Iatrogenic retroposition of the lips sequel after bicuspid extraction-a retrospective study

AIM

This study aims to explore the prevalence of Iatrogenic retroposition of the lips sequel (IRLS) after bicuspid extraction, associated dentofacial characteristics and the effectiveness of surgical treatment.

MATERIAL

and methods: Patients with bicuspid extraction as part of an orthodontic treatment plan were retrospectively included. IRLS was identified by clinical evaluation and cephalometric Legan and Burstone analysis. Association of demographic and cephalometric variables were assessed. The effectiveness of combined orthodontic-orthognathic correction of the retroposition of the lips was evaluated.

RESULTS

Out of 144 patients with extracted bicuspids, eight Class I patients, nine Class II patients and five Class III patients were seeking treatment because their lips had retruded as a consequence of compensating orthodontic treatment. Lower jaw bicuspid extraction and a decreased vertical facial height in Class II patients correlated significantly more with IRLS development. Postoperative cephalometric analysis of orthodontic-orthognathic treated patients reported improvement in lip projection and naso-labial angle. Only two Class I patients reported postoperative normalization of the lip position according to Legan and Burstone.

CONCLUSION

The consequence of bicuspid extractions on soft tissue profile differs according to skeletal jaw relation. The impact of orthognathic surgery on IRLS is beneficial, although insufficient to completely correct the facial profile when judged on cephalometric standards.

Ecology and evolution of antibiotic persistence

Bacteria have at their disposal a battery of strategies to withstand antibiotic stress. Among these, resistance is a well-known mechanism, yet bacteria can also survive antibiotic attack by adopting a tolerant phenotype. In the case of persistence, only a small fraction within an isogenic population switches to this antibiotic-tolerant state. Persistence depends on the ecological niche and the genetic background of the strains involved. Furthermore, it has been shown to be under direct and indirect evolutionary pressure. Persister cells play a role in chronic infections and the development of resistance, and therefore a better understanding of this phenotype could contribute to the development of effective antibacterial therapies. In the current review, we discuss how ecological and evolutionary forces shape persistence.

The need for secondary orthognathic surgery after high condylectomy in patients with active unilateral condylar hyperplasia

The need for secondary orthognathic surgery (OS) after a high condylectomy (HC) in patients with active unilateral condylar hyperplasia was assessed in 25 patients, reviewing patient characteristics and treatment planning. At 6-12 months after HC, 13 patients (52%) required secondary OS. The amount of mandibular dental midline shift before the HC (P=0.037), and a dental crossbite that was present before the HC (P=0.017) were significantly associated with the need for secondary OS. Overall, the mandibular dental midline coincided with the facial midline in eight patients (32%) at 2 weeks after HC. In 16% of the patients, no additional OS was needed despite this being the initial treatment plan. Additionally, the initially planned type of secondary OS was modified in six other patients. Early HC in skeletally immature patients provided very good results, both aesthetic and functional, with only two of them needing supplementary OS at 6-12 months after HC. The HC remains a valuable treatment in patients with active unilateral condylar hyperplasia, as it can eliminate the need for secondary OS and is very well tolerated by most patients.

Automatic 3D dense phenotyping provides reliable and accurate shape quantification of the human mandible

Automatic craniomaxillofacial (CMF) three dimensional (3D) dense phenotyping promises quantification of the complete CMF shape compared to the limiting use of sparse landmarks in classical phenotyping. This study assesses the accuracy and reliability of this new approach on the human mandible. Classic and automatic phenotyping techniques were applied on 30 unaltered and 20 operated human mandibles. Seven observers indicated 26 anatomical landmarks on each mandible three times. All mandibles were subjected to three rounds of automatic phenotyping using Meshmonk. The toolbox performed non-rigid surface registration of a template mandibular mesh consisting of 17,415 quasi landmarks on each target mandible and the quasi landmarks corresponding to the 26 anatomical locations of interest were identified. Repeated-measures reliability was assessed using root mean square (RMS) distances of repeated landmark indications to their centroid. Automatic phenotyping showed very low RMS distances confirming excellent repeated-measures reliability. The average Euclidean distance between manual and corresponding automatic landmarks was 1.40 mm for the unaltered and 1.76 mm for the operated sample. Centroid sizes from the automatic and manual shape configurations were highly similar with intraclass correlation coefficients (ICC) of > 0.99. Reproducibility coefficients for centroid size were < 2 mm, accounting for < 1% of the total variability of the centroid size of the mandibles in this sample. ICC’s for the multivariate set of 325 interlandmark distances were all > 0.90 indicating again high similarity between shapes quantified by classic or automatic phenotyping. Combined, these findings established high accuracy and repeated-measures reliability of the automatic approach. 3D dense CMF phenotyping of the human mandible using the Meshmonk toolbox introduces a novel improvement in quantifying CMF shape.

