Interventional management of hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor resection and bone stabilization

OBJECTIVE: The purpose of this study was to evaluate, in relation to intraoperative estimated blood loss (EBL), the effectiveness of preoperative transcatheter arterial embolization of hypervascular osseous metastatic lesions before orthopedic resection and stabilization. MATERIALS AND METHODS: Between June 1987 and November 2007, 22 patients underwent transcatheter arterial embolization of tumors of the long bone, hip, or vertebrae before resection and stabilization. Osseous metastatic lesions from renal cell carcinoma, malignant melanoma, leiomyosarcoma, and prostate cancer were embolized. All patients were treated with a coaxial catheter technique with polyvinyl alcohol (PVA) particles alone or a combination of PVA particles and coils. After embolization, each tumor was angiographically graded according to devascularization (grades 1-3) based on tumor blush after contrast injection into the main tumor-feeding arteries. RESULTS: In patients with complete devascularization (grade 1), mean EBL was calculated to be 1,119 mL, whereas in patients with partial embolization (grades 2 and 3) EBL was 1,788 mL and 2,500 mL. With respect to intraoperative EBL, no significant difference between devascularization grades was found (p > 0.05). Moderate correlation (r = 0.51, p = 0.019) was observed between intraoperative EBL and tumor size before embolization. Only low correlation (r = 0.44, p = 0.046) was found between intraoperative EBL and operating time. Major complications included transient palsy of the sciatic nerve and gluteal abscess in one patient. CONCLUSION: The results of this study support the concept that there is no statistically significant difference among amounts of intraoperative EBL with varying degrees of embolization.

Common and unexpected findings in mummies from ancient Egypt and South America as revealed by CT

Computed tomography (CT) has proved to be a valuable investigative tool for mummy research and is the method of choice for examining mummies. It allows for noninvasive insight, especially with virtual endoscopy, which reveals detailed information about the mummy's sex, age, constitution, injuries, health, and mummification techniques used. CT also supplies three-dimensional information about the scanned object. Mummification processes can be summarized as "artificial," when the procedure was performed on a body with the aim of preservation, or as "natural," when the body's natural environment resulted in preservation. The purpose of artificial mummification was to preserve that person's morphologic features by delaying or arresting the decay of the body. The ancient Egyptians are most famous for this. Their use of evisceration followed by desiccation with natron (a compound of sodium salts) to halt putrefaction and prevent rehydration was so effective that their embalmed bodies have survived for nearly 4500 years. First, the body was cleaned with a natron solution; then internal organs were removed through the cribriform plate and abdomen. The most important, and probably the most lengthy, phase was desiccation. After the body was dehydrated, the body cavities were rinsed and packed to restore the body's former shape. Finally, the body was wrapped. Animals were also mummified to provide food for the deceased, to accompany the deceased as pets, because they were seen as corporal manifestations of deities, and as votive offerings. Artificial mummification was performed on every continent, especially in South and Central America.

Low-grade endometrial stromal sarcoma with inferior vena cava tumor thrombus and intracardiac extension: radical resection may improve recurrence free survival

BACKGROUND: Endometrial stromal sarcoma (ESS) represents 0.2% of all uterine malignancies. Based on the mitotic activity, a distinction is made between low and high-grade ESS. Although the overall five-year survival rate for low-grade ESS exceeds 80%, about 50% of the patients show tumor recurrence, mostly after a long latency period. Tumor invasion of the great vessels is extremely rare. We describe a patient with advanced low-grade ESS with tumor invasion of the infrarenal aorta and the inferior vena cava. The patient presented with a large tumor thrombus extending from the inferior vena cava into the right atrium. METHODS: Review of literature and identification of 19 patients, including our own case report, with advanced low-grade ESS with invasion of the great vessels and formation of an inferior vena cava tumor thrombus. RESULTS: All 19 patients presented with an abdominal tumor mass and a tumor thrombus protruding into the inferior vena cava. The tumor thrombus extended into the right heart cavities in nine patients reaching the right atrium in four, the right ventricle in three and the pulmonary artery in two patients. There were 5 patients with an advanced primary tumor and 14 patients with an advanced recurrent tumor. Seven patients presented with synchronous metastatic disease and six patients with a pelvic tumor infiltrating the bladder, the rectosigmoid colon or the infrarenal aorta. Mean age at surgery was 45.9+/-12.3 years (median 47, range 25-65 years). Tumor thrombectomy was accomplished by cavatomy or by right atriotomy after installation of a cardiopulmonary bypass. There was no peri-operative mortality and a very low morbidity. Radical tumor resections were achieved in 10 patients. The follow-up for these 10 patients was 2+/-1.3 years (median 2, range 0.3-4.5 years). Nine patients remained recurrence free whereas one patient suffered an asymptomatic local recurrence. CONCLUSIONS: Low-grade ESS is a rare angioinvasive tumor with a high recurrence rate. Resection of an inferior vena cava tumor thrombus, even with extension into the right heart cavities, can be performed safely. Extensive radical surgery is therefore justified in the treatment of advanced tumor manifestations of a low-grade ESS potentially improving recurrence free survival.

