Magneto-dynamic tool for full arch immediate loading in post-traumatic restoration with narrow implants: A case report

New surgical techniques using narrow, tilted implants positioned through a magneto-dynamic tool in guided surgery for a Toronto restoration. A 69-year-old woman wanted fixed rehabilitation to replace her removable complete dentures. A cone-beam computed tomography showed significant bone resorption in both the maxillary and mandibular regions. The plan was to load the entire upper arch with six implants immediately, while removable partial dentures were recommended for the lower jaw. The guided surgery project was aligned with the new dentures, and the laboratory created a printed cast with dental implant analogues in planned positions. A metal-reinforced denture was constructed, and surgery was performed to place six narrow implants using the magneto-dynamic instrument. The denture was directly screwed onto multi-unit abutments. Final rehabilitation was completed after 6 months. Narrow implants can be a good option for fixed, full-arch rehabilitations. Further research is needed to confirm these findings on a larger scale.

Risk factors for intubation in severe bronchiolitis: a useful tool to decide on an early intensive respiratory support

BACKGROUND

Bronchiolitis is the most frequent lower airway infection leading hospitalization in children younger than 2 years. RSV is the typical common cause, followed by rhinovirus. Criteria for Pediatric Intensive Care Unit (PICU) admission are not defined by guidelines.

METHODS

A retrospective analysis of children with severe bronchiolitis admitted from 2013 to 2016 to our PICU was performed to identify the risk factors associated with intubation in this population. Fourteen variables were studied: sex, weight, age, nationality, provenience, duration of symptoms, risk factors for bronchiolitis development, recurrence, apnea, SpO2 in air, Modified Wood's Clinical Asthma score (M-WCAS), microbiological results, medical treatment, CPAP therapy. The relationship between these variables and the need for mechanical ventilation were explored using univariate and multivariate logistic regression analysis. A ROC analysis was used to identify cut-off for the continuous variables identified as risk factors for intubation in multivariate analysis.

RESULTS

We enrolled 93 patients: 19 of them (20.4%) were intubated. Univariate and multivariate analysis demonstrated that a M-WCAS Score ≥7, SpO2 ≤75% and apnea were significantly associated to intubation in children with severe bronchiolitis.

CONCLUSIONS

Cut-off values of the variables identified as risk factors for intubation may represent an important tool for pediatricians to decide a prompt and appropriate intensive respiratory support.

Multidrug-Resistant Bacterial Colonization and Infections in Large Retrospective Cohort of Mechanically Ventilated COVID-19 Patients1

Few data are available on incidence of multidrug-resistant organism (MDRO) colonization and infections in mechanically ventilated patients, particularly during the COVID-19 pandemic. We retrospectively evaluated all patients admitted to the COVID-19 intensive care unit (ICU) of Hub Hospital in Milan, Italy, during October 2020‒May 2021. Microbiologic surveillance was standardized with active screening at admission and weekly during ICU stay. Of 435 patients, 88 (20.2%) had MDROs isolated ≤48 h after admission. Of the remaining patients, MDRO colonization was diagnosed in 173 (51.2%), MDRO infections in 95 (28.1%), and non-MDRO infections in 212 (62.7%). Non-MDRO infections occurred earlier than MDRO infections (6 days vs. 10 days; p<0.001). Previous exposure to antimicrobial drugs within the ICU was higher in MDRO patients than in non-MDRO patients (116/197 [58.9%] vs. 18/140 [12.9%]; p<0.001). Our findings might serve as warnings for future respiratory viral pandemics and call for increased measures of antimicrobial stewardship and infection control.

RECURRENT LENTIGO MALIGNA: CONSERVATIVE CONTINUOUS TREATMENT WITH IMIQUIMOD OR REPEATED SURGERY? A LONG-TERM FOLLOW-UP DERMOSCOPIC CASE STUDY

A case of recurrent lentigo maligna in a 45-year-old woman is presented. The disease relapsed several times following the surgical excision of the lesion. An alternative treatment with imiquimod 5% cream was then used. After 4 years of follow-upfrom the last surgery, this treatment achieved total clearance of the lesion. The problems of lentigo maligna diagnosis and treatment are discussed.

Cutaneous immune-related adverse events and photodamaged skin in metastatic melanoma patients: Could the use of nicotinamide be useful?

Cutaneous immune-related adverse events occur in more than one-third of patients treated with immune checkpoint inhibitors; they are often the first clinical manifestation although they may occur months after initiation of therapy.We noticed that our patients usually have these cutaneous adverse events on photodamaged skin. In fact, out of 19 patients being treated for metastatic melanoma, patients (42%) with significant cutaneous actinic damage presented cutaneous immuno-related adverse events earlier and in a more serious form. Thus, our metastatic melanoma patients with photodamaged skin who were initiating immunotherapy were given a high oral dose of nicotinamide (500 mg twice daily)for the entire duration of therapy. In treated patients, the appearance of the first signs of cutaneous immuno-related adverse events was 180 days after starting therapy rather than 65 days for untreated patients.

