Acquisitions thérapeutiques en médecine ambulatoire en 2013 [2013 literature findings in internal general medicine].

The prescribing of antibiotics for uncomplicated skin abscesses and diverticulitis has no benefit. Some antibiotics are more at risk of causing a Clostridium difficile infection. The tests used to exclude a history of a penicillin allergy are safe. A threshold of D-dimer adjusted for the age significantly improves the specificity of the test without affecting the sensitivity. The prescription of paraclinics tests is not an effective "treatment" for the patient's anxiety. In the sleep apnea syndrome, treatment with CPAP (Continuous positive airway pressure) appears to have more benefits compared to the mandibular advancement prosthesis. The work of primary care physicians can be supported by the work of advanced practice nurses. The limitation placed on the working hours of doctors in hospitals seems to affect their ability to spend time with their patients.

Outcome of severe unilateral cerebellar hypoplasia.

Aim: Complete or subtotal absence of one cerebellar hemisphere is exceptional; only single cases have been described. We aimed to assess the long-term outcome in children with severe unilateral cerebellar hypoplasia (UCH). Method: As part of a retrospective study we describe neuroimaging features, clinical findings, and cognitive outcomes of seven children with UCH (five males, two females; age at first magnetic resonance imaging [MRI]: median 1y 3mo, range 9d-8y 10mo; age at latest follow-up: median 6y 6mo, range 2y 3mo-14y 11mo). Results: One child had abnormalities on prenatal MRI at 21 weeks' gestation. The left cerebellar hemisphere was affected in five children, and the right hemisphere in two children. The vermis was involved in five children. The volume of the posterior fossa was variable. At the latest follow-up, neurological findings included truncal ataxia and muscular hypotonia in five children, limb ataxia in three patients, and head nodding in two patients. Three children had learning disability*, five had speech and language disorders, and one had a severe behavioural disorder. Interpretation: Severe UCH is a residual change after a disruptive prenatal cerebellar insult, most likely haemorrhagic. The outcome is variable, ranging from almost normal development to marked developmental impairment. Ataxia is a frequent but not a leading sign. It seems that involvement of the cerebellar vermis is often, but not consistently, associated with a poorer cognitive outcome, whereas an intact vermis is associated with normal outcome and no truncal ataxia.

Pin guidance of reconstruction plate contour: an expanded role of external fixation

This article presents a modification of intraoperative external fixation for mandibular reconstruction with free tissue flaps. This technique is indicated when preregistration of the reconstruction plate is not possible due to transmandibular tumor extension. Once standard external fixation has been carried out and prior to segmental mandibulectomy, additional pins are fixed to the connecting rod that delineate the mandibular contour in three-dimensional (3D) space. Following mandibulectomy, these pins allow accurate contouring of the reconstruction plate and improved restoration of mandibular contour, projection, and dental occlusion. A step-by-step description of the technique using models and intraoperative photos is presented. This method of mandibular reconstruction is a simple and time-effective alternative to intraoperative computer navigation and 3D modeling in select cases of oral carcinoma where tumor infiltration of the outer mandibular cortex precludes prebending of the reconstruction plates.

