Development of labial gingival recessions in orthodontically treated patients

INTRODUCTION Our aim was to assess the prevalence of gingival recessions in patients before, immediately after, and 2 and 5 years after orthodontic treatment. METHODS Labial gingival recessions in all teeth were scored (yes or no) by 2 raters on initial, end-of-treatment, and posttreatment (2 and 5 years) plaster models of 302 orthodontic patients (38.7% male; 61.3% female) selected from a posttreatment archive. Their mean ages were 13.6 years (SD, 3.6; range, 9.5-32.7 years) at the initial assessment, 16.2 years (SD, 3.5; range, 11.7-35.1 years) at the end of treatment, 18.6 years (SD, 3.6; range, 13.7-37.2 years) at 2 years posttreatment, and 21.6 (SD, 3.5; range, 16.6-40.2 years) at 5 years posttreatment. A recession was noted (scored "yes") if the labial cementoenamel junction was exposed. All patients had a fixed retainer bonded to either the mandibular canines only (type I) or all 6 mandibular front teeth (type II). RESULTS There was a continuous increase in gingival recessions after treatment from 7% at end of treatment to 20% at 2 years posttreatment and to 38% at 5 years posttreatment. Patients less than 16 years of age at the end of treatment were less likely to develop recessions than patients more than 16 years at the end of treatment (P = 0.013). The prevalence of recessions was not associated with sex (P = 0.462) or extraction treatment (P = 0.32). The type of fixed retainer did not influence the development of recessions in the mandibular front region (P = 0.231). CONCLUSIONS The prevalence of gingival recessions steadily increases after orthodontic treatment. The recessions are more prevalent in older than in younger patients. No variable, except for age at the end of treatment, seems to be associated with the development of gingival recessions.

Sportvereine als Interessenorganisationen?! Ziel-Interessen-Divergenzen und ihre Auswirkungen

