Orthodontic Risk Perspectives among Orthodontists during Treatment: A Descriptive Pilot Study in Greece and Slovakia

This study explores orthodontists' perspectives on risks associated with orthodontic treatment, as described by Greek and Slovak orthodontists. Informed by the foundational importance of effective communication of risk perspectives in health sciences, particularly in facilitating valid consent and shared decision-making, this research addresses gaps identified in the literature concerning the consistent communication of potential treatment risks based on demographic and cultural characteristics. This study identifies 15 potential critical risks during orthodontic treatment. These risks include root resorption; temporary undesired changes to the occlusion; sleep difficulties; not achieving an ideal result; development of black triangles between teeth; taking additional X-rays; speech difficulties; using a protective splint during sports; duration of treatment; number of visits; transmission of infectious diseases; and swallowing orthodontic appliances. A questionnaire, distributed electronically to orthodontists in Greece (N1 = 570) and Slovakia (N2 = 210) from September 2022 to December 2022, aimed to assess risk communication practices, taking into consideration socio-demographic factors, such as country, gender, age, and academic-degree-related variations. A total of 168 valid questionnaires (91 from Slovakia and 77 from Greece) were obtained, indicating significant disparities in the risks emphasized and preferred forms of consent. The Greek orthodontists focused more on the risks involved, such as relapse, root resorption, temporal occlusal changes, and failure of desired movement, while the Slovak practitioners tended to be more interested in sleeping difficulties, temporal occlusal changes, and not achieving an ideal result. They also obtained written or digital consent from patients or their parents/guardians more frequently than the Greek team. Male orthodontists discussed specific risks more frequently, including relapse and extractions, whereas females preferred written or digital consent. PhD-trained orthodontists prioritized certain risks, indicating the need for tailored approaches. This study underscores the dynamic nature of risk assessment in orthodontic practice, emphasizing its ethical and strategic dimensions. The findings advocate for tailored risk communication strategies that recognize individual, contextual, and cultural factors, and the need for an orthodontic informed consent protocol for a tailored communication approach for patients to elevate the standard of care in European orthodontics. The reliance on digital tools reflects contemporary trends in enhancing patient understanding, thereby supporting ongoing innovation in orthodontic practices.

Platelet, Fibrinolytic and Other Coagulation Abnormalities in Newly-Diagnosed Patients with Chronic Thromboembolic Pulmonary Hypertension

The pathophysiological background of chronic thromboembolic pulmonary hypertension (CTEPH) has not been fully elucidated. Evidence suggests that abnormal platelet function and ineffective fibrinolysis may play a key role in the development of the disease. The purpose of this study was to evaluate platelet and coagulation function in CTEPH, using non-conventional global coagulation assays, and platelet activation and endothelial dysfunction laboratory markers. A total of 40 newly-diagnosed CTEPH patients were studied, along with 35 healthy controls. Blood samples from CTEPH patients were taken directly from the pulmonary artery. All subjects were assessed with platelet function analyzer-100, light transmission aggregometry, thromboelastometry, endogenous thrombin potential. von Willebrand antigen and activity, p-selectin, thromboxane A2 and serotonin levels were also assessed. The results showed that CTEPH patients present diminished platelet aggregation, presence of disaggregation, decreased rate of fibrinolysis, defective thrombin generation and increased levels of thromboxane A2, p-selectin, von Willebrand antigen and activity. Serotonin levels did not present any differences between the two groups. The results of this study suggest that CTEPH patients present platelet function, fibrinolytic, thrombin generation and other clot formation abnormalities. Well-designed clinical studies are needed to further evaluate the complex hemostatic abnormalities in the CTEPH setting and assess their potential clinical applications.

Orofacial Muscle Weakening in Facioscapulohumeral Muscular Dystrophy (FSHD) Patients