Biomolecular, Histological, Clinical, and Radiological Analyses of Dental Implant Bone Sites Prepared Using Magnetic Mallet Technology: A Pilot Study in Animals

Background. A new instrumentation exploiting magneto-dynamic technology (mallet) proposed for implant site preparation was investigated. Methods. In the tibias of three minipigs, two sites were prepared by mallet and two by drill technique. Primary stability (ISQ) was detected after implant positioning (T0) and at 14 days (T14). X-rays and computed tomography were performed. At T14, bone samples were utilized for histological and biomolecular analyses. Results. In mallet sites, histological evaluations evidenced a significant increase in the newly formed bone, osteoblast number, and a smaller quantity of fibrous tissue. These results agree with the significant BMP-4 augmentation and the positive trend in other osteogenic factors (biological and radiological investigations). Major, albeit IL-10-controlled, inflammation was present. For both techniques, at T14 a significant ISQ increase was evidenced, but no significant difference was observed at T0 and T14 between the mallet and drill techniques. In mallet sites, lateral bone condensation was observed on computed tomography. Conclusions. Using biological, histological, clinical, and radiological analyses, this study first shows that the mallet technique is effective for implant site preparation. Based on its ability to cause osseocondensation and improve newly formed bone, mallet technology should be chosen in all clinical cases of poor bone quality.

SARS-CoV-2 RNA in plasma samples of COVID-19 affected individuals: a cross-sectional proof-of-concept study

BACKGROUND

Recent studies showed that plasma SARS-CoV-2 RNA seems to be associated with worse COVID-19 outcome. However, whether specific population can be at higher risk of viremia are to date unexplored.

METHODS

This cross-sectional proof-of-concept study included 41 SARS-CoV-2-positive adult individuals (six affected by haematological malignancies) hospitalized at two major hospital in Milan, for those demographic, clinical and laboratory data were available. SARS-CoV-2 load was quantified by ddPCR in paired plasma and respiratory samples. To assess significant differences between patients with and patients without viremia, Fisher exact test and Wilcoxon test were used for categorical and continuous variables, respectively.

RESULTS

Plasma SARS-CoV-2 RNA was found in 8 patients (19.5%), with a median (IQR) value of 694 (209-1023) copies/mL. Viremic patients were characterized by an higher mortality rate (50.0% vs 9.1%; p = 0.018) respect to patients without viremia. Viremic patients were more frequently affected by haematological malignancies (62.5% vs. 3.0%; p < 0.001), and had higher viral load in respiratory samples (9,404,000 [586,060-10,000,000] vs 1560 [312-25,160] copies/mL; p = 0.002).

CONCLUSIONS

Even if based on a small sample population, this proof-of-concept study poses the basis for an early identification of patients at higher risk of SARS-CoV-2 viremia, and therefore likely to develop severe COVID-19, and supports the need of a quantitative viral load determination in blood and respiratory samples of haematologic patients with COVID-19 in order to predict prognosis and consequently to help their further management.

Quantification of 1,3-β-d-glucan by Wako β-glucan assay for rapid exclusion of invasive fungal infections in critical patients: A diagnostic test accuracy study

OBJECTIVES

Rapid and reliable exclusion of invasive fungal infections (IFI) by markers able to avoid unnecessary empirical antifungal treatment is still a critical unmet clinical need. We investigated the diagnostic performance of a newly available β-d-Glucan (BDG) quantification assay, focusing on the optimisation of the BDG cut-off values for IFI exclusion.

METHODS

BDG results by Wako β-glucan assay (lower limit of detection [LLOD] = 2.16 pg/mL, positivity ≥ 11 pg/mL) on two consecutive serum samples were retrospectively analysed in 170 patients, admitted to haematological wards (N = 42), intensive care units (ICUs; N = 80), or other wards (N = 48), exhibiting clinical signs and/or symptoms suspected for IFI. Only patients with proven IFI (EORTC/MSG criteria) were considered as true positives in the assessment of BDG sensitivity, specificity and predictive values.

RESULTS

Patients were diagnosed with no IFI (69.4%), proven IFI (25.3%) or probable IFI (5.3%). Two consecutive BDG values < LLOD performed within a median of 1 (interquartile range: 1-3) day were able to exclude a proven IFI with 100% sensitivity and negative predictive value (primary study goal). Test's specificity improved by using two distinct positivity and negativity cut-offs (7.7 pg/mL and LLOD, respectively), but remained suboptimal in ICU patients (50%), as compared to haematological or other patients (93% and 90%, respectively).

