Association among craniofacial morphology, ethnicity, and risk of pediatric sleep-related breathing disorders: A multicenter study

INTRODUCTION

Craniofacial morphology and ethnicity may be risk factors for sleep-related breathing disorder (SRBD) in children but have not yet been assessed in an international multicenter study. The objectives of this study were to assess the association among craniofacial features, self-reported ethnicity, and risk of SRBD in children undergoing orthodontic treatment.

METHODS

Children aged 5-18 years who presented for orthodontic evaluation were enrolled in the United States, South Africa, South Korea, Saudi Arabia, and Japan. The risk of SRBD was defined as answering ≥0.33 positive responses to the Pediatric Sleep Questionnaire. Craniofacial features included measurements in sagittal and vertical dimensions to evaluate the cranial base, maxillomandibular and dental relationships, and nasopharyngeal airway dimensions. Logistic regression was performed to assess the association among craniofacial features, ethnicity, age, body mass index, and risk of SRBD.

RESULTS

Data were obtained from 602 patients from 5 sites. A total of 76 patients (12.6%) had a risk of SRBD. The mean age was 12.5 years. Male gender (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.0-3.4; P = 0.041), Middle Eastern ethnicity (OR, 10.2; 95% CI, 4.1-25.4; P = 0.001), body mass index (OR, 1.1; 95% CI, 1.04-1.10; P = 0.001), gonial angle (OR, 0.91; 95% CI, 0.85-0.98; P = 0.011), and inferiorly positioned hyoid (OR, 1.1; 95% CI, 1.0-1.2; P = 0.002) were significantly associated with the risk of SRBD.

CONCLUSIONS

In an ambidirectional cohort study across 5 sites, male gender, Middle Eastern ethnicity, body mass index, gonial angle, and inferiorly positioned hyoid were associated with the risk of SRBD in children undergoing orthodontic treatment.

Genetic and environmental impact on mandibular growth in mono- and dizygotic twins during adolescence: A retrospective cohort study

INTRODUCTION

This study aimed to discover the genetic and environmental factors that contribute to the mandibular development of untreated monozygotic and dizygotic twins.

MATERIAL AND METHODS

The sample, taken from the Forsyth Moorrees Twin Study, included 52 untreated monozygotic twins (36 male, 16 female) and 46 untreated dizygotic twins (23 male, 23 female). At the ages of 12 and 17, lateral cephalograms were collected and traced to assess total mandibular length, mandibular ramus length, mandibular corpus length, gonial angle, SNB, and bony chin prominence. The genetic and environmental components of variation were assessed using multilevel mixed-effects structural equation modelling.

RESULTS

At 12 years of age, high additive genetic influences were observed for total mandibular length (74%), gonial angle (76%), SNB (41%), and bony chin prominence (64%), whereas strong dominant genetic components were observed for corpus length (72%), and mandibular ramus length was under unique environment influence (54%). At 17 years of age, only total mandibular length (45%), ramus length (53%), gonial angle (76%), and bony chin prominence (68%) were under strong additive genetic control, while the remainder were under strong dominant genetic control.

CONCLUSIONS

Although monozygotic and dizygotic twins share at least a portion of their DNA, additive, dominant, or environmental components were discovered during adolescence. Nonetheless, by the age of 17, the majority of the mandibular traits are under either additive or dominant genetic impact.

Three-dimensional morphometric analysis of anterior cranial base in growing patients

INTRODUCTION

The growth of the sphenoethmoidal and sphenofrontal suture in the anterior cranial base (ACB) terminates around 7 years old; therefore, ACB is used as a reference structure for superimposing radiographs in 2-dimensions (2D) and 3-dimensions (3D). The data in the literature regarding the cessation of growth of ACB in 3D is insufficient. The study aimed to evaluate the volumetric changes of ACB in growing patients on cone-beam computed tomography (CBCT) data in 3D.

METHODS

The CBCT sample was obtained from a repository of scans of subjects (n = 30) aged 6-11 years with no craniofacial anomalies or growth-related disorders. CBCTs were taken at 2 time points (approximately 12 months apart). The mean age at the initial scan (T1) was 8.4 ± 0.89 years, and the follow-up scan (T2) was 9.6 ± 0.99 years. The bones of the ACB were segmented, and 3D models of the bones were generated using Mimics software. The volumetric measurement was performed on the 3D-rendered model. Linear measurements were performed on the slices.

RESULTS

The volumetric analysis of the ACB between T1 and T2 showed a significant change (P <0.0001). There were no significant differences in volumetric changes of the ACB between the male and female subjects. The linear measurements on the right side of the cranial base showed continued growth between T1 and T2.

CONCLUSIONS

In the studied sample, growth-related changes of ACB were observed through volumetric analysis after 7 years old.

Multinational study on profile preference of laypersons

BACKGROUND

This study aimed to assess the facial profile preferences of lay people in seven locations from different countries and whether their place of residence, sex, age, race, education, or income influenced the decision.

METHODS

After altering the lip and nose in 1 mm increments in the sagittal and sagittal/vertical directions, 50 profile silhouettes with white-like facial features were rated by evaluators. The soft tissue values were integrated into the profiles, and profile preferences were identified for each location. An ANOVA with post hoc Tukey test was used to compare the differences in mean preference in each location. A multivariable regression model was used to assess the effect of the demographics of the evaluator on preference.

RESULTS

Thirteen profiles were ultimately analyzed. The mean for profile preference was significantly different across locations (P < 0.0001). For evaluators in the United States and Lebanon, the most preferred profile had the original lip and original nose. In Switzerland and South Africa, retrusive lips, and a small and less upturned nose was most preferred. In Japan and Saudi Arabia, the most preferred profile had the original lip and a protrusive nose that was less upturned. A protrusive lip with a small, upturned nose was preferred in Turkey. Profile change (P < 0.0001), location (P < 0.0001), sex (P < 0.0001), and race (P = 0.02) were significant confounders; in contrast, age, education, and income were not significant.

CONCLUSIONS

Profile preference is different among the seven locations. For the most part, lay people prefer profiles within one SD from white norms. Also, an upturned nose is the least favored in most of the locations. Sex and race are also significant confounders.

CLINICAL RELEVANCE

An orthodontic treatment plan decision is affected by an individual's preference for their facial appearance. This study helps clinicians understand how racial and regional differences may affect patients' preferences and, therefore, their expectations for orthodontic treatment results.

Effects of counterclockwise bimaxillary advancement surgery and relapse on upper airway

OBJECTIVE

The aim of this study was to evaluate the long-term volumetric changes of the upper airway compartments in response to counterclockwise bimaxillary advancement surgery with multi-piece maxillary osteotomy, and to analyse the relationship between the postoperative stability of the maxillomandibular skeletal complex, and the volumetric airway changes over-time.

METHODOLOGY

Twenty-seven sets of pre (T0), post (T1) and follow-up (T2) (20.15 months) CBCT scans were used. The upper airway was isolated into five compartments: soft and bony nasal cavity (SNC, BNC), nasopharynx (NP), oropharynx (OP) and hypopharynx (HP) using Mimics V.22 software. The volumetric changes and the correlation between the airway change and the skeletal movements were analysed using repeated measure ANOVA, and Pearson's correlation coefficient, respectively.

RESULTS

The results showed a significant decrease in SNC and BNC (10.94% and 7.69%, p < .05) at T1. However, SNC presented a significant recovery (11.73%, p < .05) at T2. NP, OP and HP segments presented significant and stable increases over time (10.41%, 53.62%, 24.70%, p < .05).

CONCLUSIONS

This surgical approach produced a significant increase in OP and HP volumes in short and long term without a significant relapse, NP showed a significant increase in long term only, SNC and BNC volumes showed a significant decrease post-surgery which was only partially maintained for BNC.

Maxillary dimensions and arch shape with palatally displaced canines

BACKGROUND/OBJECTIVES

The aim of this study was to explore the effect of palatally displaced canines on maxillary dimensions and arch shape.

METHODS

Occlusal and skeletal landmarks were plotted on cone beam computed tomography (CBCT) images of 156 orthodontic patients: 78 with palatally displaced canines (PDC) (27 left, 28 right, and 23 bilateral) and 78 controls using Mimics™ (Materialise, Belgium). Arch forms were created, and arch width, depth, and skeletal dimensions were measured. T-test (P < 0.05) was used to compare the groups. Geometric Morphometrics (GM) analysis was used to compare the groups and to explore the pattern of covariation between two sets of landmarks.