Background: Facioscapulohumeral muscular dystrophy is the third most commonly found type of muscular dystrophy. The aim of this study was to correlate the D4Z4 repeat array fragment size to the orofacial muscle weakening exhibited in a group of patients with a genetically supported diagnosis of FSHD. Methods: Molecular genetic analysis was performed for 52 patients (27 female and 25 male) from a group that consisted of 36 patients with autosomal dominant pedigrees and 16 patients with either sporadic or unknown family status. The patients were tested with the southern blotting technique, using EcoRI/Avrll double digestion, and fragments were detected by a p13E-11 telomeric probe. Spearman’s correlation was used to compare the fragment size with the degree of muscle weakening found in the forehead, periocular and perioral muscles. Results: A positive non-significant correlation between the DNA fragment size and severity of muscle weakness was found for the forehead (r = 0.27; p = 0187), the periocular (r = 0.24; p = 0.232) and the left and right perioral (r = 0.29; p = 0.122), (r = 0.32; p = 0.085) muscles. Conclusions: Although FSHD patients exhibited a decrease in muscular activity related to the forehead, perioral, and periocular muscles the genotype–phenotype associations confirmed a weak to moderate non-significant correlation between repeat size and the severity of muscle weakness. Orofacial muscle weakening and its association with a D4Z4 contraction alone may not have the significance to serve as a prognostic biomarker, due to the weak to moderate association. Further studies with larger sample sizes are needed to determine the degree of genetic involvement in the facial growth in FSHD patients.

A Severe COVID-19 Case Complicated by Right Atrium Thrombus

Patient: Male, 73-year-old

Final Diagnosis: Severe COVID-19 pneumonia complicated by right atrium thrombus

Symptoms: Fever • dyspnea • cough

Medication:—

Clinical Procedure: —

Specialty: Critical Care Medicine

Life-threatening antineutrophil cytoplasmic antibody-associated vasculitis after influenza A H1N1 infection requiring veno-venous extracorporeal membrane oxygenation

INTRODUCTION

Antineutrophil cytoplasmic autoantibody-associated vasculitis is an immune-mediated necrotizing vasculitis, affecting small- and medium-sized vessels.

CASE REPORT

A 22-year-old female patient with free medical history presented with life-threatening pulmonary hemorrhage due to antineutrophil cytoplasmic autoantibody-associated vasculitis, temporarily associated with influenza A H1N1 infection. Due to rapidly worsening respiratory failure, despite conventional management, veno-venous peripheral extracorporeal membrane oxygenation was initiated and continued for 26 days, with subsequent renal replacement therapy.

DISCUSSION

We present a case of severe antineutrophil cytoplasmic autoantibody-associated pulmonary vasculitis, managed with veno-venous extracorporeal membrane oxygenation at the initial phase. Despite the significant challenges raised with the use of extracorporeal membrane oxygenation in pulmonary hemorrhage cases, extracorporeal membrane oxygenation may have a significant impact on outcome in this setting, by providing adequate time for a successful immunosuppressive treatment.

A geometric morphometric evaluation of hard and soft tissue profile changes in borderline extraction versus non-extraction patients

OBJECTIVES

To evaluate the hard tissue and facial profile changes in matched extraction and non-extraction Class I patients by the use of geometric morphometrics.

SUBJECTS AND METHODS

From a parent sample of 542 Class I patients, previously subjected to discriminant analysis, a subsample of 68 borderline cases was obtained, 34 treated with extraction and 34 without extraction of 4 first premolars. Geometric morphometric methods (Procrustes superimposition and Principal Component Analysis) were applied on cephalometric tracings to assess the validity of the discriminant analysis in successfully identifying a morphologically homogeneous group and to evaluate inter- and intra-group skeletal and facial profile shape changes.

RESULTS

No significant pre-treatment shape difference between the two groups was found, thus validating the discriminant analysis. The non-extraction group showed increase in hard tissue facial height (P < 0.001), with slight lower lip retrusion and upper lip protrusion (P = 0.027). The extraction group showed retraction of the hard tissue and facial profile outline (P < 0.001). Permutation tests for post-treatment inter-group differences resulted in P = 0.054 for the soft tissue outline and P = 0.078 for the hard tissue skeletal component.

CONCLUSIONS

The evidence indicates that borderline cases treated with four premolar extractions will exhibit lip retrusion compared to non-extraction treatment.

Is pulmonary arterial hypertension associated with interferon-β therapy for multiple sclerosis reversible? A case study to explore the complexity

The possible causal relationship between interferon-β exposure and pulmonary arterial hypertension development requires close follow-up of patients on treatment with interferon-β http://bit.ly/2OPGSVP.

A study of the mechanical properties of as-received and intraorally exposed single-crystal and polycrystalline orthodontic ceramic brackets

BACKGROUND

Although ceramic brackets have been extensively used for decades in orthodontics there is not till today any study focusing on the possible deterioration of mechanical properties after in vivo ageing.