Antibiotics in orthognathic surgery: a retrospective analysis and identification of risk factors for postoperative infection

This study was undertaken to evaluate the infection rate following orthognathic surgery and to identify possible risk factors. A retrospective study was conducted. Patients undergoing orthognathic surgery from August 1, 2017 to July 31, 2018 were included. The outcome variable was surgical site infection (SSI). All data were analysed with respect to demographics and procedure specifications. A total of 137 patients (mean age 28.5±12.69 years) were included in this study, of whom 20 (14.6%) developed a SSI. The only risk factor identified was the type of surgery: those undergoing mandibular osteotomies (in bilateral sagittal split osteotomy (BSSO) or bimaxillary osteotomies) were far more likely to develop infections. Third molar teeth were removed during orthognathic surgery in 28.5% of the procedures, and a genioplasty was performed in 10.9%. Removal of osteosynthesis material because of infectious reasons was necessary in 10.2% of patients, with a strong association to previous SSI. In conclusion, this study showed an infection rate of 14.6% with no link to any demographic risk factor. Neither the simultaneous removal of third molar teeth nor genioplasty was found to be a risk factor for SSI. For literature comparison purposes, there is a clear need for the international guidelines defining SSI to be used.

Time has come to include Human Papillomavirus (HPV) testing in sperm donor banks

HPV is well known as a potential cause of cervical cancer. Less well known is its link to temporal subfertility that is caused by binding of infectious virions to the spermatozoa's head which induces sperm-DNA damage and causes a reduction in clinical pregnancy rates in women receiving HPV positive semen. This impact on the global fertility burden remains greatly underestimated and underexplored. This risk of reduced fertility due to infectious HPV in sperm is especially important when donor sperm insemination is considered, since testing for the presence of HPV virions before use seems warranted. We tested 514 donor sperm samples from 3 different sperm banks for 18 different HPV types. Overall 3.9% (20/514) of tested donor sperm was positive for HPV, with different prevalence among the 3 different sperm banks (3.6% bank A, 3.1% bank B and 16.7% bank C). Also the HPV virion per spermatozoon ratio in donor samples was similar across the different sperm banks (95% CI 0,01 to 1,07 HPV virions/spermatozoon). When HPV positive donor sperm was used, no clinical pregnancies resulted, whereas when HPV negative donor sperm was used the clinical pregnancy rate was 14.6%. From both a cost/benefit and a safety point of view we recommend that donor sperm should always be tested for HPV before using it for insemination.

Long term outcome after lichtenstein hernia repair using general, locoregional or local anaesthesia

BACKGROUND

Chronic pain or discomfort after hernia surgery is nowadays a more challenging concern than recurrence. This study aimed to evaluate the long-term impact of local anaesthetic repair (LA) on pain, discomfort, paraesthesia and functional outcome after Lichtenstein hernia repair as compared to locoregional (LRA) and general anaesthesia (GA).

METHODS

patients with primary or recurrent inguinal hernia underwent Lichtenstein repair with a polypropylene mesh. All patients with a follow-up of at least three years were sent a detailed questionnaire and offered an outpatient visit. Kaplan-Meier estimates and Cox proportional hazard regressions were used to analyse the relationship between time to event variables and explanatory variables including anaesthesia type.

RESULTS

Between 1994 and 2006, in two cohorts, 330 patients answered the questionnaire: 100 under GA, 35 under LRA, and 195 under LA. This represented a response rate of 95, 94, and 98% respectively. Compared to GA and LRA, LA resulted in less long term pain, discomfort and paraesthesia. Moreover, resumption of social and professional activities was faster after LA. Recurrence rates were 1, 0, and 0.5% respectively.

CONCLUSIONS

After Lichtenstein inguinal hernia repair, LA results in beneficial effects beyond the immediate postoperative period.

Six-minute walk test: reference values and prediction equation in healthy boys aged 5 to 12 years

OBJECTIVE

This study aimed to (1) generate normative data in healthy boys aged 5-12 years for the six-minute walk test (6MWT), an outcome measure currently used in clinical trials in Duchenne muscular dystrophy (DMD), (2) to describe the relation with anthropometric variables and myometry, and (3) to compare our data with published equations.