Anterior Stafne's bone cavity mimicking a periapical lesion of endodontic origin: report of two cases

INTRODUCTION: This report of 2 cases describes the diagnostic procedures used to identify 2 Stafne's bone cavities (SBC) found in unusually anterior locations in the mandible, both mimicking periapical lesions of endodontic origin. METHODS: In the first patient, a 47-year-old man, an SBC was diagnosed in the area of teeth #27, 28, and 29. In the second patient, a 62-year-old man, the SBC was a fortuitous finding, because this patient was referred for dental implant therapy. RESULTS: In both cases, the final diagnosis was achieved by using limited cone beam computed tomography (CBCT) and magnetic resonance imaging (MRI). In both patients, the lingual bone cavity was found to be occupied by accessory salivary gland tissue. CONCLUSIONS: The combination of CBCT and MRI as noninvasive diagnostic techniques seems ideal to avoid surgical explorations, incisional biopsies, or enucleations of the lesion for diagnostic purposes.

[The patent nasopalatine duct. A rare anomaly and diagnostic pitfall]

The patent nasopalatine duct is a rare anomaly in the anterior maxilla. During the early fetal period, a bilateral and epithelium-lined duct is formed within the primary palatal process as an oro-nasal communication. However, the duct obliterates and degenerates before birth. A persisting patent or through-and-through nasoplatine duct is therefore considered a developmental anomaly. A patent nasopalatine duct normally presents as one (or two) tiny openings lateral or posterior to the incisive papilla. In such a case, the ducts can be partially or completely probed with gutta-percha points with subsequent radiographic imaging. The patients report strange sensations such as squeaking noise, palatal drainage, nasal regurgitation, or airway communication between nasal and oral cavities; however, patients rarely complain about pain. About 40 cases have been documented in the literature. We describe two patients who have been referred to our department for evaluation of "sinus tracts" in the anterior palate. Since a patent nasopalatine duct can become a diagnostic pitfall, a thorough inspection of the mucosa around the incisive papilla is essential to avoid unnecessary endodontic or surgical interventions in the area of the central maxillary incisors.

Laser wavelengths and oral implantology

In modern implant dentistry there are several clinical indications for laser surgery. Different laser systems have a considerable spectrum of application in soft and hard peri-implant tissues. The literature was searched for clinical application of different laser wavelengths in peri-implant tissues: second-stage surgery of submerged implants, treatment of infrabony defects, removal of peri-implant hyperplastic overgrowths, and, possibly, the preparation of bone cavities for implant placement. This report describes the state-of-the-art application of different laser systems in modern implant dentistry for the treatment of peri-implant lesions and decontamination of implant surfaces. Our study evaluated in vitro examinations, clinical experience and long-term clinical studies. The exact selection of the appropriate laser system and wavelength was dependent on the scientific evaluation of recent literature and the level of changes in implant and tissue temperatures during laser application. The significant reduction in bacteria on the implant surface and the peri-implant tissues during irradiation and the cutting effects associated with the coagulation properties of the lasers are the main reasons for laser application in the treatment of peri-implant lesions and the successful long-term prognosis of failing oral implants. The various applications of lasers in implant dentistry are dependent on the wavelength and laser-tissue interactions.