Quantitative morphometry analysis of the fetal brain using clinical MR imaging

In vivo fetal magnetic resonance imaging provides aunique approach for the study of early human braindevelopment [1]. In utero cerebral morphometry couldpotentially be used as a marker of the cerebralmaturation and help to distinguish between normal andabnormal development in ambiguous situations. However,this quantitative approach is a major challenge becauseof the movement of the fetus inside the amniotic cavity,the poor spatial resolution provided by very fast MRIsequences and the partial volume effect. Extensiveefforts are made to deal with the reconstruction ofhigh-resolution 3D fetal volumes based on severalacquisitions with lower resolution [2,3,4]. Frameworkswere developed for the segmentation of specific regionsof the fetal brain such as posterior fossa, brainstem orgerminal matrix [5,6], or for the entire brain tissue[7,8], applying the Expectation-Maximization MarkovRandom Field (EM-MRF) framework. However, many of theseprevious works focused on the young fetus (i.e. before 24weeks) and use anatomical atlas priors to segment thedifferent tissue or regions. As most of the gyraldevelopment takes place after the 24th week, acomprehensive and clinically meaningful study of thefetal brain should not dismiss the third trimester ofgestation. To cope with the rapidly changing appearanceof the developing brain, some authors proposed a dynamicatlas [8]. To our opinion, this approach however faces arisk of circularity: each brain will be analyzed /deformed using the template of its biological age,potentially biasing the effective developmental delay.Here, we expand our previous work [9] to proposepost-processing pipeline without prior that allow acomprehensive set of morphometric measurement devoted toclinical application. Data set & Methods: Prenatal MRimaging was performed with a 1-T system (GE MedicalSystems, Milwaukee) using single shot fast spin echo(ssFSE) sequences (TR 7000 ms, TE 180 ms, FOV 40 x 40 cm,slice thickness 5.4mm, in plane spatial resolution1.09mm). For each fetus, 6 axial volumes shifted by 1 mmwere acquired under motherâeuro?s sedation (about 1min pervolume). First, each volume is segmentedsemi-automatically using region-growing algorithms toextract fetal brain from surrounding maternal tissues.Inhomogeneity intensity correction [10] and linearintensity normalization are then performed. Brain tissues(CSF, GM and WM) are then segmented based on thelow-resolution volumes as presented in [9]. Ahigh-resolution image with isotropic voxel size of 1.09mm is created as proposed in [2] and using B-splines forthe scattered data interpolation [11]. Basal gangliasegmentation is performed using a levet setimplementation on the high-resolution volume [12]. Theresulting white matter image is then binarized and givenas an input in FreeSurfer software(http://surfer.nmr.mgh.harvard.edu) to providetopologically accurate three-dimensional reconstructionsof the fetal brain according to the local intensitygradient. References: [1] Guibaud, Prenatal Diagnosis29(4) (2009). [2] Rousseau, Acad. Rad. 13(9), 2006. [3]Jiang, IEEE TMI 2007. [4] Warfield IADB, MICCAI 2009. [5]Claude, IEEE Trans. Bio. Eng. 51(4) 2004. [6] Habas,MICCAI 2008. [7] Bertelsen, ISMRM 2009. [8] Habas,Neuroimage 53(2) 2010. [9] Bach Cuadra, IADB, MICCAI2009. [10] Styner, IEEE TMI 19(39 (2000). [11] Lee, IEEETrans. Visual. And Comp. Graph. 3(3), 1997. [12] BachCuadra, ISMRM 2010.

Multisystem Langerhans' cell histiocytosis (Hand-Schüller-Christian disease) in an adult: a case report and review of the literature.

Langerhans' cell histiocytosis (LCH) is a rare and enigmatic clonal disorder that affects mainly children. It is characterized by single or multiple granulomatous mass lesions composed of cells with the Langerhans' cell phenotype. Clinical presentation and behavior are heterogeneous and can range from a solitary lytic bone lesion (i.e., eosinophilic granuloma) with a favorable course to a fatal disseminated leukaemia-like form, with a wide spectrum of intermediate clinical presentations between these two extremes. Although LCH typically involves the bone, lesions can be found in almost all organs. We are reporting the case of a multisystem LCH in a 47-year-old patient who presented with a panhypopituitarism and diabetes insipidus, and who, 5 years later, developed mandibular, mastoid and femoral lesions. The final diagnosis of LCH was made on mandibular biopsy.

Early diagnosis of osteoporosis by means of orthopantomograms and oral x-rays: a systematic review

Osteoporosis is a systemic bone disease that is characterized by a generalized reduction of the bone mass. It is the main cause of fractures in elderly women. Bone densitometry is used in the lumbar spine and hip in order to detect osteoporosis in its early stages. Different studies have observed a correlation between the bone mineral density of the jaw (BMD) and that of the lumbar spine and/or hip. On the other hand, there are studies that evaluate the findings in the orthopantomograms and perapical X-rays, correlating them with the early diagnosis of osteoporosis and highlighting the role of the dentist in the early diagnosis of this disease. Materials and methods: A search was carried out in the Medline-Pubmed database in order to identify those articles that deal with the association between the X-ray findings observed in the orthopantomograms and the diagnosis of the osteoporosis, as well as those that deal with the bone mineral density of the jaw. Results: There were 406 articles, and with the limits established, this number was reduced to 21. Almost all of the articles indicate that when examining oral X-rays, it is possible to detect signs indicative of osteoporosis. Discussion: The radiomorphometric indices use measurements in orthopantomograms and evaluate possible loss of bone mineral density. They can be analyzed alone or along with the visual indices. In the periapical X-rays, the photodensimetric analyses and the trabecular pattern appear to be the most useful. There are seven studies that analyze the densitometry of the jaw, but only three do so independently of the photodensitometric analysis. Conclusions: The combination of mandibular indices, along with surveys on the risk of fracture, can be useful as indicators of early diagnosis of osteoporosis. Visual and morphometric indices appear to be especially important in the orthopantomograms. Photodensitometry indices and the trabecular pattern are used in periapical X-rays. Studies on mandibular dual-energy X-ray absorptiometry are inconclusive

Assessment of glenoid inclination on routine clinical radiographs and computed tomography examinations of the shoulder.