Einleitung: Freiwillige Sportorganisationen wie Sportvereine sind als Interessenorganisationen zu charakterisieren, deren primärer Organisationszweck sich auf die Vertretung der Interessen ihrer Mitglieder bezieht (Nagel, 2006). Mit dieser Interessenvertretungsfunktion wird gewährleistet, dass die Vereinsziele an die Mitgliederinteressen rückgebunden bleiben und Ziel-Interessen-Kongruenz herrscht (Schimank, 2005). Die Beobachtungen der Ver-einsrealität weisen jedoch darauf hin, dass die Ziele der Vereine oftmals von den Interessen ihrer Mitglieder abweichen und im Widerspruch zueinander stehen (Baur & Burrmann, 2003; Heinemann, 2004). Vor diesem Problemhintergrund ist zu fragen: Inwiefern stimmen die Vereinsziele mit den Mitgliederinteressen überein? Und für den Fall von Ziel-Interessen-Divergenzen, welche Auswirkungen ergeben sich daraus für die Vereine? Theoretisch-methodischer Ansatz: Für die theoriegeleite Beantwortung der Fragestellungen wurde auf Grundlage einer akteurtheoretischen Kon-zeptualisierung von Vereinen als Interessenorganisationen (Nagel, 2006; Schimank, 2007) ein strukturell-individualistisches Mehr-Ebenen-Modell entwickelt, dass zum einen das Verhältnis von Vereinszielen (Vereins-ebene) und Mitgliederinteressen (Mitgliederebene) und damit die Genese von Ziel-Interessen-Divergenzen erklärt. Zum anderen liefert das Modell eine Erklärungsgrundlage, welche Auswirkungen Divergenzen (struktu-relle Vereinssituation) auf die Mitglieder haben, d.h. wie die Mitglieder auf bestehende Divergenzen reagieren (individuelle Mitgliederhandlung). Die erforderlichen Vereins- und Mitgliederdaten wurden im Rahmen zweier Teilstudien erfasst, bei denen in erster Linie quantitative Erhebungs- und Auswertungsverfahren zum Einsatz kamen. Die erste Teilstudie wurde im Fürstentum Liechtenstein zur Analyse der Ziel-Interessen-Übereinstimmung durchgeführt, wobei hierzu die Präsidenten von 17 Vereinen und 481 Mitglieder schriftlich befragt wurden. In der zweiten Teilstudie wurde im Schweizer Turnverein Länggasse Bern mit 199 Mitgliedern eine schriftliche Befragung durchgeführt, um die Auswirkungen von Divergenzen zu analysieren. Zur Erfassung des Ausmasses von Ziel-Interessen-Divergenzen wurde eine Vergleichsprüfung der Vereinsziele und Mitgliederinteressen durchgeführt. Die Liechtensteinischen Vereinspräsidenten und Vereinsmitglieder mussten diesbezüglich die Bedeutung von 23 verschiedenen Items eines entwickelten Ziel-/Interessen-Fragekataloges einschätzen und über den betragsmässigen Bedeutungsunterschied konnte das quantitative Divergenzmass bestimmt werden. Um die Frage nach den Auswirkungen zu klären, hatten die Mitglieder des Schweizer Turnvereins Länggase Bern Aussagen über ihre Reaktionen auf bestehende Divergenzen entlang einer konzipierten Handlungstypologie (exit, voice, loyalty, neglect) zu geben. Ergebnisse: Die Befunde der Vergleichsanalyse zeigen, dass in allen untersuchten Vereinen Ziel-Interessen-Divergenzen in unterschiedlichem Ausmaß existieren. Bei einem Drittel der Vereine bestehen mittlere Divergenzen und in zwei Drittel sind größere Divergenzen zu beobachten. Divergenzen bestehen dabei vor allem hinsichtlich des Brei-tensports (v.a. Erweiterung des Sportangebots), der Vereinsentwicklung (v.a. Öffnen für neue Entwicklungen) und der Geselligkeit (v.a. aussersportliches Angebot, Wahrung der Vereinstradition). Die Analyse der Auswirkungen zeigt, dass geringe und mittelstarke Divergenzen in erster Linie zu konstruktiven Reaktionen führen. Die Mitglieder machen dabei die Vereinsführung auf diese Situation aufmerksam (voice), indem sie das Problem ansprechen und Vorschläge zur Problemlösung unterbreiten. Oder sie haben aus Grün-den der Vereinsverbundenheit (loyalty) die Hoffnung und das Vertrauen, dass die Vereinsführung ohne ihr Eingreifen das Problem löst. Wenn aber großen Divergenzen existieren, die sich für die Vereine zu einem gra-vierenden Problem entwickeln, tendieren die Mitglieder hingegen verstärkt zu destruktiven Reaktionen, die sich durch Gleichgültigkeit und Desinteresse am Vereinsgeschehen (neglect) äussern, indem die Mitglieder zukünftig nicht mehr auf Vereinsanlässe gehen. Oder sie wählen die Option des Rückzugs und Austritts (exit), indem sie ihr Vereinsengagement aufgeben oder im Extremfall aus der Abteilung oder dem Verein austreten. Diskussion: In der Vereinsrealität stellen Ziel-Interessen-Divergenzen offenbar eher die Norm als die Ausnahme dar, so dass die Vereinsziele nur teilweise an die Mitgliederinteressen rückgebunden sind. Allerdings sind Divergenzen nicht grundsätzlich als Problem zu interpretieren, sondern sind vielmehr in Abhängigkeit ihrer Intensität zu beurtei-len. Diesbezüglich dürften Vereine geringfügig bis mittelmässig ausgeprägte Divergenzsituationen im laufenden Vereinsgeschehen bis zu einem gewissen Grad relativ gut aushalten und aufarbeiten können, weil die Mitglie-der in diesem Fall zu einem konstruktiven Umgang tendieren, die eine Wiederherstellung von Ziel-Interessen-Kongruenz begünstigt. Demgegenüber können sich aber grosse Divergenzen zu einem ernsthaften Problem für Vereine entfalten, weil die Mitglieder in diesem Fall zu destruktiven Reaktionen neigen, die sich negativ auf die Vereinsentwicklung auswirken dürfte. Literatur Baur, J. & Burrmann, U. (2003). Konflikte in Sportvereinen. In J. Baur & S. Braun (Hrsg.), Integrationsleistungen von Sport-vereinen als Freiwilligenorganisationen (S. 331-370). Aachen: Meyer & Meyer. Nagel, S. (2006). Sportvereine im Wandel. Akteurtheoretische Analysen zur Entwicklung von Sportvereinen. Schorndorf: Hofmann. Nagel, S. (2007). Akteurtheoretische Analyse der Sportvereinsentwicklung. Ein theoretisch-methodischer Bezugsrahmen. Sportwissenschaft, 37 (2), 186-201. Schimank, U. (2005). Der Vereinssport in der Organisationsgesellschaft: organisationssoziologische Perspektiven auf ein spannungsreiches Verhältnis. In T. Alkemeyer, B. Rigauer & G. Sobiech (Hrsg.), Organisationsentwicklungen und De-Institutionalisierungsprozesse im Sport (S. 21-44). Schorndorf: Hofmann. Schimank, U. (2007). Handeln und Strukturen. Einführung in die akteurtheoretische Soziologie. Weinheim: Juventa Verlag.