Comparison of the immediate effects of gaseous ozone and chlorhexidine gel on bacteria in cavitated carious lesions in children in vivo

Clinical application of ozone gas has been shown to arrest the progression of dentinal caries in children. In this study, we compare the immediate effects of gaseous ozone and chlorhexidine gel on bacteria in cavitated carious lesions in children. Forty children, each with at least two open occlusal carious lesions, were enrolled in the study. Two teeth were chosen randomly. In one lesion, overlying soft biological material was removed, whilst the other lesion was not excavated. Cavities were rinsed with sterile water and dried with air. A standardised sample was taken from the mesial part of each lesion. Then, gaseous ozone (HealOzone) or 1% chlorhexidine gel (Corsodyl) was applied for 30 s on both lesions of 20 children each, and a second sample was taken from the distal part of each lesion. The anaerobic microbiota was cultivated; the number of colony forming units was calculated per milligram sample. The two-sided paired t test showed no significant (P > 0.05) differences in the reduction of total bacterial counts per milligram comparing samples before and after ozone or chlorhexidine application. The tests also showed no statistically significant difference whether the superficial decayed dentine had been removed before ozone or with chlorhexidine treatment or not. It can be concluded that gaseous ozone or chlorhexidine gel application for 30 s to deep occlusal carious cavities had no significant immediate antimicrobial effects whether the superficial decayed layers dentine were removed or not.

Antibiotic resistance and genetic diversity in Staphylococcus aureus from slaughter pigs in Switzerland

Nasal carriage of Staphylococcus aureus was evaluated in pigs at slaughterhouse. The nasal cavities of 304 pigs from 54 herds were screened. Eighty-nine percent of the farms harbored pigs that were colonized with S. aureus. Among them, no MRSA were found, indicating a low prevalence. However, pigs were found to harbor S. aureus, which displayed resistance to penicillin (blaZ) (62.5%), tetracycline [tet(M)] (33.3%), streptomycin (strpS194) (27%), clindamycin [erm(B)] (4.1%), erythromycin [erm(B)] (4.1%), kanamycin (4.1%), chloramphenicol (catpC194) (2%) and gentamicin [aac(6')-Ie-aph(2')-Ia] (2%). The S. aureus isolates mainly belong to Ridom spa type t034 (31.3%), t208 (14.6%) and t899 (12.5%). These pig-associated spa types have not yet been detected in hospitalized human patients in Switzerland. Surveillance programs are now necessary at both inland and import levels to rapidly detect and suppress the emergence of MRSA in pigs in Switzerland.

Temporary zinc oxide-eugenol cement: eugenol quantity in dentin and bond strength of resin composite

Uptake of eugenol from eugenol-containing temporary materials may reduce the adhesion of subsequent resin-based restorations. This study investigated the effect of duration of exposure to zinc oxide–eugenol (ZOE) cement on the quantity of eugenol retained in dentin and on the microtensile bond strength (μTBS) of the resin composite. The ZOE cement (IRM Caps) was applied onto the dentin of human molars (21 per group) for 1, 7, or 28 d. One half of each molar was used to determine the quantity of eugenol (by spectrofluorimetry) and the other half was used for μTBS testing. The ZOE-exposed dentin was treated with either OptiBond FL using phosphoric acid (H3PO4) or with Gluma Classic using ethylenediaminetetraacetic acid (EDTA) conditioning. One group without conditioning (for eugenol quantity) and two groups not exposed to ZOE (for eugenol quantity and μTBS testing) served as controls. The quantity of eugenol ranged between 0.33 and 2.9 nmol mg−1 of dentin (median values). No effect of the duration of exposure to ZOE was found. Conditioning with H3PO4 or EDTA significantly reduced the quantity of eugenol in dentin. Nevertheless, for OptiBond FL, exposure to ZOE significantly decreased the μTBS, regardless of the duration of exposure. For Gluma Classic, the μTBS decreased after exposure to ZOE for 7 and 28 d. OptiBond FL yielded a significantly higher μTBS than did Gluma Classic. Thus, ZOE should be avoided in cavities later to be restored with resin-based materials.