BACKGROUND: Accurate assessment of glenoid inclination is of interest for a variety of conditions and procedures. The purpose of this study was to develop an accurate and reproducible measurement for glenoid inclination on standardized anterior-posterior (AP) radiographs and on computed tomography (CT) images. MATERIALS AND METHODS: Three consistently identifiable angles were defined: Angle α by line AB connecting the superior and inferior glenoid tubercle (glenoid fossa) and the line identifying the scapular spine; angle β by line AB and the floor of the supraspinatus fossa; angle γ by line AB and the lateral margin of the scapula. Experimental study: these 3 angles were measured in function of the scapular position to test their resistance to rotation. Conventional AP radiographs and CT scans were acquired in extension/flexion and internal/external rotation in a range up to ±40°. Clinical study: the inter-rater reliability of all angles was assessed on AP radiographs and CT scans of 60 patients (30 with proximal humeral fractures, 30 with osteoarthritis) by 2 independent observers. RESULTS: The experimental study showed that angle α and β have a resistance to rotation of up to ±20°. The deviation from neutral position was not more than ±10°. The results for the inter-rater reliability analyzed by Bland-Altman plots for the angle β fracture group were (mean ± standard deviation) -0.1 ± 4.2 for radiographs and -0.3 ± 3.3 for CT scans; and for the osteoarthritis group were -1.2 ± 3.8 for radiographs and -3.0 ± 3.6 for CT scans. CONCLUSION: Angle β is the most reproducible measurement for glenoid inclination on conventional AP radiographs, providing a resistance to positional variability of the scapula and a good inter-rater reliability.

Comportamento do pessegueiro (Prunus persica L. Batsch) cv. Chimarrita em diferentes sistemas de condução

A persicultura, no Brasil, é praticada há bastante tempo, porém poucos estudos foram realizados visando alternativas de manejo nos pomares para aumento de produtividade. Este trabalho teve por objetivo avaliar o desenvolvimento anual do diâmetro do tronco e produção nos terceiro e quarto anos, em pessegueiro cv. Chimarrita, enxertado sobre o porta-enxerto Capdeboscq. Foram avaliados quatro sistemas de condução: I - espaçamento de 0,5 m entre plantas, conduzido em 'Áxis colunar'; II e III - 1,0 m e 2,0 m, respectivamente, conduzidos em 'Y' e IV - 4,0 m em 'Vaso' (sistema tradicional). Entre as linhas de plantio o espaçamento foi constante de 5,0 m para todos os sistemas de condução. O pomar foi implantado em julho de 1997 na Fazenda experimental do Centro Agropecuário da Palma, propriedade da Universidade Federal de Pelotas, localizada no município de Capão do Leão, RS. Avaliou-se a taxa de crescimento anual do diâmetro do tronco, produtividade, qualidade físico-química das frutas e ocorrência de podridão parda. Os resultados obtidos na taxa de crescimento foram semelhantes em ambos os anos, porém observou-se maior incremento relativo no período 2000/2001, no sistema de condução I. A produtividade foi superior no sistema I e II diferindo do sistema IV, no entanto, a qualidade físico-química e a ocorrência de podridão parda foram semelhantes em todos os sistemas.

Klammt's elastic open activator: Ricketts' cephalometrics results

The purpose of this study is to investigate the orthodontic and orthopaedic real effects of the Klammt's Elastic Open Activator (EOA) in 25 Class II Division 1 patients in growing period. We wanted to determine statistically the cephalometrics changes produced in the patients, comparing the lateral cranium teleradiographies we took for the diagnosis with the ones we took at the end of treatment. At the end of this study we confirm that by using the EOA we obtained the desired effects, especially reducing the molar relation 2.53 mm and the overjet 2.56 mm. The EOA corrected the inclination and protrusion of incisors, although we cannot avoid the use of fixed appliances to round off. The reduction of 2.48 mm of facial convexity stands out as the most important skeletal effect; the facial depth angle increases 0.8 degree, and the maxillary depth decreases 1.16 degrees. The length of the mandibular corpus also increases 6.7 mm, although this change is mainly due to the growth of the patient. The changes in the aesthetic profile do not stand out

Different locations of dermoid cysts in the orbital region.