METHODS

The 6MWT was conducted in 442 boys according to a standardized protocol, as currently used in clinical trials in DMD. Maximal voluntary isometric contractions for knee flexion and extension were recorded with a hand-held myometer.

RESULTS

The 6MWD increased significantly with age, from 478.0 ± 44.1 m at age 5, to 650.0 ± 76.8 m at age 12, with the steepest increase between 5 and 8 years. Age- and height related percentile curves of the 6MWD were developed. Correlations with anthropometric variables were fair to good (age r = 0.60, height r = 0.57, weight r = 0.44). Myometric variables (knee flexors and extensors) showed correlations of 0.46 and 0.50 respectively. When dividing into two age categories (5-8 years, 9-12 years), these magnitudes of correlations only applied to the younger age group. Additionally, predicted values were calculated according to available reference equations (Geiger and Ben Saad), indicating an overestimation by those equations. Finally, the Geiger equation was refitted to our population.

CONCLUSION

The percentile curves according to age and height provide a useful tool in the assessment of ambulatory capacity in boys aged 5 to 12 years. Significant correlations with anthropometric variables and myometry were only found in the 5-8 years age group. The Geiger prediction equation, currently used to assess ambulatory capacity in DMD was refitted to obtain a more accurate prediction model based on a large sample with a homogenous distribution across the age categories 5 to 12 years and applying the methodology as currently used in clinical trials in DMD.

Analysis of FOXG1 Is Highly Recommended in Male and Female Patients with Rett Syndrome

We screened a cohort of 5 male and 20 female patients with a Rett spectrum disorder for mutations in the coding region of FOXG1, previously shown to cause the congenital variant of Rett syndrome. Two de novo mutations were identified. The first was a novel missense mutation, p.Ala193Thr (c.577G>A), in a male patient with congenital Rett syndrome, and the second was the p.Glu154GlyfsX301 (c.460dupG) truncating mutation in a female with classical Rett syndrome, a mutation that was previously reported in an independent patient. The overall rate of FOXG1 mutations in our cohort is 8%. Our findings stress the importance of FOXG1 analysis in male patients with Rett syndrome and in female patients when mutations in the MECP2 and CDKL5 genes have been excluded.

[Opinions of physicians and nurses regarding the prevention, diagnosis and management of delirium]

To assess the current opinions of physicians and nurses regarding the prevention, diagnosis and management of delirium, survey administration was conducted to 2256 nurses and 982 physicians within the University Hospitals of Leuven (Belgium). Response rate was 26% with 819 respondents (600 nurses; 219 physicians) completing the questionnaire. 72% of the respondents considered delirium as a minor problem or no problem at all. Yet over half of respondents working on a palliative care unit (87%, n=15), traumatological ward (67%, n=18), cardio-thoracic surgery ward (58%, n=20), intensive care unit (55%, n=120) and geriatric ward (55%, n=42) reported it as a serious problem. Delirium was considered as an underdiagnosed (85%) but preventable (75%) syndrome. Yet patients at risk are rarely (34%) or never (52%) screened for delirium. In case of screening (48%), only 4% used a specific validated assessment tool. 97% of all respondents were convinced that delirium requires an active and immediate intervention of nurse and physician. 82% of the physicians preferred haldol to treat delirium, in case of alcohol withdrawal 69% chose tranxene. Physical restraints were considered important in the management of delirium by a greater proportion of nurses (49%) than physicians (28%). The severity of the problem is underestimated. While opinions regarding the treatment were quite correct, prevention and early detection of delirium deserve more attention.

Mutations in the protamine 1 gene associated with male infertility

In elongating spermatids, human sperm chromatin undergoes a complex compaction in which the transition proteins are extensively replaced by the protamine proteins. Several human studies demonstrate that expression of the protamine proteins is altered in some men with male infertility. For this study, we screened the PRM1 (protamine 1) gene for mutations in a large cohort of 281 men seeking infertility treatment. We identified the c.102G>T transversion that results in an p.Arg34Ser amino acid change in two men. One of these patients presented with oligozoospermia associated with increased sperm DNA fragmentation. The second individual was normospermic but together with his partner sought treatment for idiopathic couple infertility. We also identified a novel missense mutation (c.119G>A, p.Cys40Tyr) in a man with oligoasthenozoospermia. These mutations were not observed in control populations. Interestingly, we also detected variants both 5' and 3' to the PRM1 open-reading frame specifically in infertile individuals. Four individuals with unexplained severe oligozoospermia were heterozygote for a c.-107G>C change that is located at -15 bp from the transcription initiation site of the gene. This mutation may influence PRM1 expression. In addition, a c.*51G>C variant was detected in the 3'UTR of PRM1 specifically in a man with severe oligoasthenozoospermia.