CONCLUSIONS

The classification of Wako's results as negative when < LLOD, and positive when > 7.7 pg/mL, could be a promising diagnostic approach to confidently rule out an IFI in both ICU and non-ICU patients. The poor specificity in the ICU setting remains a concern, due to the difficulty to interpret positive results in this fragile population.

Detection and quantification of SARS-CoV-2 by droplet digital PCR in real-time PCR negative nasopharyngeal swabs from suspected COVID-19 patients

Since SARS-CoV-2-based disease (COVID-19) spreads as a pandemic, the necessity of a highly sensitive molecular diagnosis that can drastically reduce false negatives reverse transcription PCR (rtPCR) results, raises as a major clinical need. Here we evaluated the performance of a ddPCR-based assay to quantify SARS-CoV-2 titer in 55 suspected COVID-19 cases with negative rtPCR results thanks to in-house ddPCR assay (targeting RdRp and host RNaseP). Samples were collected at ASST-GOM Niguarda between February and May 2020 at hospital admission. Clinical and imaging data were obtained for clinical staging and definition of disease severity. Patients were mainly female (45.5%) with a median age of 73 (57–84) years. ddPCR-based assay detected SARS-CoV-2 genome in nasopharyngeal samples of 19 (34.5%) patients (median viral-load: 128 copies/mL, IQR: 72–345). In 15 of them (78.9%), chest CT showed a classical COVID-19 bilateral interstitial pneumonia; 14 patients (73.7%) showed severe COVID-19 manifestations. ddPCR did not identify any trace of SARS-CoV-2 genome in the respiratory samples of the remaining 36 patients. The serological assay performed in a subgroup of 34 patients at the later stage of illness (from 3 days to 90 days after) confirmed the presence of SARS-CoV-2 antibodies in all patients tested positive for SARS-CoV-2 in ddPCR (100%). Contrariwise, negative tests were observed in 95.0% ddPCR negative patients (P<0.001). Thanks to a ddPCR-based assay, we achieved a rapid and accurate SARS-CoV-2 diagnosis in rtPCR-negative respiratory samples of individuals with COVID-19 suspect, allowing the rapid taking care and correct management of these patients.

Detection of strong inspiratory efforts from the analysis of central venous pressure swings: a preliminary clinical study

BACKGROUND

Swings of central venous pressure (ΔCVP) may reflect those of pleural and esophageal (ΔPES) pressure and, therefore, the strength of inspiration. Strong inspiratory efforts can produce some harm. Herein we preliminarily assessed the diagnostic accuracy of ΔCVP for strong inspiratory efforts in critically-ill subjects breathing spontaneously.

METHODS

We measured ΔCVP and ΔPES in 48 critically-ill subjects breathing spontaneously with zero end-expiratory pressure (ZEEP) or 10 cmH<inf>2</inf>O of continuous positive airway pressure (CPAP). The overall diagnostic accuracy of ΔCVP for strong inspiratory efforts (arbitrarily defined as ΔPES >8 mmHg) was described as the area under the receiver operating characteristic (ROC) curve, with 0.50 indicating random guess. The agreement between ΔCVP and ΔPES was assessed with the Bland-Altman analysis.

RESULTS

ΔCVP recognized strong inspiratory efforts with an area under the ROC curve of 0.95 (95% confidence intervals, 0.85-0.99) with ZEEP and 0.89 (0.76-0.96) with CPAP, both significantly larger than 0.50 (P<0.001). With the best cut-off value around 8 mmHg, the diagnostic accuracy of ΔCVP was 0.92 (0.80-0.98) with ZEEP and 0.94 (0.83-0.99) with CPAP. With ZEEP, the median difference between ΔCVP and ΔPES (bias) was -0.2 mmHg, and the 95% limits of agreement (LoA) were -3.9 and +5.5 mmHg. With CPAP, bias was -0.1 mmHg, and 95%-LoA were -5.8 and +4.5 mmHg. In both cases, ΔCVP correlated with ΔPES (r<inf>s</inf> 0.81 and 0.67; P<0.001 for both).

CONCLUSIONS

In critically-ill subjects breathing spontaneously, ΔCVP recognized strong inspiratory efforts with acceptable accuracy. Even so, it sometimes largely differed from ∆PES.

Clinical osseointegration of bone level implants with conical shape and textured surface with low primary stability

BACKGROUND

Evidence shows lower chance for osseointegration of implants without sufficient primary stability. The present retrospective study observed bone level conical screw implants with textured surface without primary stability.

METHODS

Twenty-six Stark conical screw implants, with V-Blast (Vanish Blast) surface treatment were placed with low primary stability, (insertion torque lower than 10 N/cm and visible mobility at lateral load of 250 g). A soft diet was prescribed. osseointegration was assessed applying 30 Ncm of reverse torque 6 months after placement.