RESULTS

The unilateral PDC group showed an increased first premolar, second premolar, molar widths, and an increased molar depth. No significant difference was found in arch form. The skeletal measurements were generally larger in the PDC group, but the transverse measurements were the most significant. Discriminant Function Analysis (DFA) with cross-validation allowed an accurate classification of 85.9% of the control group and 66.7% of the PDC group. The Mahalanobis distance displayed significant differences among three combinations of groups. Strong covariance was found between the second premolar and all other landmarks.

LIMITATIONS

The small sample sizes of the stratified groups precluded recognition of statistical significance.

CONCLUSIONS

Patients with unilateral PDC displayed significantly wider first, second premolar, and first molar widths, and increased first molar depths. There were no significant differences in arch form; however, GM showed significant differences between the groups and a prominent covariance function for the 2nd premolars.

Cephalometric Variability Among Siblings: A Pilot Study

OBJECTIVE

To determine whether multiple siblings resemble one another in their craniofacial characteristics as measured on cephalometric radiographs.

METHODS

This study was conducted retrospectively using the Forsyth Moorrees twin sample. A total of 32 families were included, each with ≥4 postpubertal siblings, totaling 142 subjects. Only 1 monozygotic twin was included per family. Headfilms were digitized, skeletal landmarks were located, and 6 parameters that indicated sagittal jaw relationships and vertical status were measured. Diverse statistical approaches were used. Dixon's Q-test detected outliers in a family for a given parameter. Manhattan Distance quantified similarity among siblings per parameter. Scatter plots visually displayed subject's measure relative to the mean and standard deviation of each parameter to assess the clinical relevance of the differences.

RESULTS

A total of 11 families (34.4%) had no outliers on any parameter, 13 families (40.6%) had outliers on 1 parameter, and 8 families (25%) had outliers on ≥2 parameters. We identified 29 individuals with at least 1 outlying measure (20.4%). Among these, only 2 individuals (1.4%) were significantly different from their siblings for more than 1 measurement. Although the majority of the families did not demonstrate any statistical outlier, the ranges of the measurements were clinically relevant as they might suggest different treatment. For example, the mean range of SNB (Sella-Nasion-B point) angles was 7.23°, and the mean range of MPA was 9.42°.

CONCLUSION

Although families are generally not dissimilar in their craniofacial characteristics, measurements from siblings cannot be used to predict the measurements of another sibling in a clinically meaningful way.

Longitudinal changes in the dental arch width and symmetry in identical and fraternal twins

INTRODUCTION

This study aimed to assess growth-related dental and symmetry changes in the dental arch within and between identical and fraternal twins in mixed and permanent dentition.

METHODS

Three-dimensional scanned dental models of eligible subjects were selected from the Forsyth-Moorrees Twin Study sample. This retrospective cohort study was carried out on 36 identical (18 pairs) and 28 fraternal (14 pairs) twins in mixed dentition and 36 identical (18 pairs) and 38 fraternal (19 pairs) twins in permanent dentition stages on the basis of the availability of the dental casts scanned each year from each group (Table I). Linear measurements from dental casts were performed in patients aged 8-16 years. Student t test and Pearson's correlation were used to compare the symmetry between and within the identical and fraternal twins. The resemblance and heritability patterns were retrospectively obtained from the Pearson correlation coefficient and Falconer's heritability test (H2 = 2 × b). Adjusted mixed-effects estimates and 95% confidence intervals were calculated to test the association between age and dental parameters for both mixed and permanent dentition groups.

RESULTS

Intercanine and intermolar widths significantly increased (P <0.05) during the mixed dentition but became stable after 13 years old. No statistically significant differences were found in arch symmetry between the 2 groups (ie, identical and fraternal) in any of the included measurements. Evaluation of the resemblance and heritability pattern showed nonsignificant results for all variables measured (H2 range, -0.67 to 0.56).

CONCLUSIONS

The dental arch becomes wider at a higher rate in the canine region than the molar region in both the mixed and early permanent dentition. The dental arches of twins develop symmetrically, and their growth is not mainly affected by genetics. Asymmetrical teeth will maintain their relative position to reference planes throughout growth.

Heritability of facial soft tissue growth in mono- and dizygotic twins at 12 and 17 years of age: A retrospective cohort study

OBJECTIVE

The purpose of this investigation of untreated monozygotic and dizygotic twins was to identify the genetic and environmental components to the facial soft tissue growth.

SETTINGS AND SAMPLE POPULATION

The sample consisted of 52 untreated monozygotic twins (36 male and 16 female) and 46 untreated dizygotic twins (23 male and 23 female) from the Forsyth Moorrees Twin Study (1959-1975).

MATERIALS AND METHODS

Lateral cephalograms were taken at 12 and 17 years of age and traced to analyse facial convexity, nasolabial angle, upper and lower lip thickness, upper and lower lip profile and nose prominence. The genetic and environmental components of variance were analysed with structural equation modelling for multilevel mixed-effects model.

RESULTS

At 12 years of age, strong additive genetic influence was seen for facial convexity (70%), upper lip profile (66%) and nose prominence (65%), whereas strong dominant genetic components were found for upper lip thickness (56%). Nevertheless, under unique environment influence were nasolabial angle (58%), lower lip profile (51%) and lower lip thickness (64%). At 17 years of age, only upper lip thickness (55%) and nose prominence (84%) were under strong additive genetic control, while the rest of the variables were under strong dominant genetic control. The only exception was lower lip thickness (61%), which is still influenced by the unique environment.

CONCLUSION

Although monozygotic/dizygotic twins share at least part of their genome, at both times either additive, dominant or environmental components were found. Nevertheless, at 17 years of age most of the variables are either under additive or dominant genetic influence.

Heritability of nasal characteristics assessed using lateral cephalograms

INTRODUCTION

The midface and nasal bones have a significant influence on facial esthetics. Being able to predict the ultimate size of a growing patient's nose may influence the orthodontic treatment plan. Our study aimed to determine whether significant heritability exists between parents and children using multiple soft and hard tissue measurements of nasal dimensions.

METHODS

This cross-sectional study comprised 47 Western European families from the Forsyth Moorrees Twin Study. The lateral cephalograms of each parent and postpubertal child were evaluated using 14 cephalometric variables. The resemblance and heritability patterns were estimated from the Pearson correlation coefficient and Falconer's heritability test (ie, h² = 2 × β estimate).

RESULTS

We found significant heritability between 1 or both parents to sons, daughters, or both children for 11 measurements. Daughters were more strongly influenced by their mothers than fathers, and sons showed relatively few features strongly heritable from either parent. The nasal bone length and ANB were strongly heritable with the mother, and the nose length alone was strongly heritable with the father. In addition, 4 of the 6 measurements that were significantly heritable for daughters were horizontal measurements.

CONCLUSIONS

Many nasal dimensions are significantly heritable. However, fathers more strongly influenced their daughters than sons, but mothers and daughters shared stronger and more numerous traits than fathers and daughters. Finally, horizontal traits were significantly more heritable between parents and daughters than sons.

Analysis of nasal airway symmetry and upper airway changes after rapid maxillary expansion

INTRODUCTION

The objectives of this study were to assess the changes in right vs left nasal cavity volumes and minimum cross-sectional width, nasopharyngeal, and oropharyngeal volumes of the upper airway in response to rapid maxillary expansion (RME).

METHODS

Pretreatment and posttreatment cone-beam computed tomography scans of 28 patients with a mean age of 9.86 ± 2.43 years and 20 age- and sex-matched controls were digitized and linear, angular, and volumetric measurements were obtained.

RESULTS

Nasopharyngeal volume, right, and left nasal cavity volumes, and minimum cross-sectional widths increased significantly 2 years post RME (P <0.05). These measurements did not show any significant increase in the control group (P >0.05), whereas the oropharyngeal volume increase for both groups was comparable (P = 0.92). In the experimental group, the right and left nasal cavity volumes were not significantly different at baseline or posttreatment. However, the change that occurred was significantly larger for the left nasal cavity. This change for the control group was more significant for the right nasal cavity. Maxillary right and left molar inclinations were positively correlated to the nasal cavity volume, showing that the more buccally inclined the maxillary molars were, the smaller the nasal cavity volume.