OBJECTIVES

To determine whether the mechanical properties of alumina orthodontic brackets change after intraoral ageing thereby assessing the validity of a theoretical model established for the performance of ceramics in wet environments.

MATERIALS AND METHODS

Two alumina brackets, one single crystal (Radiance, American Orthodontics, Sheboygan, WI) and one polycrystalline (Clarity, 3M, St. Paul, MN) were included in this study. Ten brackets for each group were collected from different patients after a minimum of 3-month intraoral exposure, whereas as-received brackets of the same manufacturers were used as controls. The specimens were subjected to Raman spectroscopy and were then embedded in epoxy resin and metallographic ground and polished. The mechanical properties of four groups (radiance control: RAC, radiance-retrieved RAR, clarity control: CLC and clarity-retrieved CLR) were determined using instrumented indentation testing according to ISO 14577-2002. The mechanical properties tested were Martens hardness (HM), indentation modulus (EIT), the ratio of elastic to total work, commonly known as elastic index (ηIT), and fracture toughness (KIC). The numerical results were statistically analysed employing two-way analysis of variance (ANOVA) and Tukey multiple comparison test at a = 0.05.

RESULTS

Raman analysis revealed that both brackets are made of a-Al2O3 (corundum). No statistically significant differences were found for HM (N/mm2): RAC = 7249 (1507), RAR = 6926 (1144), CLC = 8052 (1360), CLR = 7390 (2393), or for EIT (GPa): RAC = 141 (27), RAR = 139 (23), CLC = 139 (28), CLR = 131 (47). However, significant differences were identified between the two alumina brackets tested for ηIT (%): RAC = 55.7 (4.2), RAR = 54.0 (3.5), CLC = 62.5 (4.4), CLR = 61.8 (4.7), while KIC was measured only for the polycrystalline bracket (Clarity) because of the complicated fractured pattern of the single-crystal bracket. Both brackets share equal HM and EIT before and after orthodontic intraoral ageing.

LIMITATIONS

Whereas the study assessed the changes after intraoral exposure per theoretical model, which describes the reduction of critical stress to induce fracture after wetting, long-term intraoral ageing could have induced more pronounced effects.

CONCLUSIONS/IMPLICATIONS

The results of this study indicate that 3 months of intraoral ageing do not change the mechanical properties of single-crystal and polycrystalline orthodontic brackets tested, thus indicating that the Griffith theory may not be applied to the case of manufactured ceramic brackets owing possibly to internal defects.

Cardiac Catheterization versus Echocardiography for Monitoring Pulmonary Pressure: A Prospective Study in Patients with Connective Tissue Disease-Associated Pulmonary Arterial Hypertension

Standard echocardiography is important for pulmonary arterial hypertension (PAH) screening in patients with connective tissue disease (CTD), but PAH diagnosis and monitoring require cardiac catheterization. Herein, using cardiac catheterization as reference, we tested the hypothesis that follow-up echocardiography is adequate for clinical decision-making in these patients. We prospectively studied 69 consecutive patients with CTD-associated PAH. Invasive baseline pulmonary artery systolic pressure (PASP) was 60.19 ± 16.33 mmHg (mean ± SD) and pulmonary vascular resistance (PVR) was 6.44 ± 2.95WU. All patients underwent hemodynamic and echocardiographic follow-up after 9.47 ± 7.29 months; 27 patients had a third follow-up after 17.2 ± 7.4 months from baseline. We examined whether clinically meaningful hemodynamic deterioration of follow-up catheterization-derived PASP (i.e., > 10% increase) could be predicted by simultaneous echocardiography. Echocardiography predicted hemodynamic PASP deterioration with 59% sensitivity, 85% specificity, and 63/83% positive/negative predictive value, respectively. In multivariate analysis, successful echocardiographic prediction correlated only with higher PVR in previous catheterization (p = 0.05, OR = 1.235). Notably, in patients having baseline PVR > 5.45 WU, echocardiography had both sensitivity and positive predictive values of 73%, and both specificity and negative predictive value of 91% for detecting hemodynamic PASP deterioration. In selected patients with CTD-PAH echocardiography can predict PASP deterioration with high specificity and negative predictive value. Additional prospective studies are needed to confirm that better patient selection can increase the ability of standard echocardiography to replace repeat catheterization.

P1790 Is there any role of exercise Doppler echocardiography to unmask pulmonary hypertension (PH) in patients with systemic sclerosis and baseline echocardiographic measurements for PH in the gray zone?