Incident malignancies among older long-term breast cancer survivors and an age-matched and site-matched nonbreast cancer comparison group over 10 years of follow-up

BACKGROUND Of the approximately 2.4 million American women with a history of breast cancer, 43% are aged ≥ 65 years and are at risk for developing subsequent malignancies. METHODS Women from 6 geographically diverse sites included 5-year breast cancer survivors (N = 1361) who were diagnosed between 1990 and 1994 at age ≥ 65 years with stage I or II disease and a comparison group of women without breast cancer (N = 1361). Women in the comparison group were age-matched and site-matched to breast cancer survivors on the date of breast cancer diagnosis. Follow-up began 5 years after the index date (survivor diagnosis date or comparison enrollment date) until death, disenrollment, or through 15 years after the index date. Data were collected from medical records and electronic sources (cancer registry, administrative, clinical, National Death Index). Analyses included descriptive statistics, crude incidence rates, and Cox proportional hazards regression models for estimating the risk of incident malignancy and were adjusted for death as a competing risk. RESULTS Survivors and women in the comparison group were similar: >82% were white, 55% had a Charlson Comorbidity Index of 0, and ≥ 73% had a body mass index ≤ 30 kg/m(2) . Of all 306 women (N = 160 in the survivor group, N = 146 in the comparison group) who developed a first incident malignancy during follow-up, the mean time to malignancy was similar (4.37 ± 2.81 years vs 4.03 ± 2.76 years, respectively; P = .28), whereas unadjusted incidence rates were slightly higher in survivors (1882 vs 1620 per 100,000 person years). The adjusted hazard of developing a first incident malignancy was slightly elevated in survivors in relation to women in the comparison group, but it was not statistically significant (hazard ratio, 1.17; 95% confidence interval, 0.94-1.47). CONCLUSIONS Older women who survived 5 years after an early stage breast cancer diagnosis were not at an elevated risk for developing subsequent incident malignancies up to 15 years after their breast cancer diagnosis.

Major bleeding risk in anticoagulated patients receiving concomitant antiplatelet therapy: a prospective study

INTRODUCTION Current literature suggesting a higher bleeding risk during combination therapy compared to oral anticoagulation alone is primarily based on retrospective studies or specific populations. We aimed to prospectively evaluate whether unselected medical patients on oral anticoagulation have an increased risk of bleeding when on concomitant antiplatelet therapy. MATERIAL AND METHODS We prospectively studied consecutive adult medical patients who were discharged on oral anticoagulants between 01/2008 and 03/2009 from a Swiss university hospital. The primary outcome was the time to a first major bleed on oral anticoagulation within 12 months, adjusted for age, international normalized ratio target, number of medications, and history of myocardial infarction and major bleeding. RESULTS Among the 515 included anticoagulated patients, the incidence rate of a first major bleed was 8.2 per 100 patient-years. Overall, 161 patients (31.3%) were on both anticoagulant and antiplatelet therapy, and these patients had a similar incidence rate of major bleeding compared to patients on oral anticoagulation alone (7.6 vs. 8.4 per 100 patient-years, P=0.81). In a multivariate analysis, the association of concomitant antiplatelet therapy with the risk of major bleeding was not statistically significant (hazard ratio 0.89, 95% confidence interval, 0.37-2.10). CONCLUSIONS The risk of bleeding in patients receiving oral anticoagulants combined with antiplatelet therapy was similar to patients receiving oral anticoagulants alone, suggesting that the incremental bleeding risk of combination therapy might not be clinically significant.