CONCLUSIONS

Nasopharyngeal and right and left nasal cavity volumes and minimum cross-sectional widths increase significantly after RME in young children. Expansion decreases the degree of difference in volume between the right and left nasal cavities. The buccal inclination of maxillary molars is correlated with nasal cavity volume.

Does rapid maxillary expansion enlarge the nasal cavity and pharyngeal airway? A three-dimensional assessment based on validated analyses

OBJECTIVES

To evaluate the three-dimensional changes following rapid maxillary expansion (RME) of the nasal cavity (NC) and pharyngeal airway (PA) in growing patients, using innovative and validated evaluation methods and to investigate whether a correlation between skeletal expansion and increase in airway volume exists.

SETTINGS AND SAMPLE POPULATION

Records of patients who had cone beam computed tomography taken before and after orthodontic treatment with or without RME were retrospectively collected and divided into two groups: (a) RME, 39 patients (mean age 10.40 ± 1.74 years); and (b) control, 29 patients, matched for age (mean age 11.07 ± 1.45 years) and follow-up period.

MATERIAL AND METHODS

Total and partial volumes of the NC and the PA were calculated. The PA centerline was determined to assess the minimal cross-sectional area and hydraulic diameter. Paired and unpaired t test were applied to compare the difference between time points and between groups. One-way ANOVA and post hoc Tukey's tests were used to compare subgroups with respect to changes in palatal width and lacrimal ducts distance.

RESULTS

All of the NC, PA and skeletal parameters were significantly enlarged after RME. The NC volume and inter-molar distance in the RME were significantly larger compared to the control group. The initially lower mean values of minimal cross-sectional area and hydraulic diameter in the RME group when compared to the control group normalized after RME treatment.

CONCLUSIONS

Based on validated analyses, the NC volume increase was evident after RME in the long term after controlling for growth.

Longitudinal assessment of salivary vitamin D binding protein during orthodontic tooth movement

Background

Vitamin D is critical for bone physiology. In this study, we quantified Vitamin D Binding Protein (VitDBP) levels in saliva as a measure of Vitamin D during orthodontic tooth movement.

Methods

In this longitudinal study, saliva samples were collected from 73 orthodontic patients for 4 timepoints for the first six months of orthodontic treatment, along with dental casts at the beginning and the end of the study period. The saliva was measured for VitDBP as a biological marker for bone apposition and clinical tooth movement. We used the absolute change in Little's Irregularity Index as a quantitative measure for alignment. In addition, we measured the levels of alkaline phosphatase (ALP) in saliva as a marker of bone turnover.

Results

Both low (< 2.75 ng/ml) and high (> 6.48 ng/ml) VitDBP levels were associated with reduced tooth movement. Significant (p < 0.05) seasonal changes in VitDBP using a two-season year model were found with lower levels observed in the summer (Apr–Sept) than in the winter (Oct–Mar).

Conclusions

Clinically significant orthodontic tooth movement is associated with an optimal range of VitDBP in saliva. Normal levels of VitDBP correlated with more orthodontic tooth movement, suggesting a "normal" range of salivary content of VitDBP. Given the strong trend that is independent of the confounding factors (ex. age, race or gender), the predictive value or salivary VitDBP for tooth movement should be studied in larger cohorts in future studies.

Genetic and environmental components of vertical growth in mono- and dizygotic twins up to 15-18 years of age

OBJECTIVES

To determine the additive genetic and environmental contributions to the vertical growth of craniofacial structures.

MATERIALS AND METHODS

The sample consisted of 64 untreated monozygotic (44 male, 20 female) and 61 untreated dizygotic twins (32 male, 29 female). Lateral cephalograms taken at 15 and 18 years of age were traced to analyze the sella-nasion-nasal line angle (SN-NL), nasal line-mandibular line angle (ML-NL), sella-nasion-mandibular line angle (SN-ML), sella-nasion-sella-gnathion angle (Y-axis), posterior face height/anterior face height (PFH/AFH), and lower anterior face height/anterior face height (LAFH/AFH). The genetic and environmental components of variance were analyzed with structural equation modeling for multilevel mixed effects.

RESULTS

At 15 years of age, strong dominant genetic control was seen for NL-ML (81%), LAFH/AFH (73%), and Y-axis (57%), whereas strong additive genetic components were found for PFH/AFH (78%), SN-NL (58%), and SN-ML (57%). Unique environmental factors accounted for 18-42% of observed variance, with SN-NL being affected the most (42%). At 18 years of age, only LAFH/AFH (86%) was under strong dominant genetic control, whereas the remainder were under additive genetic influence. The sole exception was SN-NL, which changed from additive to unique environmental influence.

CONCLUSIONS

Either additive or dominant genetic components were found at 15 or 18 years of age for most vertical variables. Environmental factors accounted for about 10-40%, with SN-NL being mostly affected.

Vertical growth in mono-and dizygotic twins: A longitudinal cephalometric cohort study

OBJECTIVE

The aims of this longitudinal analysis of untreated monozygotic and dizygotic twins were to investigate vertical changes of the craniofacial structures during growth, to determine the concordance between genetically twins and to assess the genetic component for the various aspects of vertical growth.

SETTINGS AND SAMPLE POPULATION

The sample consisted of 34 pairs of untreated monozygotic twins (23 male, 11 female) and 30 untreated dizygotic siblings of multiple birth (8 male, 8 female and 14 mixed) from the Forsyth Moorrees Twin Study (1959-1975); lateral cephalograms taken from 6 to 18 years of age were analysed at 3-year intervals.

MATERIALS AND METHODS

Cephalograms were traced, and longitudinal changes between twins in six angular and proportional vertical cephalometric variables (SN-NL, ML-NL, SN-ML, y-axis, PFH/AFH and LAFH/AFH) were analysed with intraclass correlation coefficients and linear regression modelling.

RESULTS

The concordance between monozygotic/dizygotic twins at 18 years of age was moderate to high with intraclass correlation coefficient values between 0.51 and 0.66. Additionally, sex differences in concordance at 18 years of age were found for three variables. High heritability (66%-79%) was observed for 5 of the 6 variables (LAFH/AFH, ML-NL, y-axis, SN-ML, PFH/AFH), while SN-NL showed limited heritability (34%).

CONCLUSIONS

Although monozygotic/dizygotic twins share at least part of their genetic material, differences in the vertical dimension were found. This supports the complex developmental mechanism of the human face and the varying influence of genetic and environmental factors.

Volumetric changes of the upper airway following maxillary and mandibular advancement using cone beam computed tomography

The objective of this project was to retrospectively evaluate changes in volume of different compartments of the upper airway in response to maxillary, mandibular, and bimaxillary advancement surgeries and to predict the extent of volumetric changes associated with these surgical movements. Pre- and post-surgical cone beam computed tomography scans of 36 patients were evaluated for changes in nasal cavity, nasopharyngeal, oropharyngeal, and hypopharyngeal compartments. The amount of movement for each surgery was measured from skeletal landmarks to reference planes and was correlated with volumetric changes. Maxillary advancement of 4.0±2.2mm increased the oropharyngeal volume significantly (41.40%), and mandibular advancement of 3.8±1.6mm also significantly increased the oropharyngeal volume (21.17%). Bimaxillary advancement of 5.1±1.3mm for the maxilla and 6.4±3.1mm for the mandible significantly increased nasopharyngeal (27.45%), oropharyngeal (66.39%), and hypopharyngeal (52.48%) volumes. Furthermore, for every millimeter anterior movement, oropharyngeal volume increased by 2319.2±771.8mm³. Bimaxillary advancement showed a greater increase than isolated maxillary and mandibular advancement in all pharyngeal compartments. Every millimeter of advancement in the bimaxillary group led to a significant increase in oropharyngeal volume, while every millimeter downward movement showed a significant increase in nasopharyngeal volume.

Postoperative Positional and Dimensional Changes of Mandibular Canal after Bilateral Sagittal Split Set-Back Osteotomy

Objective

This preliminary study was planned to provide information about preoperative mandibular canal (MC) position and the postoperative positional changes of MC and length in three dimensions, with the purpose of providing some assistance in reducing inferior alveolar neurosensory disturbance (IAND).