Background

The usefulness of exercise Doppler echocardiography (EDE) is uncertain in identifying patients with pulmonary hypertension (PH). Recently the cut off value for the definition of PH was changed and was set at the level of mean pulmonary arterial pressure (PAP) &gt;20 mmHg, measured by right heart catheterization (RHC).

Purpose

We examined whether EDE can unmask the presence of PH in patients with systemic sclerosis (SSc) whose baseline echocardiographic assessment for PH is non-diagnostic.

Methods

Forty-one patients with SSc (2 men and 39 women; mean age 61.2 ± 10 years) underwent treadmill symptom-limited EDE using a modified Bruce protocol. Tricuspid regurgitation velocity (TRV) was recorded within 60 seconds after the termination of the test. Inclusion criteria comprised: preserved left (ejection fraction &gt;50%), and right ventricular function (tricuspid annulus plane systolic excursion &gt;15 mm), lack of left side moderate or severe valvulopathy, presence of mild or moderate TR, satisfactory exercise tolerance and baseline TRV in the range of 2.6-3.0 m/s. All patients had RHC within 48 hours after EDE.

Results

In 5 cases the quality of post-exercise TRV was poor and further analysis was confined to 36 patients. RHC confirmed the presence of PH (mean PAP &gt;20 mmHg) in 14 cases (38.9%). All patients had pulmonary capillary wedge pressure &lt;15 mmHg. The increase in TRV from baseline to post-exercise was 1.25 ± 0.6 m/s. Ten patients developed post-exercise TRV ≥3.7 m/s of whom in 8 RHC validated PH. Post-exercise TRV was positively correlated with mean PAP obtained by RHC (r = 0,652, p &lt; 0.001). A cut-off value of post-exercise TRV ≥3.7 m/s had a sensitivity of 57.1%, a specificity of 90% and a diagnostic accuracy of 77.8% in detecting PH validated by RHC.

Conclusions

EDE has a moderate diagnostic accuracy for the identification of PH in patients with SSc whose baseline echocardiographic measurements for PH lie in the gray zone.

Past history of stage I/II solid tumor malignancy impacts considerably on sepsis mortality: a propensity score matching analysis from the hellenic sepsis study group

Background

Whether past history of solid stage I/II inactive cancer has an impact on 28-day mortality of sepsis remains unclear. We aimed to determine the impact of history of stage I or II solid tumor malignancy in complete remission the last 3 years on sepsis outcome.

Methods

Using the database of the Hellenic Sepsis Study Group from 1553 patients with sepsis admitted in the ICU, 83 patients with sepsis by Sepsis-3 definition with past-history of stage I/II inactive solid malignancy the last 3 years were depicted. A comparator group of 83 patients fully matched for age, severity, type of infection and comorbidities was selected by propensity score matching.

Results

Mortality after 28 days was 37.3% in the comparator group and 54.2% in the solid tumor stage I/II group (odds ratio for death 1.98; p: 0.030). Following step-wise forward Cox regression analysis, septic shock (hazard ratio 1.80), acute renal injury (hazard ratio 2.06), history of coronary heart disease (hazard ratio 0.36) and history of stage I/II solid tumor malignancy (hazard ratio 1.79) were the only independent variables associated with 28-day mortality. Serum levels of procalcitonin and of soluble urokinase plasminogen activator receptor were similar between the two groups of comparisons.

Conclusions

Past history of stage I/II solid malignancy is an independent risk factor for unfavorable outcome from sepsis the first 28 days.

Torturous path of an elastic gap band: Interdisciplinary approach to orthodontic treatment for a young patient who lost both maxillary central incisors after do-it-yourself treatment

Spacing between the maxillary anterior teeth is a common concern for young patients and their parents. Patients often consider a diastema to be an annoying but minor problem; they might consult their general dentists for help, or try to address the issue themselves by applying elastic "gap bands." Moreover, parents, without any informed consent, sometimes accept this erroneous method as an easy and inexpensive treatment approach. A 9-year-old boy had severe acute periodontitis involving the maxillary central incisors caused by the placement of an elastic band and its apical migration. Despite periodontal and surgical interventions, the maxillary central incisors were finally extracted, and the patient started orthodontic treatment. The orthodontic treatment plan included maxillary lateral incisor substitution to replace the lost central incisors and mesialization of the maxillary posterior dentition. An interdisciplinary approach with excellent cooperation among the orthodontist, general dentist, and other dental specialists obtained an esthetically pleasing and optimized functional result. Treating the diastema between the anterior teeth with elastic gap bands and without fixed orthodontic appliances should be avoided. Patients should seek proper orthodontic advice for even small-scale orthodontic problems to prevent catastrophic outcomes, as exhibited in this case report.