RESULTS

The 26 implants that did not achieve primary stability still had a survival rate of 96% after the observation period and were classified as successful according with ICOI Pisa consensus conference success, survival, failure classification .96% of the implants showed clinical osteointegration and were successfully restored. After 12 months, all implants remained functional.

CONCLUSIONS

It can be concluded that bone-level implants with V-Blast surface in absence of functional loading are able to achieve osteointegration, even with low primary stability.

Pulp vitality during ultrasonic tooth preparation. Part 2

BACKGROUND

Ultrasonic devices have a lot of dental application specially in hygiene and surgery. However there are some disadvantages like cut slowness and heat production. Prosthodontics application is less investigated. In particular the heat production could be an important factor for the clinician. In fact more than 5.5 °C temperature increasing could determine pulp necrosis during tooth preparation. The aim of this study is to investigate the increasing of temperature during finishing line repositioning and polishing phases using ultrasounds inserts and to verify if it remains within the limit of 5.5 °C.

METHODS

A sample of 32 human molars (extracted for periodontal reasons) was selected. The teeth were endodontically treated and prepared with burs in order to obtain a prosthetic round chamfer preparation, leaving the apical portion pervious for inserting the thermocouple probe. Then, they were inserted in plaster cubes up to the cement-enamel junction. A wall has been selected for each tooth for margin repositioning and finishing and prepared with the piezoelectric instrument (Multipiezo Touch with TipHolder DB2, Mectron, Carasco, Genoa, Italy). A mechanical arm was used to standardize the operator-dependent parameters. These parameters were: the pressure exerted on the dental wall, the cutting length and the time required for margin repositioning and finishing. The test phase consisted in a first stage of margin repositioning using an regular ultrasound tip with a diamond grain of 120 micron (DB120, Mectron, Carasco, Italy) (group 1), followed by a second finishing step conducted by a extra fine ultrasound tip with a diamond grain of 60 micron (DB60, Mectron, Carasco, Italy) (group 2). Each test lasted 60 seconds: this was the time that the mechanical arm needed to accomplish 32 rides. During these stages the intrapulpal temperature has been recorded thanks to a thermocouple. The obtained temperature data were analyzed by Kruskal-Wallis test and Mann-Withney post-hoc test, without Bonferroni correction (P<0.001).

RESULTS

The average pulpal temperature increase was 4.65 °C with a standard deviation of 0.99 °C for the DB 120 ultrasonic tip and 5.40 °C with a standard deviation of 0.84 °C for the DB 60 ultrasonic tip. However, neither of the instruments reach the medium critical level of 5.5°C reported in the literature, there are some single values who exceed it. There is statistically significant difference using tips with different granulometries within the two groups (P value =0.013).

CONCLUSIONS

Ultrasonic tools are very performing to achieve results in repositioning and polishing of prepared tooth. The in-vitro analysis show that the pulp temperature increasing remains within the safe limits literature shows. It is important underline the polishing phase is the most critical and the clinicians have to pay attention to irrigation and pression to avoid pulp damages. Additional clinical studies have to be performed to confirm these results.

Micro- CT evaluation of sealers removal by reciprocal instrumentation followed by continuous ultrasonic irrigation in teeth with oval root canals

Background

The ability of the Reciproc system (R40) followed by continuous ultrasonic irrigation (CUI) to remove filling material from oval root canals of mandibular premolars filled with gutta-percha and AH Plus or Bio-C Sealer was evaluated by microtomography (micro-CT).

Material and Methods

The straight and oval root canals of 42 mandibular premolars were prepared with the ProDesign R 35.05 reciprocal file and randomly divided into two groups according to the material used to fill the canals (n=21): Group AH - Master Cone and AH Plus; Group BC - Master Cone and Bio-C Sealer. After filling and provisional sealing, the teeth were stored at 100% relative humidity and a temperature of 37°C for 30 days. The filling material was then removed with an R40 file. The material was considered completely removed when the R40 file reached the working length (WL), and no remaining filling material was visible on the canal walls. CUI was then performed. The teeth were scanned by micro- CT before and after removal of the filling material. The remaining filling material was measured in mm in the last apical 5 mm. The data were analyzed with the nonparametric Friedman test and subsequently with the Dunn test. The Mann-Whitney U test was also performed. Statistical significance was accepted at the 5% level.

Results

After instrumentation with the Reciproc R40, the volume of residual filling material was significantly greater in the BC group than in the AH group (P = 0.035). After CUI, there was no difference in the volume of residual material between the two groups (P = 0.705).

Conclusions

Bio-C sealer was more difficult to remove with the Reciproc file than AH Plus. CUI improved the removal of residual filling material regardless of sealer type. However, no technique was able to completely clear the canals of filling material. Key words:Bioceramic cement, CUI, micro-CT, reciproc, retreatment.