Is there good simulation basic training for end-to-side vascular microanastomoses?

BACKGROUND Microvascular anastomosis is the cornerstone of free tissue transfers. Irrespective of the microsurgical technique that one seeks to integrate or improve, the time commitment in the laboratory is significant. After extensive previous training on several animal models, we sought to identify an animal model that circumvents the following issues: ethical rules, cost, time-consuming and expensive anesthesia, and surgical preparation of tissues required to access vessels before performing the microsurgical training, not to mention that laboratories are closed on weekends. METHODS Between January 2012 and April 2012, a total of 91 earthworms were used for 150 microsurgical training exercises to simulate vascular end-to-side microanastomosis. The training sessions were divided into ten periods of 7 days. Each training session included 15 simulations of end-to-side vascular microanastomoses: larger than 1.5 mm (n=5), between 1.0 and 1.5 mm (n=5), and smaller than 1.0 mm (n=5). A linear model with the main variables being the number of weeks (as a numerical covariate) and the size of the animal (as a factor) was used to determine the trend in time of anastomosis over subsequent weeks as well as the differences between the different size groups. RESULTS The linear model shows a significant trend (p<0.001) in time of anastomosis in the course of the training, as well as significant differences (p<0.001) between the groups of animals of different sizes. For microanastomoses larger than 1.5 mm, the mean anastomosis time decreased from 19.3±1.0 to 11.1±0.4 min between the first and last week of training (decrease of 42.5%). For training with smaller diameters, the results showed a decrease in execution time of 43.2% (diameter between 1.0 and 1.5 mm) and 40.9% (diameter<1.0 mm) between the first and last periods. The study demonstrates an improvement in the dexterity and speed of nodes execution. CONCLUSION The earthworm appears to be a reliable experimental model for microsurgical training of end-to-side microanastomoses. Its numerous advantages are discussed here and we predict training on earthworms will significantly grow and develop in the near future. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Non-AIDS defining cancers in the D:A:D Study - time trends and predictors of survival: a cohort study

Background Non-AIDS defining cancers (NADC) are an important cause of morbidity and mortality in HIV-positive individuals. Using data from a large international cohort of HIV-positive individuals, we described the incidence of NADC from 2004–2010, and described subsequent mortality and predictors of these. Methods Individuals were followed from 1st January 2004/enrolment in study, until the earliest of a new NADC, 1st February 2010, death or six months after the patient’s last visit. Incidence rates were estimated for each year of follow-up, overall and stratified by gender, age and mode of HIV acquisition. Cumulative risk of mortality following NADC diagnosis was summarised using Kaplan-Meier methods, with follow-up for these analyses from the date of NADC diagnosis until the patient’s death, 1st February 2010 or 6 months after the patient’s last visit. Factors associated with mortality following NADC diagnosis were identified using multivariable Cox proportional hazards regression. Results Over 176,775 person-years (PY), 880 (2.1%) patients developed a new NADC (incidence: 4.98/1000PY [95% confidence interval 4.65, 5.31]). Over a third of these patients (327, 37.2%) had died by 1st February 2010. Time trends for lung cancer, anal cancer and Hodgkin’s lymphoma were broadly consistent. Kaplan-Meier cumulative mortality estimates at 1, 3 and 5 years after NADC diagnosis were 28.2% [95% CI 25.1-31.2], 42.0% [38.2-45.8] and 47.3% [42.4-52.2], respectively. Significant predictors of poorer survival after diagnosis of NADC were lung cancer (compared to other cancer types), male gender, non-white ethnicity, and smoking status. Later year of diagnosis and higher CD4 count at NADC diagnosis were associated with improved survival. The incidence of NADC remained stable over the period 2004–2010 in this large observational cohort. Conclusions The prognosis after diagnosis of NADC, in particular lung cancer and disseminated cancer, is poor but has improved somewhat over time. Modifiable risk factors, such as smoking and low CD4 counts, were associated with mortality following a diagnosis of NADC.