Platelet and coagulation disorders in newly diagnosed patients with pulmonary arterial hypertension

There is a complex and not fully elucidated association between pulmonary arterial hypertension (PAH) and coagulation disorders. The goal of this study was to evaluate platelet function, coagulation and fibrinolysis in PAH patients at diagnosis, before PAH-specific treatment initiation. We enrolled 20 healthy controls and 30 PAH patients (20 with connective tissue disease (CTD-PAH) and 10 idiopathic (iPAH)). None of the participants was on any antiplatelet or anticoagulation therapy. Blood samples from PAH patients were collected during the initial right heart catheterization. All subjects were assessed with platelet function analyzer-100 (PFA-100), epinephrine (Epi) and ADP-induced light transmission aggregometry (LTA), thromboelastometry (ROTEM) and endogenous thrombin potential (ETP). Our results showed that Epi and ADP-LTA values were significantly lower in newly diagnosed PAH patients compared to controls. Disaggregation was present in 73% of patients, a characteristic not seen in healthy individuals. In ROTEM assay, CT and CFT measurements were significantly higher and a angle lower compared to controls. ETP testing revealed significantly reduced outcomes in AUC, Cmax and Tmax. When CTD-PAH and iPAH patient groups were compared, iPAH ADP-LTA values were significantly decreased compared to CTD-PAH. In conclusion, newly diagnosed PAH patients presented with decreased platelet aggregation, clot propagation and thrombin generation, along with delayed initiation of the coagulation process. These hemostatic deficits could indicate an "exhaustion" of the coagulation process that could be caused by endothelial dysfunction and chronic activation of the procoagulant pathways. Further studies are warranted to confirm these laboratory findings and assess their potential clinical significance.

Soft tissue changes following extraction vs. nonextraction orthodontic fixed appliance treatment: a systematic review and meta-analysis

The aim of this systematic review was to assess the effect of systematic extraction protocols during orthodontic fixed appliance treatment on the soft tissue profile of human patients. Nine databases were searched until December 2016 for controlled clinical studies including premolar extraction or nonextraction treatment. After elimination of duplicate studies, data extraction, and risk-of-bias assessment according to the Cochrane guidelines, random-effects meta-analyses of mean differences (MD) or standardized mean differences (SMD) and their 95% CIs were performed, followed by subgroup, meta-regression, and sensitivity analyses. Extraction treatment was associated with increased lower lip retraction (24 studies; 1,456 patients; MD = 1.96 mm), upper lip retraction (21 studies; 1,149 patients; MD = 1.26 mm), nasolabial angle (21 studies; 1,089 patients; MD = 4.21°), soft-tissue profile convexity (six studies; 408 patients; MD = 1.24°), and profile pleasantness (three studies; 249 patients; SMD = 0.41). Patient age, extraction protocol, and amount of upper incisor retraction during treatment were significantly associated with the observed extraction effects, while the quality of evidence was very low in all cases due to risk of bias, baseline confounding, inconsistency, and imprecision. Although tooth extractions seem to affect patient profile, existing studies are heterogenous and no consistent predictions of profile response can be made.

Vertical skeletal changes after extraction and non-extraction treatment in matched class I patients identified by a discriminant analysis: cephalometric appraisal and Procrustes superimposition

Background

In the long-lasting debate of extraction versus non-extraction treatment, the impact of extractions on the skeletal vertical dimension remains rather unclear. The aim of this retrospective research study was to obtain a bias-free sample of morphologically similar borderline patients treated with or without extraction of the four first premolars and to retrospectively evaluate the vertical changes that occurred.

Methods

A borderline sample of 83 patients, 41 treated with four first premolar extractions and 42 treated without, was obtained by means of discriminant analysis applied to a previously investigated parent sample of 542 class I patients. The pretreatment and posttreatment cephalometric radiographs were analyzed digitally, and seven measurements were assessed for vertical skeletal changes. Also, average tracings between the two treatment groups were evaluated using the Procrustes superimposition method.