Methods

MC was examined on CBCT data using SimPlant Pro Standalone 13.0. MC locations were measured in all dimensions, with respect to mandibular bony borders.

Results

The results showed that MC is frequently located in the midthird of the ramus anteroposteriorly and superoinferiorly and in the midthird of the corpus superoinferiorly. Postoperatively, ramus width was increased, ramus length was decreased significantly, and MC was repositioned laterally and inferiorly. MC length was decreased on both sides, non-correlated with the set-back amounts.

Conclusion

Preoperative results may be beneficial for the prediction of MC position for surgeons, and postoperative results will be used for the following studies to correlate postoperative positional changes with IAND.

Evaluation of two different rapid maxillary expansion surgical techniques and their effects on the malar complex based on 3d cone-beam computed tomography

We compared and evaluated the effects of two techniques used for surgically assisted rapid maxillary expansion (SARME) using three-dimensional (3D) cone-beam computed tomography, focusing on changes in soft and hard tissue in the malar region. A conventional Le Fort I osteotomy group (10 patients, mean age: 19.3 years) and a high Le Fort I group (12 patients, mean age: 20.4 years) underwent 3D analyses. Changes in hard and soft tissue of the malar region were compared. The average increases in the bone malar width and soft malar width in the high Le Fort I group between the pre- and postoperative periods were 1.43 ± 1.23 and 1.39 ± 1.19 mm, respectively. The average increases in the bone malar depth on the right and left sides in the high Le Fort I group were 1.34 ± 0.81 and 1.60 ± 0.54 mm, respectively. Progress in hard tissues did not reflect significant changes in soft tissue.

CONTEXT

Effects of high Le Fort I SARME on the malar complex.

AIMS

To compare and evaluate the effects of two techniques used for SARME, using 3D cone-beam computed tomography, focusing on changes in hard and soft tissues in the malar region.

SETTINGS AND DESIGN

A conventional Le Fort I osteotomy group (10 patients, mean age: 19.3 years) and a high Le Fort I group (12 patients, mean age: 20.4 years).

METHODS AND MATERIAL

Each group underwent 3D analyses, and changes in hard and soft tissues of the malar region were compared.

STATISTICAL ANALYSIS USED

The SPSS software (ver. 15.0 for Windows) was used. The Kolmogorov-Smirnov test, Student's t test, and paired-samples test were conducted.

RESULTS

The average increases in the bone malar width and soft malar width in the high Le Fort I group between the pre- and postoperative periods were 1.43 ± 1.23 and 1.39 ± 1.19 mm, respectively. The average increases in the bone malar depth on the right and left sides in the high Le Fort I group were 1.34 ± 0.81 and 1.60 ± 0.54 mm, respectively.

CONCLUSIONS

Progress in hard tissues did not reflect significant changes in soft tissue.

Hounsfield Units: a new indicator showing maxillary resistance in rapid maxillary expansion cases?

OBJECTIVE

To determine if density measurements of several maxillary regions in Hounsfield Units (HU) and outcomes of rapid maxillary expansion (RME) are correlated. Is correlation powerful enough to give us direct information about maxillary resistance to RME?

MATERIALS AND METHODS

Twenty-two computed tomographic (CT) scans (14 years) are used in this archive study. Two CT records were collected, one before RME (T1) and one after 3 months of retention period (T2). Maxillary measurements were made using dental and skeletal landmarks in first molar and first premolar slides to measure the effects of RME. Density of midpalatal suture (MPSD) and segments of maxillary bone is measured in HU at T1. Correlation analysis was conducted between density measurements and maxillary variables. Regression analysis was then performed for variables that showed positive correlation.

RESULTS

There was no correlation between density and skeletal measurements. Intermolar angle (ImA) in molar slice showed statistically significant correlation with density measurements. The ImA variable showed the highest correlation with MPSD in frontal section (r  =  0.669, P < .01).

CONCLUSIONS

There is correlation of 32.1-43.3% between density measurements and ImA increase. Our density measurements explain a certain percentage of ImA increase, but density is not the only and definitive indicator of changes after RME.

Prevalence and characteristics of non-syndromic hypodontia among Turkish orthodontic patient population

Background:

Hypodontia is often used as a collective term for congenital absence of primary or secondary teeth, although specifically it describes the absence of one to six teeth excluding third molars. The prevalence of hypodontia varies from 0.03 to 10.1% in various populations.

Materials and Methods:

In this retrospective study, we reviewed the records of Turkish orthodontic patients treated between 1994 and 2003. A total of 1236 orthodontic patients (507 girls, 729 boys) were included in this study. The age of the patients ranged from 11 to 20 years. Data were collected and entered into the SPSS 20 program for statistical analysis. The Chi-square test was used to analyze differences in the distribution of hypodontia, sex, and malocclusion type.

Results:

In the total sample of 1236 patients who were orthodontically treated, hypodontia was found in 82 children, including 45 girls and 37 boys. The prevalence of hypodontia was 7%. Patients with more severe hypodontia showed a tendency to exhibit a class II relationship. The mandibular second premolar were the most commonly missing teeth in 48 girls and 26 boys.

Conclusion:

Hypodontia may lead to some clinical problems including malocclusions, esthetic and functional complaints, and also psychological problems. All cases should be evaluated by an interdisciplinary approach for appropriate treatment choice. Our data emphasize the importance of detailed and careful radiographic examination. This helps in long-term and effective treatment planning according to a child's individual requirements.

Rapid-maxillary-expansion induced rhinological effects: a retrospective multicenter study

Conventional dental-borne rapid maxillary expansion (RME) leads to a widening of the airways, followed by improved nasal breathing. Although combined skeletal-dental appliances are nowadays being inserted increasingly often and provide a force at the center of resistance in the nasomaxillary complex, no study exists so far that shows whether this treatment may improve the expansionary effect on the airways. In this study, low-dose computed tomography (CT) images from 31 patients (average age 14.63 ± 0.38 years) were examined retrospectively. Both records (T0 = before expansion and T1 = immediately after maximum expansion) were taken in a time interval of 25 days to avoid growth influence. Five patients were treated with Hyrax RME, 6 patients with Hybrid RME, and 20 patients with acrylic cap RME. The total airway volume increased highly significantly (mean +7272.6 mm(3); P < 0.001, power = 0.998), representing an average airway expansion of +11.54 % (2.35 %/mm activation). While the nasopharynx and oropharynx showed highly significant expansion (P < 0.000, power = 0.999), the airway at the laryngopharynx did not change significantly (P > 0.779, power = 0.05). Although the patients were significantly older in the Hybrid RME group (P = 0.006), the positive rhinological effects were comparable within all groups of different appliances (P > 0.316). Hybrid RME may, therefore, be an advisable procedure in patients with nasomaxillary impairment and pronounced patient's age.

[Surgically assisted rapid maxillary expansion. An evaluation of different surgical techniques and their effect on maxillary dentoskeletal complex based on cone-beam computed tomography. Preliminary report]

AIM

To evaluate and compare the dentoskeletal effects associated with surgically assisted rapid maxillary expansion (SARME) performed with (+) and without (-) pterygomaxillary disjunction (PD), utilizing cone beam computed tomography (CBCT).

MATERIALS AND METHODS

A retrospective study of 9 patients (1 male, 8 females, mean age 18.9 years) undergoing SARME who were divided into two groups. In group (-PD) the surgical technique followed involved bilateral LeFort I type of osteotomy plus midline osteotomy. In group (+PD) same protocol was followed and pterygoid disjunction was performed additionally. Three-dimensional CBCT scans were obtained preoperatively and 3-6 month postretention. A Hyrax type acrylic bonded expander was used. MIMICS 14.0 (Materialise Europe, Belgium) software was used to evaluate transverse expansion at skeletal, dentoalveolar and dental level. Additionally dental inclinations, alveolar bending and the pattern of expansion sagittally were assessed. Wilcoxon's and Mann Whitney U tests were used for comparisons.