Malnutrition and Perioperative Nutritional Support in Retroperitoneal Sarcoma Patients: Results from a Prospective Study

INTRODUCTION

Retroperitoneal soft tissue sarcomas (RPSs) are mesenchymal neoplasms. The prevalence of protein energetic malnutrition (PEM) and its impact in RPS patients who were candidates for surgery is unknown.

MATERIALS AND METHODS

A prospective feasibility study enrolled 35 patients with primary RPS who were candidates for extended multivisceral resection. PEM was screened at enrollment. Preoperative high protein β-hydroxy-β-methyl butyrate oral nutritional support (ONS) was provided according to the degree of PEM. After surgery, nutritional support followed standard practice, targeting at least 1 g/kg/day protein and 20 kcal/kg/day caloric intake within the third postoperative day (POD). PEM was re-evaluated before surgery on POD 10, and at 4 and 12 months after surgery. Primary outcomes were the patient's compliance to preoperative ONS and the physician's compliance to postoperative nutritional targets.

RESULTS

PEM was documented in 46% of patients at baseline; ONS met a 91% adherence (overall well tolerated). After ONS, PEM reduced to 38% (p = 0.45). The postoperative caloric target was reached on day 4.1 (standard error ± 2.7), with a protocol adherence rate of 52%. On POD 10, 91% of patients experienced PEM, the worsening of which was greater after resection of four or more organs (p = 0.06). At 4 and 12 months after surgery, almost all patients had fully recovered. A significant correlation between PEM at surgery and postoperative complications was found (p = 0.04).

CONCLUSIONS

Relevant PEM prevalence in RPS is documented for the first time. PEM correlates with greater morbidity. In this setting, preoperative ONS was feasible and well-tolerated. Disease-related factors for PEM and the ideal perioperative caloric target in the context of extended multivisceral resection need to be further investigated. Nutritional support should be included in enhanced recovery after surgery programs for RPS.

TRIAL REGISTRY

ClinicalTrials.gov identifier: NCT03877588.

Piezoelectric implant surgery and immediate loading in the aesthetic zone

BACKGROUND

Replacement of missing teeth in the anterior aesthetic zone has challenged clinicians with fixed, removable or implant prosthodontics. Problems have been encountered could void aesthetic and functional results. The aim of this study was to present a clinical case report in which clinician challenged a very strong aesthetic case with an innovative surgical and prosthetic approach.

METHODS

A patient who presented to the authors with a maxillary central incisor that had a hopeless prognosis secondary to acute localized severe periodontitis. The patient was treated by extracting the tooth and replacing it immediately with a platform switched implant using piezoelectric surgery. The implant was then restored with an immediate, non-occlusal loading provisional restoration.

RESULTS

The implant became osseointegrated and was ultimately restored with a definitive abutment and crown restoration.

CONCLUSIONS

Innovative approaches could represent a valid alternative to restore patients functionally and aesthetically.

Temperature variations in pulp chamber: an in-vitro comparison between ultrasonic and rotating instruments in tooth preparation. Part 1

BACKGROUND

The purpose of this study was to analyze pulpal temperature increase generated by prosthodontic margin repositioning and finishing with ultrasonic and rotating instruments. The temperature changes recorded were also correlated with the residual dentin thickness.

METHODS

A sample of 32 human extracted molars was selected. The teeth were endodontically treated and prepared with prosthetic round chamfer preparation. Then, they were inserted in plaster cubes up to the cement-enamel junction, leaving the apical portion pervious for inserting the thermocouple probe. The conventional technique, which involves the use of a high-speed contra-angle handpiece, was compared with an ultrasonic method (Crown Prep, Mectron, Carasco, Italy). For margin repositioning and finishing, two walls were randomly selected for each tooth: one was included in the test group and cut with the piezoelectric instrument (Multipiezo Touch TipHolder DB2, Mectron, Carasco, Genoa, Italy), the other one was inserted in the control group and cut with the high speed contra-angle handpiece (Kavo, Biberach, Germany). To standardize the operator-dependent parameters, it was used a mechanical arm controlled by a computer. These parameters were the pressure exerted on the dental wall, the cutting length and the time required for margin repositioning and finishing. For both test and control group, test phase consisted in a first stage of margin repositioning using an ultrasound tip or a diamond bur with a greater granulometry (120 µm for the ultrasound tip and 125 µm for the diamond bur), followed by a second finishing step conducted by an ultrasound tip or a diamond bur with smaller granulometry (60 µm for the ultrasound tip and 30 µm for the diamond bur). During these stages the intrapulpal temperature was recorded thanks to a thermocouple. Before and after these steps, the thickness of the remaining dental walls was measured with a caliber.