BACKGROUND: Dermoid cysts are frequent unilateral congenital benign tumors that can be found at different locations throughout the body. In the orbital region, dermoid cysts occur predominantly in the supero-temporal quadrant. However, different orbital locations are possible, making this entity an important differential diagnosis for orbital tumors. PATIENTS AND METHODS: We retrospectively reviewed the charts of 23 consecutive patients operated in our institution between 2005 and 2014 for orbital tumors that were diagnosed as congenital dermoid or epidermoid cysts. RESULTS: There were 21 dermoid and 2 epidermoid cysts. The median age at surgery time was 7 years (range 1-41). There were 15 females and 8 males. Eleven cysts were located supero-temporally (47.8%), seven supero-medially (30.4%), two temporally (8.7%), one at the frontal bone (4.4%) and two in the fossa of the lacrimal gland (8.7%). The mean cyst diameter was 13.1 mm±5.0 (SD). None had signs of malignant disease. No recurrence was observed after complete excision. CONCLUSION: Dermoid cysts of orbital region are mostly located in the supero-temporal quadrant. However, other orbital locations are possible and dermoid cysts must thus be considered in the differential diagnosis of any mass in the orbital region.

Multiple Myeloma with primary manifestation in the mandible: a case report

Multiple myeloma is a monoclonal malignant proliferation of plasma cells that causes osteolytic lesions in the vertebrae, ribs, pelvic bone, skull and jaw. We report on a clinical case of an 81-year-old male patient who presented with a tumefaction in the mandibular symphysis region, which had evolved over the previous seven months. In the radiographic examination, an extensive osteolytic lesion was observed in the region mentioned above. An incisional biopsy was performed and a histopathological study revealed a malignant hematopoietic neoplasm formed by plasmacytoid cells. During the bone gammagraphy a dissemination of the disease was detected in the scapula, clavicle and ribs. The diagnosis was multiple myeloma. Knowledge about the maxillofacial manifestations of multiple myeloma is important for the early diagnosis of the disease, since its primary form can manifest itself in the jaw. In the clinical case presented here, we highlight the interdisciplinarity needed to obtain a diagnosis and treatment of multiple myeloma

Nasoangiofibroma juvenil: concordância interobservadores no estadiamento por tomografia computadorizada

Com o advento da tomografia computadorizada, a avaliação dos locais de acometimento e extensão do nasoangiofibroma juvenil tornou-se mais precisa, o que facilitou o correto estadiamento pré-operatório. O objetivo deste trabalho é avaliar a concordância interobservadores, por meio da análise por tomografia computadorizada, de 15 casos de nasoangiofibroma juvenil em relação à extensão para locais relacionados com altos índices de recidivas. Todos os pacientes eram do sexo masculino, com idade média de 15,8 anos. A análise da concordância entre os observadores quanto à extensão e envolvimento da fossa infratemporal, seios esfenóide e cavernoso e fossa craniana média foi excelente, em relação à fissura orbitária superior foi boa e em relação à base do processo pterigóide e fossa craniana anterior foi ruim. Concluiu-se que a análise apresenta alta concordância entre os observadores para os locais estabelecidos, com exceção da base do processo pterigóide e da fossa craniana anterior.

Changes of Root Length and Root-to-Crown Ratio after Apical Surgery: An Analysis by Using Cone-beam Computed Tomography.