Are implants more reliable than severely compromised endodontically treated teeth as abutments for zirconia-based FPDs? : In vitro results of long-term preclinical load simulation

OBJECTIVES The aim was to study the impact of the defect size of endodontically treated incisors compared to dental implants as abutments on the survival of zirconia two-unit anterior cantilever-fixed partial dentures (2U-FPDs) during 10-year simulation. MATERIALS AND METHODS Human maxillary central incisors were endodontically treated and divided into three groups (n = 24): I, access cavities rebuilt with composite core; II, teeth decoronated and restored with composite; and III as II supported by fiber posts. In group IV, implants with individual zirconia abutments were used. Specimens were restored with zirconia 2U-FPDs and exposed to two sequences of thermal cycling and mechanical loading. Statistics: Kaplan-Meier; log-rank tests. RESULTS During TCML in group I two tooth fractures and two debondings with chipping were found. Solely chippings occurred in groups II (2×), IV (2×), and III (1×). No significant different survival was found for the different abutments (p = 0.085) or FPDs (p = 0.526). Load capability differed significantly between groups I (176 N) and III (670 N), and III and IV (324 N) (p < 0.024). CONCLUSION Within the limitations of an in vitro study, it can be concluded that zirconia-framework 2U-FPDs on decoronated teeth with/without post showed comparable in vitro reliability as restorations on implants. The results indicated that restorations on teeth with only access cavity perform worse in survival and linear loading. CLINICAL RELEVANCE Even severe defects do not justify per se a replacement of this particular tooth by a dental implant from load capability point of view.

Cortical remodeling during menopause, rheumatoid arthritis, glucocorticoid and bisphosphonate therapy

Bone mass, bone geometry and its changes are based on trabecular and cortical bone remodeling. Whereas the effects of estrogen loss, rheumatoid arthritis (RA), glucocorticoid (GC) and bisphosphonate (BP) on trabecular bone remodeling have been well described, the effects of these conditions on the cortical bone geometry are less known. The present review will report current knowledge on the effects of RA, GC and BP on cortical bone geometry and its clinical relevance. Estrogen deficiency, RA and systemic GC lead to enhanced endosteal bone resorption. While in estrogen deficiency and under GC therapy endosteal resorption is insufficiently compensated by periosteal apposition, RA is associated with some periosteal bone apposition resulting in a maintained load-bearing capacity and stiffness. In contrast, BP treatment leads to filling of endosteal bone cavities at the epiphysis; however, periosteal apposition at the bone shaft seems to be suppressed. In summary, estrogen loss, RA and GC show similar effects on endosteal bone remodeling with an increase in bone resorption, whereas their effect on periosteal bone remodeling may differ. Despite over 50 years of GC therapy and over 25 years of PB therapy, there is still need for better understanding of the skeletal effects of these drugs as well as of inflammatory disease such as RA on cortical bone remodeling.

Assessment of the Matrix Degenerative Effects of MMP-3, ADAMTS-4 and HTRA1 injected into a bovine Intervertebral Disc Organ Culture Model

Study Design. In vitro study to develop an intervertebral disc degeneration (IDD) organ culture model, using coccygeal bovine intervertebral discs (IVDs) and injection of proteolytic enzymes MMP-3, ADAMTS-4 and HTRA1.Objective. This study aimed to develop an in-vitro model of enzyme-mediated IDD to mimic the clinical outcome in humans for investigation of therapeutic treatment options.Summary of Background Data. Bovine IVDs are comparable to human IVDs in terms of cell composition and biomechanical behavior. Researchers injected papain and trypsin into them to create an IDD model with a degenerated nucleus pulposus (NP) area. They achieved macroscopic cavities as well as a loss of glycosaminoglycans (GAGs). However, none of these enzymes are clinically relevant.Methods. Bovine IVDs were harvested maintaining the endplates. Active forms of MMP-3, ADAMTS-4 and HTRA1 were injected at a dose of 10μg/ml each. Phosphate buffered saline (PBS) was injected as a control. Discs were cultured for 8 days and loaded diurnally (day 1 to day 4 with 0.4 MPa for 16 h) and left under free swelling condition from day 4 to day 8 to avoid expected artifacts due to dehydration of the NP. Outcome parameters included disc height, metabolic cell activity, DNA content, glycosaminoglycan (GAG) content, total collagen content, relative gene expression and histological investigation.Results. The mean metabolic cell activity was significantly lower in the NP area of discs injected with ADAMTS-4 compared to the day 0 control discs. Disc height was decreased following injection with HTRA1, and was significantly correlated with changes in GAG/DNA of the NP tissue. Total collagen content tended to be lower in groups injected with ADAMTS4 and MMP-3.Conclusion. MMP-3, ADAMTS-4 and HTRA1 neither provoked visible matrix degradation nor major shifts in gene expression. However, cell activity was significantly reduced and HTRA1 induced loss of disc height which positively correlated with changes in GAG/DNA content. The use of higher doses of these enzymes or a combination thereof may therefore be necessary to induce disc degeneration