RESULTS

The average pulpal temperature increase was 5.03±0.98 °C for the ultrasonic preparation (test group) and 3.55±0.95 °C for the conventional technique (control group). The difference was statistically significant (P value <0.001). However, neither of the instruments reached the critical level of 5.5 °C reported in the literature. The mean initial dentin thicknesses was 1.82±0.47 mm for the control group and 1.59±0.54 mm for the test group but the analysis of the residual dentin thicknesses revealed a greater reduction of the walls worked up with high speed contra-angle handpiece (mean 0.9±0.5 mm), which was therefore more aggressive than the ultrasonic instrument (mean 1.1±0.5 mm). A very weak negative correlation was present between the thickness of the wall at baseline and the increment of temperature.

CONCLUSIONS

Within limitations of this study, temperature increasing of ultrasonic instruments shows a statistical difference related to rotary ones. But, as literature shows, the ultrasonic advantages are margin precision, preservation of soft tissues and reduction of operating times. Furthermore, in relation with results of this study, they could be considered safe for pulp vitality because the increase in pulpal temperature is similar to traditional instruments and it does not exceed the critical level of 5.5 °C.

Unexpected postpneumonectomy exertion-induced acute right heart failure

INTRODUCTION

Thoracic surgery can have serious side effects. Accurate preoperative evaluation to assess which patients with anatomically resectable disease are suitable candidates for surgery is mandatory.

CASE DESCRIPTION

A 58-year-old man, scheduled for left pneumonectomy for lung cancer, passed all the preoperative examinations suggested by guidelines and underwent the surgery. Three days after pneumonectomy, he experienced hemorrhagic shock and subsequent acute respiratory distress syndrome. Fifteen days after left pneumonectomy, he experienced exertional acute right heart failure (ARHF). We administered sildenafil and he improved, clinically and echocardiographically. During the following 2 years of follow-up, he was asymptomatic at rest but under exercise test, he developed pulmonary hypertension with echocardiographic signs of right ventricular impairment.

CONCLUSIONS

In patients scheduled for major lung resections, preoperative stress echocardiography may give an adjunctive value to cardiopulmonary exercise test, quantifying the exercise-induced reduction in right ventricle ejection fraction and identifying asymptomatic patients at risk for postoperative ARHF.

Sevoflurane improves respiratory mechanics and gas exchange in a case series of infants with severe bronchiolitis-induced acute respiratory distress syndrome

This report describes the successful use of a new intervention to improve respiratory mechanics and gas exchange in a relatively homogeneous group of infants with severe bronchiolitis‐induced PARDS after failure of conventional treatment. These results may open a new interesting area of research and management for PARDS patients.

Evaluation of a New Ultrasonic Insert for Prosthodontic Preparation

PURPOSE

This paper describes a new ultrasonic instrument (tipholder DB1 with crown prep tip inserts) designed to optimize prosthodontic margin repositioning and finishing.

MATERIALS AND METHODS

The insert movement was assessed, and it was demonstrated that tipholder DB1 provides its inserts with an elliptical-like movement, making the entire insert surface able to cut. Then, 20 extracted teeth were prepared using tipholder DB1, sonic instruments, and traditional drills. Dental surface roughness produced using each of the three tools was measured using a roughness tester. Results were compared using univariate analysis of variance and Bonferroni post hoc test.

RESULTS

The roughness produced using tipholder DB1 with crown prep insert presented no statistically significant differences compared to the roughness produced using sonic instruments and traditional drills.

CONCLUSION

Tipholder DB1 with crown prep inserts is a promising treatment for margin repositioning and finishing.

Medical-surgical activity and the current state of training of urology residents in Spain: Results of a national survey

OBJECTIVES

To determine the actual state of medical-surgical activity and training for urology residents in Spain.

MATERIAL AND METHOD

We designed 2 anonymous surveys, which were uploaded with the Google Docs^© tool so that the respondents could answer the surveys online. The online collection period was September 2015 to January 2016. The collected data were processing using the statistical programme IBM SPSS for Windows, Version 21.0 and the programme R version 3.2.3.

RESULTS

The total number of responders was 163. In reference to the number of physically present on-call residents, the majority conducted between 4 and 6 shifts a month. Eighty-four of those surveyed indicated that they were in the operating room less than 20hours a week, and 43 of these even less than 10hours. Thirty percent of those surveyed had not performed any transurethral resection. The majority had performed at least one prostatic adenomectomy, but had not performed any major oncologic procedure, either laparoscopically or openly. In the questions concerning training and training courses, we found that most of the residents trained in laparoscopy at the hospital or at home. The overall satisfaction for the residence was assessed at 2.6. Based on this score, the overall satisfaction could be considered moderate.