Results

The variables of SN to Go-Gn and Y-axis showed adjusted intergroup differences of − 0.91° and − 1.11° (P = 0.04). Comparing the mean intra-group differences of all the variables simultaneously, a significant difference was found between the two treatment groups (overall P value = 0.04). In the extraction group, only the gonial angle showed a significant decrease (P = 0.01) while the overall P value evaluating the intra-group differences between pre- and posttreatment was significant (overall P value < 0.01). In the non-extraction group, the variable of N-ANS/N-Me showed a significant decrease (P = 0.02) and the overall P value evaluating the intra-group differences between pre- and posttreatment was also significant (overall P value < 0.01). Differences in treatment duration were assessed using a log-normal model and showed that extraction treatment lasted significantly longer than non-extraction treatment (P < 0.01).

Conclusions

The borderline group of patients identified by the discriminant analysis exhibited similar morphological characteristics at treatment’s onset; therefore, the posttreatment changes could safely be attributed to the choice of extraction or non-extraction treatment and not to pre-existing differences. Treatment choice had an impact on the patients’ vertical skeletal dimensions. Patients treated with four first premolar extractions showed a slight decrease in the vertical skeletal measurements, whereas non-extraction patient treatment showed a slight increase. The treatment time was also significantly higher in the extraction group.

Diaphragmatic ultrasonography as an adjunct predictor tool of weaning success in patients with difficult and prolonged weaning

BACKGROUND

Diaphragmatic ultrasonography has been recently considered as a new weaning predictor method. Previous studies checked diaphragmatic excursion and thickness during quiet or deep breathing in unselected populations of critically ill patients. Our study aimed to investigate diaphragmatic excursion during quiet and unassisted breathing, in comparison to standard predictor tools, such as Rapid Shallow Breathing Index (RSBI) and Maximal Inspiratory Pressure (Pimax), in patients with difficult and/or prolonged weaning.

METHODS

Patients with difficult and/or prolonged weaning, who met the criteria for spontaneous breathing trial, were assessed. The excursion of each hemidiaphragm (DEx) was evaluated by B-mode and M-mode ultrasonography while patient was on quiet breathing and at supine position. RSBI and Pimax were simultaneously recorded and weaning outcome was recorded.

RESULTS

Thirteen male and fourteen female patients were included. DEx [median and interquartile range, mm] was 14 (8.5-22) for the right hemidiaphragm (RDEx) and 12 (7-23) for the left (LDEx). We found no difference in DEx between sexes. Among the four weaning predictor tools, LDEx at a cut-off 10 mm was the best index to predict weaning success (sensitivity 86%, specificity 85%, Negative Predictive Value 94%). The optimal cut-off values, as determined by the area under the receiver operating characteristic curve, were 10 mm for RDEx, 7 mm for LDEx, 57 breaths/min/L for RSBI and -20 cmH2O for Pimax.

CONCLUSIONS

Our results suggest that DEx threshold of 10 mm and 7 mm for right and left hemidiaphragms respectively could be used as adjunct tool in the predictive algorithm of weaning in difficult to wean patients.

Cardiovascular risk in pulmonary alveolar proteinosis

We hypothesized that cardiovascular events and/or indices of cardiac dysfunction may be increased in pulmonary alveolar proteinosis (PAP). Systemic and pulmonary arterial hypertension, arrhythmias, pulmonary embolism, stroke and ischemic heart attack were reported. Patients underwent serum anti-GM-CSF antibodies, disease severity score (DSS), Doppler transthoracic echocardiograph, glucose, thyroid hormones, lipids, troponin and pro-Brain natriuretic peptide (BNP) examination. Thirteen patients (8 female) were studied, median age of 47. Pro-BNP inversely related to DLCO% and TLC%; troponin directly related to DSS, age, P(A-a)O2, left atrium-, left ventricle-end-diastole diameter and BMI. On multiple regression analysis DSS was the only parameter significantly and strongly related with troponin (R(2) = 0.776, p = 0.007). No cardiovascular event was reported during follow-up. In PAP cardiovascular risk indices relate to lung disease severity. Therefore, PAP patients could be at increased risk for cardiovascular events. Quantitation of its magnitude and potential links to lungs' physiologic derangement will be addressed in future studies.