Long-term follow-up after Lichtenstein hernioplasty in a general surgical unit

This retrospective study of 142 consecutive males operated on, including the learning-curve period, is aimed at evaluating the long-term outcome (>3 years) of Lichtenstein hernia repair. The response rate was 95%. One recurrence (0.7%) and one femoral hernia occurred. Pain persisted more than 2 weeks in 26% of patients, more than 3 months in 8%, and after 3 years in 4%. The corresponding figures for discomfort without need for analgesics are 49, 14, and 11%. Paresthesia persisted over 1 year in 9%. Morbidity due to extensive section of the cremaster muscle and shooting nuisance during ejaculation occurred in four patients. The mean social inactivity period was 3.2 weeks, the time to work resumption 5.4 weeks. The Lichtenstein hernioplasty proved to have a low recurrence rate and immediate morbidity, but the prevalence of chronic pain or discomfort are not to be underestimated.

[Acid base balance in the fetus during labor: pathophysiology and exploration methods]

Although the majority (about 90%) of cerebral palsies are related to antenatal or postnatal causes, search for acute fetal distress during labor remains one of the primary objectives of obstetrical surveillance. Acute fetal distress leads to hypoxemia which induced hypoxia and then asphyxia of most of the organs, including the noble organs such as the brain. Most of the parameters used for fetal monitoring have good sensitivity but low specificity. Furthermore, there is a weak correlation between the different parameters measured and the neonatal status which remains difficult to predict with certainty. The general "philosophy" behind fetal monitoring consists in detecting warning signs and, when warning signs are observed, to measure one or more other parameters to assess the state of hypoxia and its consequences. Fetal heart rate is a warning sign used by all teams. Irrespective of the method used to analyze fetal heart rate when anomalies are detected, metabolic acidosis induced by anoxia is an indispensable element for assessing severity. The development of fetal hypoxia is related to two essential phenomena: anaerobic glycolysis with lactate production and glycogenolysis to meet energy needs. Metabolic acidosis can be measured directly by scalp pH or lactate measurements, or indirectly by measuring its effect on heart conduction as expressed in the ST segment. The underlying physiological mechanisms and the methods used to evaluate acid base balance are described here.

Clinical, radiological and functional results of remedial antireflux operations

Fifty-five patients were reoperated on for an unsatisfactory outcome after antireflux surgery. Presenting symptoms were heartburn alone (27), heartburn and dysphagia (10), dysphagia alone (9), chest pain (4), left shoulder pain (1), left shoulder pain and fever (1), and signs of anemia (3). The symptom of dysphagia was usually of immediate onset whereas heartburn reoccurred after a symptom-free period (p = 0.014). The most common failed antireflux procedure was a Nissen fundoplication (37). The incompleteness of the residual wrap, its location around the stomach and the irreducibility of the gastro-oesophageal junction below the diaphragm were accurately predicted by barium swallow study in 70, 83 and 92% of the patients, respectively. Abnormal oesophageal body motility was related to oesophagitis, herniation of the residual repair into the chest or both (16/20), and it normalized in 6 of the 11 patients evaluated at follow-up. Oesophageal acid exposure and prevalence of oesophagitis were higher in patients with heartburn than in those with other symptoms (p < 0.02). Intraoperative findings were breakdown of the repair, its location around the stomach, its herniation into the chest, its too excessive tightness, a gastric fistula, or any combination. Remedial surgery consisted of a new antireflux procedure (42), a new antireflux procedure combined with closure of a gastric fistula (3), a closure of a gastric fistula alone (1), a closure of the crura (4), an oesophageal resection (3), a total gastrectomy (1), and a duodenal diversion (1).(ABSTRACT TRUNCATED AT 250 WORDS)

[Vaginal sonographic diagnosis of the missing umbilical cord syndrome]

The Syndrome of Missing Cord has been diagnosed in a case of early pregnancy by means of transvaginal ultrasound. The sonographic criteria of this syndrome are described and correlated with the anatomical and pathological findings.

[Reoperation following failure of anti-reflux surgery]

Reoperation is the treatment of choice of failed antireflux procedures. Preoperative full-scale evaluation of both residual anatomy and function of the upper digestive tract is mandatory. Conservative surgery is almost always feasible. Success rate of reoperations is high with experienced teams.