CONCLUSIONS

Efforts should be directed towards standardising the acquisition of surgical and nonsurgical skills, ensuring access to training courses, establishing a minimum of required operations per year and achieving an objective assessment of the specialty.

Predicting the effect of maternal docosahexaenoic acid (DHA) supplementation to reduce early preterm birth in Australia and the United States using results of within country randomized controlled trials

The DHA to Optimize Mother Infant Outcome (DOMInO) and Kansas DHA Outcomes Study (KUDOS) were randomized controlled trials that supplemented mothers with 800 and 600mg DHA/day, respectively, or a placebo during pregnancy. DOMInO was conducted in Australia and KUDOS in the United States. Both trials found an unanticipated and statistically significant reduction in early preterm birth (ePTB; i.e., birth before 34 weeks gestation). However, in each trial, the number of ePTBs were small. We used a novel Bayesian approach to estimate statistically derived low, moderate or high risk for ePTB, and to test for differences between the DHA and placebo groups. In both trials, the model predicted DHA would significantly reduce the expected proportion of deliveries in the high risk group under the trial conditions of the parent studies. Among the next 300,000 births in Australia we estimated that 1112 ePTB (95% credible interval 51-2189) could be avoided by providing DHA. And in the USA we estimated that 106,030 ePTB (95% credible interval 6400 to 175,700) could be avoided with DHA.

Docosahexaenoic acid supplementation (DHA) and the return on investment for pregnancy outcomes

The Kansas University DHA Outcomes Study (KUDOS) found a significant reduction in early preterm births with a supplement of 600mg DHA per day compared to placebo. The objective of this analysis was to determine if hospital costs differed between groups. We applied a post-hoc cost analysis of the delivery hospitalization and all hospitalizations in the following year to 197 mother-infant dyads who delivered at Kansas University Hospital. Hospital cost saving of DHA supplementation amounted to $1678 per infant. Even after adjusting for the estimated cost of providing 600mg/d DHA for 26 weeks ($166.48) and a slightly higher maternal care cost ($26) in the DHA group, the net saving per dyad was $1484. Extrapolating this to the nearly 4 million US deliveries per year suggests universal supplementation with 600mg/d during the last 2 trimesters of pregnancy could save the US health care system up to USD 6 billion.

Long chain polyunsaturated fatty acid supplementation in infancy increases length- and weight-for-age but not BMI to 6 years when controlling for effects of maternal smoking

Long chain polyunsaturated fatty acids (LCPUFA) are added to infant formula but their effect on long-term growth of children is under studied. We evaluated the effects of feeding LCPUFA-supplemented formula (n = 54) compared to control formula (n = 15) throughout infancy on growth from birth-6 years. Growth was described using separate models developed with the MIXED procedure of SAS(®) that included maternal smoking history and gender. Compared to children fed control formula, children who consumed LCPUFA supplemented formula had higher length-/stature-/and weight-for-age percentiles but not body mass index (BMI) percentile from birth to 6 years. Maternal smoking predicted lower stature (2-6 years), higher weight-for-length (birth-18 months) and BMI percentile (2-6 years) independent of LCPUFA effects. Gender interacted with the effect of LCPUFA on stature, and the relationship between smoking and BMI, with a larger effect for boys. Energy intake did not explain growth differences. A relatively small control sample is a limitation.

Selective pulmonary vasodilation improves ventriculovascular coupling and gas exchange in a patient with unrepaired single-ventricle physiology

We describe a 63-year-old patient with unrepaired tricuspid valve atresia and a hypoplastic right ventricle (single-ventricle physiology) who presented with progressive symptomatic hypoxia. Her anatomy resulted in parallel pulmonary and systemic circulations, pulmonary arterial hypertension, and uncoupling of the ventricle/pulmonary artery. Hemodynamic and coupling data were obtained before and after pulmonary vasoactive treatment, first inhaled nitric oxide and later inhaled treprostinil. The coupling ratio (ratio of ventricular to vascular elastance) shunt fractions and dead space ventilation were calculated before and after treatment. Treatment resulted in improvement of the coupling ratio between the ventricle and the vasculature with optimization of stroke work, equalization of pulmonary and systolic flows, a decrease in dead space ventilation from 75% to 55%, and a significant increase in 6-minute walk distance and improved hypoxia. Inhaled treprostinil significantly increased 6-minute walk distance and improved hypoxia. This is the first report to show that pulmonary vasoactive treatment can be used in a patient with unrepaired single-ventricle anatomy and describes the hemodynamic effects of inhaled therapy on ventriculovascular coupling and gas exchange in the pulmonary circulation in this unique physiology.