Extraction decision and identification of treatment predictors in Class I malocclusions

BACKGROUND

The extraction rate in orthodontics varies throughout the years. While the extraction decision is easily made or excluded in clear-cut cases, it still remains controversial what makes an orthodontist decide to extract in borderline cases. The aim of this retrospective study was to identify the percentage of extraction cases in a large group of Class I malocclusions and to clarify which variables contributed most to the extraction decision.

METHODS

The sample consisted of 542 randomly selected records of Class I patients treated in a university graduate program and in five private orthodontic offices. Of these patients, 331 were female and 211 male. The mean age was 14.55 (standard deviation (SD) 5.36) for the non-extraction group and 14.52 (SD 4.86) for the extraction group. The extensive series of 32 linear and angular measurements derived from the cephalometric analysis and the dental casts, along with the variables of age and gender, fueled a stepwise discriminant analysis.

RESULTS

The percentage of the patients treated with four first premolar extractions was 26.8%. The results showed that the variables of lower crowding, lower lip to E-plane, upper crowding, and overjet accounted most for the decision to extract at a very significant level (Sig. 0.000). The discriminant analysis assigned a classification power of 83.9% to the predictive model (p<0.0001). Fisher's linear discriminant functions provided a mathematical model, according to which any case can be classified into the adequate treatment group.

CONCLUSIONS

In a large contemporary sample of 542 Class I patients, the extraction rate was 26.8%. The most important measurements when the orthodontist decides extractions in Class I cases are lower crowding, lower lip to E-plane, upper crowding, and overjet. In clinical orthodontic practice, the findings facilitate treatment by providing evidence-based treatment predictors for Class I malocclusions.

The impact of extraction vs nonextraction treatment on soft tissue changes in Class I borderline malocclusions

OBJECTIVE

To obtain through the use of discriminant analysis a relatively bias-free sample of extraction and nonextraction, Class I, equally susceptible to both treatments' malocclusions and to analyze retrospectively the soft tissue changes between the two different treatment groups.

MATERIALS AND METHODS

The cephalometric, model, and demographic data of 215 patients (females and males) fueled a stepwise discriminant analysis that provided the borderline homogenous subsample (30 extraction and 32 nonextraction cases). The pretreatment and postreatment cephalograms of the borderline sample were then subjected to a thorough soft tissue cephalometric analysis.

RESULTS

The results indicated that the three variables that played the most important role in the clinician's treatment decision were indicators of lower crowding, soft tissue convexity, and lower incisor protrusion. Significant differences (P < .001) regarding upper and lower lip protrusion, upper lip thickness (P < .05), and the nasiolabial angle (P < .05) occurred.

CONCLUSION

Extraction treatment of Class I borderline malocclusions led to significant soft tissue changes regarding the upper and lower lip position and thickness as well as the nasiolabial angle, whereas the nonextraction treatment resulted in significant upper lip retraction and lower lip protraction.

C5a and TNF-alpha up-regulate the expression of tissue factor in intra-alveolar neutrophils of patients with the acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is characterized by the presence of fibrin-rich inflammatory exudates in the intra-alveolar spaces and the extensive migration of neutrophils into alveoli of the lungs. Tissue factor (TF)-dependent procoagulant properties of bronchoalveaolar lavage fluid (BALF) obtained from ARDS patients favor fibrin deposition, and are likely the result of cross-talk between inflammatory mediators and hemostatic mechanisms. However, the regulation of these interactions remains elusive. Prompted by previous findings suggesting that neutrophils, under certain inflammatory conditions, can express functional TF, we investigated the contribution of intra-alveolar neutrophils to the procoagulant properties of BALF from patients with ARDS. Our results confirm that the procoagulant properties of BALF from ARDS patients are the result of TF induction, and further indicate that BALF neutrophils are a main source of TF in intra-alveolar fluid. We also found that BALF neutrophils in these patients express significantly higher levels of TF than peripheral blood neutrophils. These results suggest that the alveolar microenvironment contributes to TF induction in ARDS. Additional experiments indicated that the ability of BALF to induce TF expression in neutrophils from healthy donors can be abolished by inhibiting C5a or TNF-alpha signaling, suggesting a primary role for these inflammatory mediators in the up-regulation of TF in alveolar neutrophils in ARDS. This cross-talk between inflammatory mediators and the induction of TF expression in intra-alveolar neutrophils may be a potential target for novel therapeutic strategies to limit ARDS-associated disturbances of coagulation.