RESULTS AND DISCUSSION

All linear transverse measurements at dental and dentoalveolar level were found to have a statistically significant increase (P < 0.05) in both treatment groups. No statistically significant differences were found between the two groups as well as within groups on skeletal level (except of the anterior expansion of maxilla between piriform rims bilaterally). In -PD group significant buccal tipping of the 1(st) premolar was observed as well as increased buccal bending of the alveolar crest.

CONCLUSION

This study confirms that SARME is an effective treatment of maxillary transverse deficiency. CBCT is an adequate tool to assess dentoskeletal treatment effects.

Simultaneous alveolar cleft closure and dental midline correction with curvilinear intraoral distraction

This article describes a new method that enables vector control during alveolar distraction osteogenesis in the treatment of a cleft palate patient. The patient presented with unilateral complete cleft lip and palate, and the alveolar part of the defect was covered by a mobile buccal flap. The distraction was performed by sliding the surgically released tooth segment with the help of an intraoral distractor over 1.5-mm stainless steel archwires held by metal crowns. This vector-controlled method enabled new bone and attached gingiva formation in harmony with the proper alveolar shape.

Dimensional changes of maxillary sinuses and pharyngeal airway in Class III patients undergoing bimaxillary orthognathic surgery

OBJECTIVE

To evaluate the pharyngeal airway and maxillary sinus volume changes after mandibular setback surgery combined with maxillary advancement and/or impaction surgery.

MATERIALS AND METHODS

Seventeen Class III skeletal patients (11 females, 6 males) who required bimaxillary orthognathic surgery were selected. Volumetric measurements were performed using cone beam computed tomography (CBCT) scans preoperatively and 3.9 ± 0.87 months postoperatively. All the CBCT scans were assessed and analyzed using MIMICS 14.0 software. Preoperative and postoperative volumes of pharyngeal airway and maxillary sinuses and the relationship between the amounts of surgical movement of the jaws and the above volumes were statistically evaluated.

RESULTS

The pharyngeal airway area presented no significant change except for the lower and total pharyngeal airway volumes in males, in whom a significant decrease was observed (4196.27 ± 2061.11 mm(3) and 3375.53 ± 3624.67 mm(3), respectively). No significant change was observed in the minimal cross-sectional area of the pharyngeal airway. There was a significant decrease in the volume of the maxillary sinuses after the surgery by 3448.09 ± 3315.56 mm(3). No correlation was found between the amount of skeletal movement and the change in the volume of pharyngeal airway or maxillary sinuses.

CONCLUSION

There was a significant decrease only for lower and total pharyngeal airway volumes in males and a significant decrease in the volume of the maxillary sinuses.

Clinical evidence of dose-dependent interaction between aspirin and angiotensin-converting enzyme inhibitors

Since coronary artery and cerebrovascular diseases are the most common serious complications of long standing hypertension, there is a great potential for combining treatment with aspirin and angiotensin-converting enzyme inhibitors (ACE-I). However, the data regarding interaction of aspirin and ACE-I in relation to blood pressure control and survival benefits are controversial and inconclusive. We presumed that the appearance of dry cough in some of the patients following initiation of ACE-I treatment could be used as a marker for the presence of their influence, whereas ACE-I cough attenuation after addition of aspirin to treatment could be a sign of aspirin and ACE-I interaction on clinical level. The present study was aimed to use ACE-I induced cough as a clinical marker of ACE-I activity to determine whether dose-dependent aspirin and ACE-I interaction does exist. In a cohort of 750 consecutive ACE-I treated hypertensive and postinfarction outpatients we identified 78 (10.4%) non-smoking ACE-I related coughers. Out of them, 31 (21 men, 10 women; mean age 61 +/- 0.9 years) agreed to take part in the study, which was aimed to compare two regimens of combined ACE-I and aspirin treatment (self-matched control data): intermediate (500 mg daily) vs low-dose aspirin (100 mg daily). On each visit the life quality, cough severity (CS, 0-4) and frequency (CF, 0-10) scores were registered. Low doses of aspirin demonstrated an excellent safety profile and did not influence any life quality score and ACE-I induced cough. In contrast, intermediate doses completely abolished cough in 17 patients and reduced coughing in other 11 patients. Cough severity and cough frequency scores decreased, respectively, from 2.7 +/- 1.1 to 0.7 +/- 1.2 (P < 0.001) and from 7.1 +/- 2.3 to 2.0 +/- 2.2 (P < 0.0001). Overall, the cough frequency score method alone could identify a clear modification of cough in 26 (84%) patients, and cough severity score method alone in 24 (77%). Using the combined frequency/severity score method a modification of cough could be identified in 28 (90%) of the patients receiving intermediate dose of aspirin. Aspirin did not influence heart rate and blood pressure control either in hypertensives or in postinfarction patients. We conclude that using ACE-I induced cough as a clinical marker of ACE-I activity demonstrates that an interaction between ACE-I and aspirin at 500 mg/day does exist. We did not find any evidence supporting the presence of a clinically significant interaction between ACE-I and aspirin at 100 mg/day. Thus, combined treatment by low dose aspirin and ACE-I seems to be both safe and useful.

The combined cough frequency/severity scoring: a new approach to cough evaluation in clinical settings

Cough assessment is an important component in the clinical evaluation of patients with respiratory and cardiovascular disorders (asthma, chronic obstructive lung disease, congestive heart failure, etc.). A dry bothersome cough is the most common adverse class effect of all angiotensin-converting enzyme inhibitors (ACE-I). The present study was aimed to determine the feasibility of a new combined frequency/severity cough scoring method in patients with ACE-I induced cough before and after their modification with aspirin addition. The study was designed to compare two different regimens of active treatment: intermediate (500 mg) versus low (100 mg) dose aspirin in ACE-I cough suppression (self-matched control data) and comprised 21 patients (14 men, 7 women; mean age 62 +/- 11 years) on ACE-I treatment. ACE-I treatment was discontinued and the dry cough completely disappeared, but returned in all patients within one week (rechallenge period) after ACE-I reintroducing. Severity of cough was defined as follows: 0--no cough at all; 1--occasional hems; 2--mild, isolated cough, without additional symptoms; 3--moderate, paroxysmal cough, without additional symptoms; 4--severe, strenuous cough, accompanied by chest discomfort. In addition to cough severity score, cough frequency score (0-10) was obtained using a visual analog scale: 0 = I never cough; 10 = I cough all day. Low doses of aspirin were ineffective to suppress ACE-I induced cough. In contrast, intermediate doses completely abolished cough in 14 patients and reduced coughing in all but one patient. Cough severity and cough frequency scores decreased, respectively, from 2.6 +/- 1.1 to 0.7 +/- 1.0 (p<0.001) and from 6.9 +/- 2.2 to 2.1 +/- 2.4 (p<0.0001). Overall, the cough frequency score method alone could identify a beneficial modification of cough in 17 (81%) patients and cough severity score method alone in 17 (76%). Using the combined cough frequency/severity scoring, a beneficial modification of cough could be identified in 20 (95%) of patients. The new combined cough frequency/severity scoring is suitable for clinical practice and can improve the identification of dynamic cough modifications during treatment period as compared with the conventional frequency score method. It may have important implications in the evaluation of patients with respiratory and cardiovascular disorders.

Retrograde embolism and atherosclerosis development in the human thoracic aorta: are the fluid dynamics explanations valid?

The mechanisms of atherosclerosis development in the thoracic aorta is miscellaneous and still only partially understood. The marked variability of the sites of deposition of atherosclerotic plaques in the aorta could not be clarified based solely on the risk-factors theory of atherosclerosis. The sites of deposition of atherosclerotic plaques are considered to be affected by blood-flow patterns that cause areas of altered shear stress on the aortic wall. Close relations between protruding aortic plaques (PAP), stroke and peripheral emboli were established. The analysis of PAP distribution and motion to characterize atherogenesis in the human thoracic aorta and the pathogeneses of embolic events was performed. We concluded that protruding aortic plaques and markers of relative aortic flow instability (occurrences of vortices) are predominantly noticed in the human arch and in the descending aorta, whereas the ascending aorta showed lesser prevalence of atheromatosis. Reversal and rotational blood-flow in the thoracic aorta most likely exist in all patients with systemic emboli and mobile protruding aortic atheromas. Therefore, retrograde cerebral embolism from distal aortic plaques is conceivable.