Natural history of optical coherence tomography-detected non-flow-limiting edge dissections following drug-eluting stent implantation

Aims: Angiographic evidence of edge dissections has been associated with a risk of early stent thrombosis. Optical coherence tomography (OCT) is a high-resolution technology detecting a greater number of edge dissections -particularly non-flow-limiting- compared to angiography. Their natural history and clinical implications remain unclear. The objectives of the present study were to assess the morphology, healing response, and clinical outcomes of OCT-detected edge dissections using serial OCT imaging at baseline and at one year following drug-eluting stent (DES) implantation. Methods and results: Edge dissections were defined as disruptions of the luminal surface in the 5 mm segments proximal and distal to the stent, and categorised as flaps, cavities, double-lumen dissections or fissures. Qualitative and quantitative OCT analyses were performed every 0.5 mm at baseline and one year, and clinical outcomes were assessed. Sixty-three lesions (57 patients) were studied with OCT at baseline and one-year follow-up. Twenty-two non-flow-limiting edge dissections in 21 lesions (20 patients) were identified by OCT; only two (9%) were angiographically visible. Flaps were found in 96% of cases. The median longitudinal dissection length was 2.9 mm (interquartile range [IQR] 1.6-4.2 mm), whereas the circumferential and axial extensions amounted to 1.2 mm (IQR: 0.9-1.7 mm) and 0.6 mm (IQR: 0.4-0.7 mm), respectively. Dissections extended into the media and adventitia in seven (33%) and four (20%) cases, respectively. Eighteen (82%) OCT-detected edge dissections were also evaluated with intravascular ultrasound which identified nine (50%) of these OCT-detected dissections. No stent thrombosis or target lesion revascularisation occurred up to one year. At follow-up, 20 (90%) edge dissections were completely healed on OCT. The two cases exhibiting persistent dissection had the longest flaps (2.81 mm and 2.42 mm) at baseline. Conclusions: OCT-detected edge dissections which are angiographically silent in the majority of cases are not associated with acute stent thrombosis or restenosis up to one-year follow-up.

Enhanced antibiotic multi-resistance in nasal and faecal bacteria after agricultural use of streptomycin

Streptomycin is used in arboriculture to control fire blight. Using sheep as a model, multidrug-resistant bacteria in mammals were found to be selected after the intentional release of streptomycin into the environment. Escherichia coli and Staphylococcus spp. were isolated from the faeces and nasal cavities, respectively, of sheep grazing on a field sprayed with streptomycin at concentrations used in orchards (test group) and on a field without streptomycin (control group). Before the application of streptomycin, the percentage of streptomycin-resistant E. coli isolates in faeces was 15.8% in the control group and 14.7% in the test group. After the application of streptomycin, the overall number of streptomycin-resistant E. coli isolates was significantly higher in the test group (39.9%) than in the control group (22.3%). Streptomycin-resistant Staphylococcus isolates were only detected after the application of streptomycin. Streptomycin resistance was frequently associated with resistance to sulfamethoxazole, ampicillin, tetracycline and chloramphenicol and less frequently to cefotaxime in E. coli, and to tetracycline, fusidic acid and tiamulin in Staphylococcus spp. This study shows that the application of low concentrations of streptomycin on grass, as occurs during the spraying of orchards, selects for multidrug-resistant nasal and enteric bacterial flora, including extended-spectrum beta-lactamase-producing E. coli.

Blood vessel anomalities in the oral cavity of two calves

Two calves were presented with a congenital mass in the rostral mandibular gingiva. In both cases the masses relapsed after surgical removal. Histologically, the two masses were composed of irregularly arranged vascular cavities, embedded in loosely arranged stroma and alcian-blue PAS positive ground substance. Radiologically, a destruction of the alveolar cavity was recognized in both cases, which was in case 1 histologically compatible with bone resorption and remodeling associated with the infiltration of abundant granulation tissue. A literature survey revealed that no consistent criteria for a correct classification for vascular tumours exists, resulting in the fact that comparable lesions were named differently in the past. We therefore propose to classify such lesions as congential vascular malformation until distinct morphological, immunohistochemical and molecular genetic analysis criteria will exist.