetime.

CONCLUSION

Increasing the cost of sugar and/or SSBs will reduce the daily intake of sugar, which will reduce caries incidence and subsequent progression, thereby preventing caries-attributed tooth-loss and saving treatment costs.

Remineralization potential and caries preventive efficacy of CPP-ACP/Xylitol/Ozone/Bioactive glass and topical fluoride combined therapy versus fluoride mono-therapy - a systematic review and meta-analysis

OBJECTIVE

To compare the remineralization potential and caries preventive efficacy of CPP-ACP/bioactive glass/xylitol/ozone and topical fluoride (TF) combined therapy versus TF mono-therapy.

MATERIAL AND METHODS

Embase, PubMed, Scopus, Web of Science and Cochrane databases were searched. 4457 records were screened and 26 trials were included. Data from 16 trials was pooled using Review Manager 5.4. Level of significance was p < .05. The certainty of the evidence was evaluated using GRADE.

RESULTS

Pooled analysis of two trials for white spot lesions (WSLs) regression (SMD -0.6, 95% CI: [-1.07 to -0.14], p = .01) and three trials for post-intervention DIAGNOdent values (SMD -1.24, 95% CI: [-1.96 to -0.52], p = .0007) significantly favoured CPP-ACP-TF combined therapy over TF mono-therapy. The sub-group analysis for caries increment (SMD -0.14, 95% CI: [-0.21 to -0.07], p < .0001) and the post intervention S mutans count (SMD -0.42, 95% CI: [-0.62 to -0.23], p < .0001) significantly favours 'xylitol-TF' and 'CPP-ACP-TF' combined therapy respectively. The high/unclear risk of bias, imprecision and indirectness of the included trials presented a low certainty of evidence.

CONCLUSION

CPP-ACP-TF exhibits superiority over TF monotherapy in remineralizing existing lesions and demonstrates better antibacterial effect, whereas it is not more effective for preventing caries incidence. However, Xylitol exerts an added benefit over fluoride alone in preventing caries increment. The low-certainty evidence highlights the need for more good quality trials.

Dilemma of diagnosing thoracic sarcoidosis in tuberculosis endemic regions: An imaging-based approach. Part 1

Sarcoidosis is a multi-systemic disorder of unknown etiology, although commonly believed to be immune-mediated. Histologically, it is characterized by noncaseating granuloma which contrasts against the caseating granuloma seen in tuberculosis (TB), an infectious disease that closely mimics sarcoidosis, both clinically as well as radiologically. In TB-endemic regions, the overlapping clinico-radiological manifestations create significant diagnostic dilemma, especially since the management options are markedly different in the two entities. Part 1 of this review aims to summarize the clinical, laboratory, and imaging features of sarcoidosis, encompassing both typical and atypical manifestations, in an attempt to distinguish between the two disease entities.

Dilemma of diagnosing thoracic sarcoidosis in tuberculosis-endemic regions: An imaging-based approach. Part 2

The second part of the review discusses the role of different existing imaging modalities in the evaluation of thoracic sarcoidosis, including chest radiograph, computed tomography, magnetic resonance imaging, endobronchial ultrasound, and positron emission tomography. While summarizing the advantages and pitfalls of each imaging modality, the authors propose imaging recommendations and an algorithm to be followed in the evaluation of clinically suspected case of sarcoidosis in tuberculosis-endemic regions.

Radiology of anal and lower rectal cancers

Lower rectal and anal cancers are distinct from neoplasms involving rest of the rectum. These are relatively difficult to manage owing to important relationships with the sphincter muscles. Involvement of the latter portends a poorer prognosis and increased chance of recurrence. Lymphatic drainage of these tumours is into the systemic circulation and the exact set of lymph nodes involved depends on the precise location of the tumour. The role of imaging includes assessment of local invasion, infiltration of adjacent pelvic organs, assessment of locoregional lymphatic spread and metastasis, post-chemoradiation restaging as well as post-treatment surveillance.

Screening for second malignancies in mycosis fungoides: non-Hodgkin lymphoma, Hodgkin lymphoma, lung cancer, bladder cancer and melanoma

BACKGROUND

Patients with mycosis fungoides (MF) are at increased risk of developing non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL), lung cancer, bladder cancer and melanoma. The characteristics of patients developing these malignancies have not been specifically delineated. In addition, there are no established guidelines for screening MF patients for second malignancies.

MATERIALS/METHODS

We identified 742 patients with MF who developed second malignancies in the Surveillance Epidemiology and End Result-18 database.