Coronary benefits of calcium antagonist therapy for patients with hypertension

Calcium antagonists effective in lowering blood pressure are a heterogeneous group including three main classes: phenylalkylamines, benzothiazepines and dihydropyridines. Dihydropyridines have a dual mode of action upon the endothelium contributing to their beneficial antihypertensive effects: (1) direct relaxation by inhibition of smooth muscle L-type calcium current, and (2) indirect relaxation through release of nitric oxide from the vascular endothelium. Calcium antagonists may affect many calcium-dependent events in the formation of atherosclerosis such as the localized accumulation of collagen, elastin, and calcium together with monocyte infiltration and smooth muscle proliferation and migration. In the INSIGHT calcification study, the overall treatment effect of nifedipine demonstrated significant inhibition of coronary calcium progression over a three-year period. Calcium antagonists improve symptoms and reduce ischemia in hypertensive patients with ischemic heart disease. Although in placebo-controlled trials calcium antagonists demonstrated a significant reduction in cardiovascular morbidity and mortality, they may be less effective than other types of antihypertensive drugs in preventing ischemic heart disease.

Coronary artery disease but not coronary calcification is associated with elevated levels of cardiolipin, beta-2-glycoprotein-I, and oxidized LDL antibodies

BACKGROUND

Autoimmune factors have been shown to play a role in atherosclerosis. The aim of this study is to correlate 5 autoantibodies (anticardiolipin, anti-CL, beta2-glycoprotein-I, beta2GPI, phosphatidylcholine, oxidized low-density lipoprotein, oxLDL, endothelial cell) with the presence of coronary heart disease, angiographic findings, and with coronary artery calcification.

METHODS

The levels of the 5 autoantibodies and a control antifibroblast line of 126 coronary heart disease patients and 20 healthy controls were measured. Fifty-one patients underwent coronary angiography, and 98 patients had coronary artery calcium determination using spiral computerized tomography (dual mode).

RESULTS

Levels of 3 autoantibodies (anti-CL, beta2GPI, oxLDL) were significantly elevated in coronary heart disease patients compared with controls (p < 0.001, p = 0.001, p < 0.001, respectively). Within the subgroup of patients with significant coronary artery stenosis, anti-CL antibodies were also elevated (p = 0.008). No correlation was found between anti-CL, and anti-beta2GPI autoantibody levels and coronary calcium scores as measured by spiral computerized tomography. However, anti-oxLDL antibodies were raised in patients with no calcification detected by spiral computerized tomography, compared with the patients with any coronary calcification (p = 0.046).

CONCLUSION

Anti-CL, beta2GPI and oxLDL antibodies are elevated in coronary heart disease patients regardless of coronary calcification.

Caseous calcification of the mitral annulus: a neglected, unrecognized diagnosis

BACKGROUND

Mitral annular calcification is a common echocardiographic finding. Caseous calcification is a rare variant seen as a large mass with echolucencies that resembles a tumor, occasionally resulting in exploratory cardiotomy. The aim of this study was to assess the prevalence of caseous calcification of the mitral annulus, to evaluate patient characteristics and the echocardiographic variables for diagnosing this entity, and to describe the clinical outcome on follow-up of such patients.

METHODS

Caseous calcification was defined as a large, round, echo-dense mass with smooth borders situated in the periannular region, with no acoustic shadowing artifacts and containing central areas of echolucencies resembling liquefaction. Eighteen patients were diagnosed by 2-dimensional echocardiography as having caseous calcification of the mitral annulus. One had calcification of the tricuspid annulus. Nine patients underwent transesophageal echocardiographic studies.

RESULTS

A typical finding of a round, sometimes semilunar, large, echo-dense, soft mass with central echolucencies seen on both transthoracic and in particular transesophageal echocardiography, resembling a periannular mass, was demonstrated. The mass was posteriorly located in all mitral patients. Transesophageal echocardiography added limited information. Three patients underwent mitral valve replacement. The operative findings were a solid mass adherent to the posterior portion of the mitral valve. Sectioning revealed a toothpaste-like, white, caseous material. Sixteen (84%) patients were treated conservatively. On follow-up of 3.8 +/- 2.4 years, 4 patients died of unrelated causes.

CONCLUSION

The characteristic appearance of a large, soft, echo-dense mass containing central areas of echolucencies resembling liquefaction at the posterior periannular region of the mitral valve on 2D echocardiography is compatible with the diagnosis of caseous abscess. Such a finding should not be confused with a tumor. Transesophageal echocardiography does not appear to contribute to the diagnosis. This rather impressive lesion appears to carry a benign prognosis.

Long-term diuretic therapy in patients with coronary disease: increased colon cancer-related mortality over a 5-year follow-up

OBJECTIVES

Recent studies have suggested that long-term diuretic therapy may be associated with increased risk of renal cell carcinoma. This carcinoma is not a common malignancy, but it shares risk factors with the considerably more widespread colon cancer (CC). However, there are no data whether or not a relationship between long-term diuretic therapy and CC mortality exists. In this study we tested the hypothesis that long-term diuretic therapy may be associated with increased CC mortality over a 5.6-year follow-up period.

SUBJECTS AND METHODS

The study sample comprised 14 166 patients aged 45 to 74 years with a previous myocardial infarction and/or stable anginal syndrome, screened for participation in the bezafibrate infarction prevention (BIP) study. There were 2153 patients receiving diuretics and 12 013 patients receiving no diuretics.

RESULTS

During the follow-up 139 (6.5%) new cases of cancer were diagnosed in the diuretic-treated group compared with 622 (5.2%) in the group receiving no diuretics (P = 0.02). Colon cancer mortality was significantly higher in the diuretic-treated patients (0.1 vs 0.5%, P = 0.001), whereas mortality differences for other cancer types were not documented. Multivariate analysis identified diuretics as an independent predictor of increased colon cancer incidence and colon cancer mortality with a hazard ratio (HR) of 2.0 (95% CI 1.2-3.2) for colon cancer incidence and 3.7 (95% CI 1.7-8.3) for mortality. However, the association between diuretic therapy and higher incidence of colon cancer was observed only among non-users of aspirin. A relatively lower colon cancer incidence was observed in the furosemide subgroup, and higher in the small combined amiloride/hydrochlorthiazide subgroup (HR 3.15, 95% CI 1.15-8.65).

CONCLUSION

Long-term exposure to diuretic therapy may be associated with an increased colon cancer-related mortality.

Calcium channel blocker nifedipine slows down progression of coronary calcification in hypertensive patients compared with diuretics

Calcium controls numerous events within the vessel wall. Permeability of the endothelium is calcium dependent, as are platelet activation and adhesion, vascular smooth muscle proliferation and migration, and synthesis of fibrous connective tissue. Double-helix computerized tomography is a noninvasive technique that can detect, measure, and compare coronary calcification in the coronary arteries. Using this method, our objective was to determine whether administration of nifedipine once daily in lieu of diuretics in high-risk hypertensive patients will arrest or slow down the progression of coronary artery calcification. The study was designed as a side arm of INSIGHT (International Nifedipine Study: Intervention as Goal for Hypertension Therapy), aimed to show the efficacy of nifedipine once daily versus co-amilozide (hydrochlorothiazide 25 mg, amiloride 2.5 mg) in high-risk hypertensive patients. A total of 201 patients with a total calcium score of >/=10 at the onset of study who underwent an annual double-helix computerized tomography for 3 years were analyzed for efficacy. Inhibition of coronary calcium progression was significant in the nifedipine versus the co-amilozide group during the first year (3.18% versus 27%, respectively, P=0.02), not significant during the second year (28.5% versus 47%, respectively, P=0.14), and significant during the third year (40% versus 78%, respectively, P=0.02). The results point to a slower progression of coronary calcification in hypertensive patients on nifedipine once daily versus co-amilozide.

Impaired fasting glucose concentrations in nondiabetic patients with ischemic heart disease: a marker for a worse prognosis

BACKGROUND

The issue of whether glucose concentrations below the diabetic threshold may be predictive of increased cardiovascular risk has not yet been fully elucidated. The current study evaluates the prognosis of nondiabetic patients with ischemic heart disease (IHD) and impaired fasting glucose (IFG) over a 7.7-year follow-up period.