A quantitative phenytoin GC-MS method and it's validation for samples from human ex situ brain microdialysis, blood and saliva using solid-phase extraction

This study describes the development and validation of a gas chromatography-mass spectrometry (GC-MS) method to identify and quantitate phenytoin in brain microdialysate, saliva and blood from human samples. A solid-phase extraction (SPE) was performed with a nonpolar C8-SCX column. The eluate was evaporated with nitrogen (50°C) and derivatized with trimethylsulfonium hydroxide before GC-MS analysis. As the internal standard, 5-(p-methylphenyl)-5-phenylhydantoin was used. The MS was run in scan mode and the identification was made with three ion fragment masses. All peaks were identified with MassLib. Spiked phenytoin samples showed recovery after SPE of ≥94%. The calibration curve (phenytoin 50 to 1,200 ng/mL, n = 6, at six concentration levels) showed good linearity and correlation (r² > 0.998). The limit of detection was 15 ng/mL; the limit of quantification was 50 ng/mL. Dried extracted samples were stable within a 15% deviation range for ≥4 weeks at room temperature. The method met International Organization for Standardization standards and was able to detect and quantify phenytoin in different biological matrices and patient samples. The GC-MS method with SPE is specific, sensitive, robust and well reproducible, and is therefore an appropriate candidate for the pharmacokinetic assessment of phenytoin concentrations in different human biological samples.

Longitudinal polysomnographic assessment from acute to subacute phase in infratentorial versus supratentorial stroke

Background: Regulation of sleep and sleep-related breathing resides in different brain structures. Vascular lesions can be expected to differ in their consequences on sleep depending on stroke topography. However, studies addressing the differences in sleep and sleep-related breathing depending on stroke topography are scarce. The aim of the present investigation was to compare the sleep and sleep-related breathing of patients with supratentorial versus infratentorial stroke. Methods: This study was part of the prospective multicenter study SAS-CARE-1 (Sleep-Disordered Breathing in Transient Ischemic Attack (TIA)/Ischemic Stroke and Continuous Positive Airway Pressure (CPAP) Treatment Efficacy (SAS-CARE); NCT01097967). We prospectively included 14 patients (13 male, age 66 ± 6 years) with infratentorial lesions and 14 patients (14 male, age 64 ± 7 years) with supratentorial lesions, matched for age and stroke severity. Polysomnography was recorded in all during the acute phase within 9 days after stroke onset and 3 months later. Results: During the acute phase after stroke, patients with infratentorial lesions had significantly more sleep-related breathing disorders than patients with supratentorial lesions with an apnea-hypopnea index >20 observed in 8 (57%) patients with infratentorial stroke and in only 2 (14%) patients with supratentorial stroke. Sleep-related breathing improved from the acute to the subacute phase (3 months), albeit remaining elevated in a significant proportion of subjects. Sleep parameters did not differ between the two patient groups but there was a general improvement of sleep from the acute to the subacute phase which was comparable for both patient groups. Although stroke severity was mild, recovery after 3 months was worse in patients with infratentorial stroke with 12 of 14 patients with supratentorial stroke being symptom free (NIHSS = 0), while this was the case for only 6 of 14 patients with infratentorial stroke. Conclusions: Patients with infratentorial lesions are at an increased risk for sleep-related breathing disorders, which are frequent in this group. Monitoring of sleep-related breathing is therefore especially recommended in patients with infratentorial stroke. Because of the absence of reliable differences in sleep parameters between the two patient groups, polygraphy, with reduced diagnostic costs, rather than polysomnography could be considered. The higher prevalence of sleep-related breathing disorders and the poorer recovery of patients with infratentorial lesions suggest that early treatment interventions should be considered.

Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial

IMPORTANCE International guidelines advocate a 7- to 14-day course of systemic glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the optimal dose and duration are unknown. OBJECTIVE To investigate whether a short-term (5 days) systemic glucocorticoid treatment in patients with COPD exacerbation is noninferior to conventional (14 days) treatment in clinical outcome and whether it decreases the exposure to steroids. DESIGN, SETTING, AND PATIENTS REDUCE: (Reduction in the Use of Corticosteroids in Exacerbated COPD), a randomized, noninferiority multicenter trial in 5 Swiss teaching hospitals, enrolling 314 patients presenting to the emergency department with acute COPD exacerbation, past or present smokers (≥20 pack-years) without a history of asthma, from March 2006 through February 2011. INTERVENTIONS Treatment with 40 mg of prednisone daily for either 5 or 14 days in a placebo-controlled, double-blind fashion. The predefined noninferiority criterion was an absolute increase in exacerbations of at most 15%, translating to a critical hazard ratio of 1.515 for a reference event rate of 50%. MAIN OUTCOME AND MEASURE Time to next exacerbation within 180 days. RESULTS Of 314 randomized patients, 289 (92%) of whom were admitted to the hospital, 311 were included in the intention-to-treat analysis and 296 in the per-protocol analysis. Hazard ratios for the short-term vs conventional treatment group were 0.95 (90% CI, 0.70 to 1.29; P = .006 for noninferiority) in the intention-to-treat analysis and 0.93 (90% CI, 0.68 to 1.26; P = .005 for noninferiority) in the per-protocol analysis, meeting our noninferiority criterion. In the short-term group, 56 patients (35.9%) reached the primary end point; 57 (36.8%) in the conventional group. Estimates of reexacerbation rates within 180 days were 37.2% (95% CI, 29.5% to 44.9%) in the short-term; 38.4% (95% CI, 30.6% to 46.3%) in the conventional, with a difference of -1.2% (95% CI, -12.2% to 9.8%) between the short-term and the conventional. Among patients with a reexacerbation, the median time to event was 43.5 days (interquartile range [IQR], 13 to 118) in the short-term and 29 days (IQR, 16 to 85) in the conventional. There was no difference between groups in time to death, the combined end point of exacerbation, death, or both and recovery of lung function. In the conventional group, mean cumulative prednisone dose was significantly higher (793 mg [95% CI, 710 to 876 mg] vs 379 mg [95% CI, 311 to 446 mg], P < .001), but treatment-associated adverse reactions, including hyperglycemia and hypertension, did not occur more frequently. CONCLUSIONS AND RELEVANCE In patients presenting to the emergency department with acute exacerbations of COPD, 5-day treatment with systemic glucocorticoids was noninferior to 14-day treatment with regard to reexacerbation within 6 months of follow-up but significantly reduced glucocorticoid exposure. These findings support the use of a 5-day glucocorticoid treatment in acute exacerbations of COPD. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN19646069.

Combined effects of heterogeneity, anisotropy, and saturation on steady state flow and transport: A laboratory sand tank experiment

Field soils show rather different spreading behavior at different water saturations, frequently caused by layering of the soil material. We performed tracer experiments in a laboratory sand tank. Such experiments complement and help comprehension of field investigations. We estimated, by image analysis, the first two moments of small plumes traveling through a two-dimensional, heterogeneous medium with strongly anisotropic correlation structure. Three steady state regimes were analyzed. Two main conclusions were drawn. First, low saturation led to very large heterogeneity and to strong preferential flow. Thus the description of the flow paths and the prediction of the solute arrival times require, in this case, more accurate knowledge about the topological structure. Second, saturation-dependent macroscopic anisotropy is an essential element of transport in unsaturated media. For this reason, small structural soil features should be properly upscaled to give appropriate effective soil parameters to be input in transport models.