Docosahexaenoic acid (DHA) supplementation in pregnancy differentially modulates arachidonic acid and DHA status across FADS genotypes in pregnancy

Some FADS alleles are associated with lower DHA and ARA status assessed by the relative amount of arachidonic acid (ARA) and docosahexaenoic acid (DHA) in plasma and red blood cell (RBC) phospholipids (PL). We determined two FADS single nucleotide polymorphisms (SNPs) in a cohort of pregnant women and examined the relationship of FADS1rs174533 and FADS2rs174575 to DHA and ARA status before and after supplementation with 600mg per day of DHA. The 205 pregnant women studied were randomly assigned to placebo (mixed soy and corn oil) (n=96) or 600mg algal DHA (n=109) in 3 capsules per day for the last two trimesters of pregnancy. Women homozygous for the minor allele of FADS1rs174533 (but not FADS2rs174575) had lower DHA and ARA status at baseline. At delivery, minor allele homozygotes of FADS1rs174533 in the placebo group had lower RBC-DHA compared to major-allele carriers (P=0.031), while in the DHA-supplemented group, all genotypes had higher DHA status compared to baseline (P=0.001) and status did not differ by genotype (P=0.941). Surprisingly, DHA but not the placebo decreased ARA status of minor allele homozygotes of both FADS SNPs but not major allele homozygotes at delivery. Any physiological effects of changing the DHA to ARA ratio by increasing DHA intake appears to be greater in minor allele homozygotes of some FADS SNPs.

Effects of docosahexaenoic acid supplementation during pregnancy on fetal heart rate and variability: a randomized clinical trial

DHA (22:6n-3) supplementation during infancy has been associated with lower heart rate (HR) and improved neurobehavioral outcomes. We hypothesized that maternal DHA supplementation would improve fetal cardiac autonomic control and newborn neurobehavior. Pregnant women were randomized to 600 mg/day of DHA or placebo oil capsules at 14.4 (+/-4) weeks gestation. Fetal HR and HRV were calculated from magnetocardiograms (MCGs) at 24, 32 and 36 weeks gestational age (GA). Newborn neurobehavior was assessed using the Neonatal Behavioral Assessment Scale (NBAS). Post-partum maternal and infant red blood cell (RBC) DHA was significantly higher in the supplemented group as were metrics of fetal HRV and newborn neurobehavior in the autonomic and motor clusters. Higher HRV is associated with more responsive and flexible autonomic nervous system (ANS). Coupled with findings of improved autonomic and motor behavior, these data suggest that maternal DHA supplementation during pregnancy may impart an adaptive advantage to the fetus.

Extracorporeal lung perfusion and ventilation to improve donor lung function and increase the number of organs available for transplantation

INTRODUCTION

Ex vivo lung perfusion (EVLP) has been validated as a valuable technique to increase the pool of organs available for lung transplantation.

MATERIAL AND METHODS

After a preclinical experience, we obtained permission from the Ethics Committee of our institution to transplant lungs after EVLP reconditioning. ABO compatibility, size match, and donor arterial oxygen pressure (PaO(2))/fraction of inspired oxygen (FiO(2)) ≤ 300 mm Hg were considered to be inclusion criteria, whereas the presence of chest trauma and lung contusion, evidence of gastric content aspiration, pneumonia, sepsis, or systemic disease were exclusion criteria. We only considered subjects on an extra corporeal membrane oxygenation (ECMO) bridge to transplantation with rapid functional deterioration. Using Steen solution with packed red blood cells oxygenated with 21% O(2), 5% to 7% CO(2) was delivered, targeted with a blood flow of approximately 40% predicted cardiac output. Once normothermic, the lungs were ventilated with a tidal volume of 7 mL/kg a PEEP of 5 cmH(2)O and a respiratory rate of 7 bpm. Lungs were considered to be suitable for transplantation if well oxygenated [P(v-a) O(2) > 350 mm Hg on FiO(2) 100%], in the absence of deterioration of pulmonary vascular resistance and lung mechanics over the perfusion time.

RESULTS

From March to September 2011, six lung transplantations were performed, including two with EVLP. The functional outcomes were similar between groups: at T72 posttransplantation, the median PaO(2)/FiO(2) were 306 mm Hg (range, 282 to 331 mm Hg) and 323 mm Hg (range, 270 to 396 mm Hg) (P = 1, EVLP versus conventional). Intensive care unit ICU and hospital length of stay were similar (P = .533 and P = .663, respectively) with no mortality at 60 days in both groups. EVLP donors were older (49 ± 6 y versus 21 ± 7 y, P < .05), less well oxygenated (184 ± 6 mm Hg versus 570 ± 30, P < .05), displaying higher Oto scores (9.5 ± 0.7 versus 1.7 ± 1.5, P < .05).

CONCLUSIONS

The first 6 months of the EVLP program allowed us to increase the number of organs available for transplantation with short-term outcomes comparable to conventional transplantations.