METHODS

A total of 11,853 patients with documented coronary artery disease aged between 45 and 74 years were examined. Patients were divided into 3 groups on the basis of their fasting blood glucose levels at screening: nondiabetic individuals, patients with IFG, and undiagnosed diabetic patients. Patients who were on any type of pharmacologic antidiabetic treatment were excluded from the study. Mortality rates were assessed separately for each group.

RESULTS

The population comprised 9773 nondiabetic patients (82.4%, glucose up to 109 mg/dL), 1258 patients with IFG levels (10.6%, glucose 110-125 mg/dL), and 822 diabetic subjects (7%, glucose > or =126 mg/dL). Patients were followed up from 6.2 to 9.0 years (mean follow-up period 7.7 +/- 1.5 years). Crude mortality was lower in the nondiabetic subjects than in the 2 other groups. All-cause mortality in the nondiabetic group was 14.3% compared to 20.1% in patients with IFG and 24.3% in the undiagnosed (P <.001). Multivariate adjustment showed the lowest mortality in nondiabetic subjects, who exhibited a survival rate of 0.86 at the end of the follow-up, whereas the lowest survival-0.75-was seen among undiagnosed diabetic patients (P =.0001). An intermediate value of 0.78 was documented for patients with IFG (P <.01). After multivariate analysis, with nondiabetic patients as the reference group, IFG was identified as a consistent predictor of increased all-cause and IHD mortality with hazard ratios of 1.39 (95% confidence interval 1.21-1.59) and 1.29 (95% confidence interval 1.01-1.64), respectively.

CONCLUSIONS

The main finding of this study is the substantially increased mortality rate among nondiabetic coronary patients with IFG, who had fasting glucose levels markedly lower than hitherto acknowledged as defining overt diabetes.

Fluid dynamics and atherosclerosis development in the human thoracic aorta: a transesophageal echocardiographic evaluation of protruding aortic plaque distribution and motion

The pathogeneses of atherosclerosis in the thoracic aorta is heterogeneous and still incompletely elucidated. Protruding aortic plaques (PAP), reliable markers of atherosclerosis development and extension, could be easily identified by transesophageal echocardiography (TEE). A close relation between atherosclerosis development in the thoracic aorta, stroke and peripheral emboli were established. The purpose of this study was to use PAP distribution and motion on TEE to characterize atherogenesis in the human thoracic aorta. Out of 569 consecutive patients (age range 18-83 years), 108 were referred for TEE to evaluate recent embolism (Group I). The remaining 461 patients were referred for TEE for reasons unrelated to embolism (Group II). The plaque thickness was measured perpendicularly to the aortic wall. In the subgroup of patients with multiple mobile lesions, multiple vortices were suggested to be present when simultaneous rotations in different directions were found. The presence of a fixed PAP was associated with a statistically significant, albeit moderate, increase in the risk for embolism (adjusted odds ratio 4.1). The presence of mobile lesions was linked to an abrupt augmentation in this risk (adjusted odds ratio 30.1). Among the 35 patients in Group I there were 69 PAP: 8 (12%) in the ascending, 28 (41%) in the arch and 33 (48%) in the descending aorta. A total of 34 mobile lesions was detected: 1 (one patient) in the ascending aorta, 15 (10 patients) in the arch and 18 (11 patients) in the descending aorta. There was no significant difference between the arch and the descending aorta regarding the frequency of the plaques in these regions, whereas the ascending aorta presented the lowest prevalence for atheromatosis. Diastolic retrograde and rotational flows were observed in all patients. There were 16 multiple mobile PAP in 6 patients: in all these cases simultaneous rotations of mobile aortic plaques (MAP) in different directions (highly suggestive for the presence of multiple vortices and significant flow instability) were found in the arch and the descending but not the ascending aorta. Protruding aortic plaques and signs of relative aortic flow instability (presence of vortices) are mainly observed in the human arch and in the descending aorta, whereas the ascending aorta presented the lowest prevalence for atheromatosis. This issue may have significant implications in the study of atherosclerosis development in the human thoracic aorta and the pathogeneses of embolic events.

Oral antidiabetic treatment in patients with coronary disease: time-related increased mortality on combined glyburide/metformin therapy over a 7.7-year follow-up

BACKGROUND

A sulfonylurea--usually glyburide--plus metformin constitute the most widely used oral antihyperglycemic combination in clinical practice. Both medications present undesirable cardiovascular effects. The issue whether the adverse effects of each of these pharmacologic agents may be additive and detrimental to the prognosis for coronary patients has not yet been specifically addressed.

HYPOTHESIS

This study was designed to examine the survival in type 2 diabetics with proven coronary artery disease (CAD) receiving a combined glyburide/metformin antihyperglycemic treatment over a long-term follow-up period.

METHODS

The study sample comprised 2,275 diabetic patients, aged 45-74 years, with proven CAD, who were screened but not included in the bezafibrate infarction prevention study. In addition, 9,047 nondiabetic patients with CAD represented a reference group. Diabetics were divided into four groups on the basis of their therapeutic regimen: diet alone (n = 990), glyburide (n = 953), metformin (n = 79), and a combination of the latter two (n = 253).

RESULTS

The diabetic groups presented similar clinical characteristics upon recruitment. Crude mortality rate after a 7.7-year follow-up was lower in nondiabetics (14 vs. 31.6%, p<0.001). Among diabetics, 720 patients died: 260 on diet (mortality 26.3%), 324 on glyburide (34%), 25 on metformin alone (31.6%), and 111 patients (43.9%) on combined treatment (p<0.000001). Time-related mortality was almost equal for patients on metformin and on combined therapy over an intermediate follow-up period of 4 years (survival rates 0.80 and 0.79, respectively). The group on combined treatment presented the worst prognosis over the long-term follow-up, with a time-related survival rate of 0.59 after 7 years, versus 0.68 and 0.70 for glyburide and metformin, respectively. After adjustment to variables for prognosis, the use of the combined treatment was associated with an increased hazard ratio (HR) for all-cause mortality of 1.53 (95% confidence interval [CI] 1.20-1.96), whereas glyburide and metformin alone yielded HR 1.22 (95% CI 1.02-1.45) and HR 1.26 (95% CI 0.81-1.96), respectively.

CONCLUSIONS

We conclude that after a 7.7-year follow-up, monotherapy with either glyburide or metformin in diabetic patients with CAD yielded a similar outcome and was associated with a modest increase in mortality. However, time-related mortality was markedly increased when a combined glyburide/metformin treatment was used.

Autoantibodies to oxidized low-density lipoprotein in coronary artery disease

BACKGROUND

The significance of antioxidized low-density lipoprotein (oxLDL) antibodies in atherogenesis is not yet clear, and there are conflicting data regarding anti-oxLDL levels in early hypertension.

METHODS

The levels of anti-oxLDL antibodies were studied in coronary artery disease patients with (n = 82) or without (n = 36) hypertension, in association to other risk factors for coronary artery disease.

RESULTS

The levels of anti-oxLDL antibodies did not differ significantly between coronary artery disease patients with or without hypertension. (0.132 +/- 0.146 v 0.153 +/- 0.158 optical density at 405 nm, respectively; P = .48). No significant differences in anti-oxLDL antibodies were found between men and women with and without hypertension, between hypertensive patients with normal and abnormal blood pressure measurements, and between medicated and nonmedicated hypertensive patients. The presence of diabetes mellitus, smoking, and hypercholesterolemia, either solely or in combination, did not result in significant differences in antibody levels in the hypertensive or normotensive patients.

CONCLUSIONS

Although the levels of oxLDL antibodies might be modified in early hypertension, once advanced coronary artery disease has developed the presence of hypertension does not affect anti-oxLDL levels.

Usefulness of spiral computed tomography (dual-slice mode) for the detection of coronary artery calcium in patients with chronic atypical chest pain, in typical angina pectoris, and in asymptomatic subjects with prominent atherosclerotic risk factors

The prevalence and extent of coronary calcium were retrospectively assessed by spiral computed tomography in 541 patients (mean age 62 +/- 9 years), of whom 101 had typical angina pectoris, 307 had atypical chest pain, and 133 were asymptomatic subjects with prominent atherosclerotic risk factors. The highest prevalence of coronary calcium was in men with angina pectoris (89%), whereas it was not detected in 48% of men and 56% of women with atypical chest pain.