RESULTS

The majority of second malignancy patients were white and male, mean age 55-67 years at diagnosis of MF, and mean age 61-72 years at diagnosis of second malignancy. The majority of patients diagnosed with second malignancies had early stage MF. MF patients with NHL, lung cancer, and bladder cancer tended to be diagnosed at earlier stages of the second malignancy than patients without MF and demonstrated better 5-year overall survival. There was no improvement in stage at diagnosis or survival for MF patients who were diagnosed with melanoma compared to patients without MF.

CONCLUSIONS

Improvements in survival in MF/NHL, MF/lung cancer and MF/bladder cancer patients may reflect differences in disease biology secondary to having MF or the importance of increased contact with the healthcare system. MF/melanoma data suggest that patients require regular pigmented-lesion-focused skin examinations. Tools for screening include regular lymph node examinations, pigmented-lesion-focused examinations and detailed review of systems questions. Smoking cessation counseling is key intervention in this population, as is ensuring that all age- and sex-specific cancer screenings are up-to-date (e.g. lung cancer screening, mammography, and colonoscopy). The utility of regular imaging for second malignancy screening and lab testing such as routine urinalysis requires additional study and expert consensus.

Comparing the Effectiveness of Topical Fluoride and Povidone Iodine with Topical Fluoride Alone for the Prevention of Dental Caries among Children: A Systematic Review and Meta-analysis

Background

Combined use of povidone iodine (PI) along with topical fluorides (TF) has been suggested as a promising strategy to reduce dental caries incidence and cariogenic bacterial load. However, the available literature presents mixed evidence regarding its effectiveness as compared to TF application alone.

Aim and objective

'TF + PI' vs TF alone in the prevention of dental caries among 1-12-year-old children assessed through caries increment and mean S. mutans and Lactobacillus counts.

Materials and methods

Five databases (Cochrane Central Register of Controlled Trials, EBSCOhost, PubMed/Medline, Scopus, and Web of Science) were searched for relevant literature. Out of 72 studies that were screened, 7 eligible studies were included out of which 4 studies were subjected to meta-analysis. The generic inverse variance test was used to assess the primary outcome reported as mean ± SD/events occurred (caries incidence), whereas for mean post-intervention S. mutans colony count, inverse variance function was used. The Cochrane's Collaboration tool and Modified Downs and Black scoring criteria were used to evaluate the quality of the included articles. Heterogeneity across the studies was assessed using the I ² statistic. Statistical significance was set at p < 0.05.

Results

Overall, for primary and permanent dentition combined, the dental caries incidence was found to be significantly lower in the 'TF + PI' combined therapy group as compared to TF alone [SMD -0.4 (-0.78 to -0.03), p = 0.04]. The two groups showed no significant difference with respect to post-intervention S. mutans count [SMD -0.1 (-0.57 to +0.37), p = 0.69]. No study was found that compared post-intervention Lactobacillus count between the two groups.

Conclusion

Based on the pooled analysis from the limited literature available, there is a very low quality of evidence that 'TF + PI' combined therapy is more effective in the prevention of new caries lesions among 1-12-year-old children as compared to TF use alone. Future clinical trials with robust methodologies are recommended to generate conclusive evidence.

Clinical significance

PI application might exert an added benefit with TF in preventing the occurrence of new carious lesions among 1-12-year-old children.

How to cite this article

Gupta A, Nishant, Sharda S, et al. Comparing the Effectiveness of Topical Fluoride and Povidone Iodine with Topical Fluoride Alone for the Prevention of Dental Caries among Children: A Systematic Review and Meta-analysis. Int J Clin Pediatr Dent 2020;13(5):559-565.

Eculizumab-Associated Moraxella lacunata Bacteremia and Systemic Inflammatory Response Syndrome in a Toddler with Atypical Hemolytic Uremic Syndrome

Moraxella lacunata, a low-virulence Gram-negative coccobacillus, is classically associated with conjunctivitis and upper respiratory tract infections; systemic infections such as sepsis have rarely been reported, especially in children. We describe a 28-month-old girl with atypical hemolytic uremic syndrome and stage II chronic kidney disease on long-term eculizumab therapy who presented with systemic inflammatory response syndrome and was found to have Moraxella lacunata bloodstream infection. Eculizumab, a humanized monoclonal anti-C5 antibody, has been associated with susceptibility to infections with encapsulated bacteria, especially Neisseria meningitidis. This is the first report of an invasive bacterial infection with Moraxella lacunata in a pediatric eculizumab recipient.