INTRODUCTION: Apical surgery is an important treatment option for teeth with post-treatment periodontitis. Although apical surgery involves root-end resection, no morphometric data are yet available about root-end resection and its impact on the root-to-crown ratio (RCR). The present study assessed the length of apicectomy and calculated the loss of root length and changes of RCR after apical surgery. METHODS: In a prospective clinical study, cone-beam computed tomography scans were taken preoperatively and postoperatively. From these images, the crown and root lengths of 61 roots (54 teeth in 47 patients) were measured before and after apical surgery. Data were collected relative to the cementoenamel junction (CEJ) as well as to the crestal bone level (CBL). One observer took all measurements twice (to calculate the intraobserver variability), and the means were used for further analysis. The following parameters were assessed for all treated teeth as well as for specific tooth groups: length of root-end resection and percentage change of root length, preoperative and postoperative RCRs, and percentage change of RCR after apical surgery. RESULTS: The mean length of root-end resection was 3.58 ± 1.43 mm (relative to the CBL). This amounted to a loss of 33.2% of clinical and 26% of anatomic root length. There was an overall significant difference between the tooth groups (P < .05). There was also a statistically significant difference comparing mandibular and maxillary teeth (P < .05), but not for incisors/canines versus premolars/molars (P = .125). The mean preoperative and postoperative RCRs (relative to CEJ) were 1.83 and 1.35, respectively (P < .001). With regard to the CBL reference, the mean preoperative and postoperative RCRs were 1.08 and 0.71 (CBL), respectively (P < .001). The calculated changes of RCR after apical surgery were 24.8% relative to CEJ and 33.3% relative to CBL (P < .001). Across the different tooth groups, the mean RCR was not significantly different (P = .244 for CEJ and 0.114 for CBL). CONCLUSIONS: This CBCT-based study demonstrated that the RCR is significantly changed after root-end resection in apical surgery irrespective of the clinical (CBL) or anatomic (CEJ) reference levels. The lowest, and thus clinically most critical, postoperative RCR was observed in maxillary incisors. Future clinical studies need to show the impact of resection length and RCR changes on the outcome of apical surgery.

Estudo da drenagem linfática e eficácia da tomografia computadorizada na detecção de metástases linfonodais em pacientes clinicamente N0 com carcinoma espinocelular de boca e orofaringe

O exame clínico não é suficiente para avaliar, com precisão, o envolvimento linfonodal em carcinomas de boca e orofaringe. Avaliamos 21 pacientes portadores de carcinoma espinocelular de boca e orofaringe, estadiados clinicamente como N0. Em todos os pacientes foi feita tomografia computadorizada de face e pescoço, e linfocintilografia. A sensibilidade e a especificidade da tomografia computadorizada foram de 16% e 73% para o lado homolateral, e 0% e 90% para o contralateral, respectivamente. Drenagem linfática foi vista em 76,2% dos casos. A não-migração ocorreu em casos de difícil injeção do radiofármaco, como fossa amigdaliana e região retromolar. A migração bilateral ocorreu apenas em casos de soalho bucal, em que havia envolvimento da linha mediana. A partir desses resultados conclui-se que a tomografia computadorizada foi menos eficiente que o exame clínico. Porém, o tomógrafo utilizado foi o não-helicoidal e, portanto, a eficácia do tomógrafo helicoidal não foi avaliada. A linfocintilografia foi útil na avaliação de pacientes clinicamente N0 e estamos utilizando o método para avaliar linfonodo sentinela nos carcinomas de boca.

Short-Term Heparin Kinetics during Catheter Ablation of Atrial Fibrillation.

BACKGROUND: Percutaneous catheter ablation of atrial fibrillation (CA-AF) is a treatment option for symptomatic drug-refractory atrial fibrillation (AF). CA-AF carries a risk for thromboembolic complications that has been minimized by the use of intraprocedural intravenous unfractionated heparin (UFH). The optimal administration of UFH as well as its kinetics are not well established and need to be precisely determined. METHODS AND RESULTS: A total 102 of consecutive patients suffering from symptomatic drug-refractory AF underwent CA-AF. The mean age was 61 ± 10 years old. After transseptal puncture of the fossa ovalis, weight-adjusted UFH bolus (100 U/kg) was infused. A significant increase in activated clotting time (ACT) was observed from an average value of 100 ± 27 seconds at baseline, to 355 ± 94 seconds at 10 min (T10), to 375 ± 90 seconds at 20 min (T20). Twenty-four patients failed to reach the targeted ACT value of ≥300 seconds at T10 and more than half of these remained with subtherapeutic ACT values at T20. This subset of patients showed similar clinical characteristics and amount of UFH but were more frequently prescribed preprocedural vitamin K1 than the rest of the study population. CONCLUSIONS: In a typical intervention setting, UFH displays unexpected slow anticoagulation kinetics in a significant proportion of procedures up to 20 minutes after infusion. These findings support the infusion of UFH before transseptal puncture or any left-sided catheterization with early ACT measurements to identify patients with delayed kinetics. They are in line with recent guidelines to perform CA-AF under therapeutic anticoagulation.