Clinical impact of borderline and undiagnosed diabetes mellitus in patients with coronary artery disease

The present study was aimed to evaluate the prevalence and prognostic significance of unrecognized and newly defined borderline diabetes (with fasting blood sugar 126 to 139 mg/dl) by the American Diabetes Association criteria in coronary patients over a 7.7-year follow-up. Both undiagnosed and newly diagnosed borderline diabetes were associated with an unfavorable metabolic profile. The mortality of the borderline diabetics tended to be higher than in their nondiabetic counterparts. but this tendency did not reach statistical significance. A significant excess in long-term mortality was observed among the undiagnosed diabetes group.

Coronary calcium and anti-cardiolipin antibody are elevated in patients with typical chest pain

The aim of this study was to examine whether detection of coronary calcium and the autoimmune response associated with atherosclerosis, either solely or in combination, are different in patients with typical and atypical chest pain. Coronary calcium as detected by spiral computerized tomography and levels of antibodies against cardiolipin (CL), oxidized low-density lipoprotein (ox-LDL), and beta2-glycoprotein-I (beta2-GPI) were studied in patients with typical chest pain (n = 52), atypical chest pain (n = 19), or without chest pain (n = 21). Patients with typical chest pain had higher mean levels of coronary calcium (expressed as natural transformation of total coronary calcium score) compared with patients with atypical chest pain and controls (5.04 vs 3.21 and 2.75, respectively; p < 0.001). The levels of anti-CL were (mean +/- SD of optical density multiplied by 1,000): 262 +/- 140, 170 +/- 82, and 230 +/- 115 for patients with typical chest pain, atypical chest pain, and controls, respectively (p = 0.016). No significant difference was found between groups regarding anti-ox-LDL and anti-beta2-GPI autoantibody levels. In the typical chest pain group, there was a higher prevalence of high total coronary calcium scores (p = 0.03) and high anti-CL levels (p = 0.01) than in the atypical chest pain group. Eighteen of 52 patients with typical chest pain (35%) had both high calcium scores and high antibody levels, whereas none of the 19 patients (0%) who had atypical chest pain had high levels of both (p = 0.003). A combination of both coronary calcium and anti-CL was associated with higher area under the receiver operator characteristic curves than for each separately. High coronary calcium scores or high anti-CL levels are found more often in typical than in atypical chest pain patients, but a combination of high levels of both can better differentiate typical from atypical chest pain patients.

Retrograde flow in the thoracic aorta in patients with systemic emboli: a transesophageal echocardiographic evaluation of mobile plaque motion

STUDY OBJECTIVES

Blood flow in the aorta is complex and incompletely characterized. Mobile aortic plaques (MAPs), moving freely with the pulsatile aortic flow, in fact represent natural tracers that reflect the flow pattern itself. Our aim was to use MAP motion on transesophageal echocardiography (TEE) in order to characterize flow patterns in the atheromatous thoracic aorta of patients with systemic emboli.

DESIGN AND PATIENTS

The study group was recruited from 250 patients referred for TEE to evaluate recent embolism. Among them, 22 patients (14 men and 8 women; mean +/- SD age, 66.3 +/- 7.2 years; 16 patients with cerebrovascular and 6 patients with peripheral emboli) with MAPs of > or = 3 mm in length formed the study group. The longest amplitudes of three spatial components of mobile lesion motions were measured: x (antegrade/retrograde [A/R]), y (up/down [U/D], and z (right/left [R/L]).

RESULTS

A total of 33 mobile lesions were detected: 3 in the ascending aorta (1 patient), 13 in the arch (10 patients), and 17 in the descending aorta (11 patients). The length of mobile plaque components ranged from 3 to 13 mm; amplitudes of A/R, U/d, R/L, and retrograde flow motions ranged from 3 to 26 mm, from 1 to 16 mm, from 1 to 17 mm, and from 1 to 13 mm, respectively. Systolic rotational motion was clockwise in six patients (27%), counterclockwise in five patients (23%), incomplete (semicircle) in six patients (27%), and alternate clockwise/counterclockwise in five patients (23%). Diastolic rotational motion was clockwise in 5 patients (23%), counterclockwise in 6 patients (27%), and incomplete (semicircle) in 11 patients (50%). There were 18 multiple MAPs in seven patients: in all these cases, simultaneous rotations of MAP in different directions (as a marker for the presence of multiple vortices) were found. In nine patients with cerebral embolism, MAPs on the distal part of aortic arch solely were found; in five of them, all alternative potential sources of stroke were excluded. Therefore, retrograde cerebral embolism from distal aortic plaques in these patients is highly probable.

CONCLUSIONS

Retrograde and rotational blood flow in the thoracic aorta probably exists in all patients with systemic emboli and mobile protruding aortic atheromas. Therefore, retrograde cerebral embolism from distal aortic plaques is theoretically possible.

Blunted responses of doppler-derived aortic flow parameters during whole-body heavy isometric exercise in heart transplant recipients

BACKGROUND

Relatively light isometric exercise (handgrip) in heart transplant recipients induces attenuated increments in heart rate, blood pressure, and systemic vascular resistance, but hemodynamic response to whole-body, heavy isometric exercise is unknown. The aim of our study was to investigate the influences of whole-body, heavy, isometric exercise on Doppler-derived parameters in these patients.

METHODS

We investigated 18 patients, aged 54.0 +/- 2 years, 1.6 +/- 1.0 years after cardiac transplantation and 18 sedentary healthy volunteers, aged 51.8 +/- 4 years (p = not significant). Patients performed supine, isometric exercise by stretching a whole-body isometric device at 50% of maximal voluntary contraction for 3 minutes.

RESULTS

Resting heart rate, blood pressure, and rate-pressure product were higher in transplanted patients when compared with the healthy volunteers (p < 0.001 for all). However, during isometric exercise, these parameters increased to a lesser extent in the transplanted compared with the healthy subjects-heart rate, 12% vs 40% (p < 0.001); mean arterial pressure, 20% vs 27% (p < 0.05); and rate-pressure product, 39% vs 85% (p < 0.001). In the healthy volunteers, peak-flow velocity, mean acceleration, flow-velocity integral, and stroke volume decreased by 30% to 40% with isometric exercise (p < 0.001 for all), whereas systemic vascular resistance increased by 36% (p < 0.001) and cardiac output did not change. In the transplanted patients, all above parameters remained unchanged. Heavy, whole-body isometric exercise was well tolerated in heart transplant recipients in this study, without hemodynamic deterioration or other complications.

CONCLUSIONS

With whole-body, heavy isometric exercise, Doppler-derived aortic flow parameters demonstrate blunted responses or remain unchanged among heart transplant recipients. The observed phenomenon may have implications for studies of exercise physiology in transplant recipients.

Tracking coronary calcification by using dual-section spiral CT: a 3-year follow-up

PURPOSE

To investigate the accuracy of dual-section spiral computed tomography (CT) in tracking the progression of coronary calcification, as measured during a 3-year follow-up.

MATERIALS AND METHODS

Two hundred forty-six patients with hypertension (mean age, 66 years +/- 6 [SD]) were preselected in accordance with the International Nifedipine Study Intervention as a Goal for Hypertension Therapy protocol. Subjects had no clinical coronary arterial disease prior to the study and no cardiovascular events during follow-up. All participants underwent baseline CT (3.2-mm section thickness; reconstruction increment, 1.5 mm) and follow-up CT after 3 years. Calcification progression was defined as any increase in total calcification score (TCS) and analyzed in accordance with five baseline TCS categories: 1-9, 10-35, 36-100, 101-250, and greater than 250.

RESULTS

At baseline CT, 152 patients had a TCS greater than 0, and 106 (70%) showed progression after 3 years, while 94 had a baseline TCS of 0; of these, 26 (28%) showed progression (P: <.01 between groups). The mean TCS was significantly higher in each baseline TCS category after 3 years. The percentage increase was negatively correlated with baseline TCS (P: <.01) and ranged from 466% in the lowest category to 38% in the highest.

CONCLUSION

Dual-section spiral CT depicts significant change in TCS over time and is useful in tracking calcified coronary atherosclerosis.