A step-by-step diagnosis of exclusion in a twin pregnancy with acute respiratory failure due to non-fatal amniotic fluid embolism: a case report

INTRODUCTION

Respiratory failure may develop during the later stages of pregnancy and is usually associated with tocolysis or other co-existing conditions such as pneumonia, sepsis, pre-eclampsia or amniotic fluid embolism syndrome.

CASE PRESENTATION

We present the case of a 34-year-old healthy woman with a twin pregnancy at 31 weeks and 6 days who experienced acute respiratory failure, a few hours after administration of tocolysis (ritodrine), due to preterm premature rupture of the membranes. Her chest discomfort was significantly ameliorated after the ritodrine infusion was stopped and a Cesarean section was performed 48 hours later under spinal anesthesia; however, 2 hours after surgery she developed severe hypoxemia, hypotension, fever and mild coagulopathy. The patient was intubated and transferred to the intensive care unit where she made a quick and uneventful recovery within 3 days. As there was no evidence for drug- or infection-related thromboembolic or myocardial causes of respiratory failure, we conclude that our patient experienced a rare type of non-fatal amniotic fluid embolism.

CONCLUSION

In spite of the lack of solid scientific support for our diagnosis, we conclude that our patient suffered an uncommon type of amniotic fluid embolism syndrome and we believe that this report highlights the need for extreme vigilance and a high index of suspicion for such a diagnosis in any pregnant individual.

A fatal case of recurrent amiodarone-induced thyrotoxicosis after percutaneous tracheotomy: a case report

Background

Amiodarone is a widely used antiarrythmic drug, which may produce secondary effects on the thyroid. In 14–18% of amiodarone-treated patients, there is overt thyroid dysfunction, usually in the form of amiodarone-induced thyrotoxicosis, which can be difficult to manage with standard medical treatment.

Case presentation

Presented is the case of a 65-year-old man, under chronic treatment of atrial fibrillation with amiodarone, who was admitted to the Intensive Care Unit with acute cardio-respiratory failure and fever. He was recently hospitalized with respiratory distress, attributed to amiodarone-induced pulmonary fibrosis. Clinical and laboratory investigation revealed thyrotoxicosis due to amiodarone treatment. He was begun on thionamide, prednisone and beta-blockers. After a short term improvement of his clinical status the patient underwent percutaneous tracheotomy due to weaning failure from mechanical ventilation, which led to the development of recurrent thyrotoxicosis, unresponsive to medical treatment. Finally, the patient developed multiple organ failure and died, seven days later.

Conclusion

We suggest that percutaneous tracheotomy could precipitate a thyrotoxic crisis, particularly in non-euthyroid patients suffering from concurrent severe illness and should be performed only in parallel with emergency thyroid surgery, when indicated.

Prevention of nosocomial maxillary sinusitis in the ICU: the effects of topically applied α-adrenergic agonists and corticosteroids

OBJECTIVE

We investigated the efficacy of locally applied nasal decongestant agents and corticosteroids for preventing nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma.

DESIGN AND SETTING

A prospective, open-label randomized study in two intensive care units (ICUs).

PATIENTS

79 consecutive multiple trauma patients admitted to the ICU who were expected to be mechanically ventilated for more than 3 days.

INTERVENTIONS

Patients were randomly assigned to receive either a combination of a locally applied nasal decongestant agents: 2 drops twice/day of xylometazoline nasal solution 0.1% and 100microg budesonide (NDCA group, n=39) or placebo (control group, n=40).

MEASUREMENTS

For the diagnosis of radiological maxillary sinusitis patients underwent paranasal computed tomography within 48h of admission and thereafter every 4-7 days. Infectious maxillary sinusitis was diagnosed by microbiological analysis of fluid aspirated after transnasal puncture of maxillary sinuses.

RESULTS

Radiological maxillary sinusitis was detected in 54% of patients in the NDCA group (n=21) but in 82% of controls (p<0.01), and infectious maxillary sinusitis in 8% of the NDCA group (n=3) but in 20% of controls (n=8; p=0.11). The most common pathogen micro-organisms identified from maxillary aspirates were Acinetobacter (32%) followed by anaerobes (21%).

CONCLUSION

Our results indicate that the combination of locally applied xylometazoline hydrochloride and budesonide reduces the incidence of radiological maxillary sinusitis and may reduce also that of nosocomial maxillary sinusitis in mechanically ventilated patients with multiple trauma.