A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia

Objective Severe pulmonary hypoplasia and pulmonary arterial hypertension are associated with reduced survival in congenital diaphragmatic hernia (CDH). We aimed to determine whether fetal endoscopic tracheal occlusion (FETO) improves survival in cases of severe isolated CDH. Methods Between May 2008 and July 2010, patients whose fetuses had severe isolated CDH (lung-to-head ratio < 1.0, liver herniation into the thoracic cavity and no other detectable anomalies) were assigned randomly to FETO or to no fetal intervention (controls). FETO was performed under maternal epidural anesthesia supplemented with fetal intramuscular anesthesia. Tracheal balloon placement was achieved with ultrasound guidance and fetoscopy between 26 and 30 weeks of gestation. All cases that underwent FETO were delivered by the EXIT procedure. Postnatal therapy was the same for both treated fetuses and controls. The primary outcome was survival to 6 months of age. Other maternal and neonatal outcomes were also evaluated. Results Twenty patients were enrolled randomly to FETO and 21 patients to standard postnatal management. The mean gestational age at randomization was similar in both groups (P = 0.83). Delivery occurred at 35.6 +/- 2.4 weeks in the FETO group and at 37.4 +/- 1.9 weeks in the controls (P < 0.01). In the intention-to-treat analysis, 10/20 (50.0%) infants in the FETO group survived, while 1/21 (4.8%) controls survived (relative risk (RR), 10.5 (95% CI, 1.5-74.7), P < 0.01). In the receivedtreatment analysis, 10/19 (52.6%) infants in the FETO group and 1/19 (5.3%) controls survived (RR, 10.0 (95% CI, 1.4-70.6) P < 0.01). Conclusion FETO improves neonatal survival in cases with isolated severe CDH. Copyright (C) 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Relationship Between Occlusion and Lisping in Children With Cleft Lip and Palate

Introduction: The literature suggests that individuals with history of cleft lip and palate who present with midfacial growth deficiency are at higher risk of presenting lisping. The relationship between distortions during production of linguoalveolar fricative sounds and the severity of malocclusion, however, has not been established for the population with cleft. Objective: To study the association between lisping and dental arch relationship. Methodology: Speech samples and dental arch casts were obtained from 106 children with operated unilateral cleft lip and palate (UCLP) during the stage of mixed dentition and before orthodontic treatment. Videotaped productions of the phrase/u saci saiw sedu/were rated by speech-language pathologists for the identification of lisping during [s]. Dental arch casts were rated by orthodontists using the Goslon Yardstick and the Five-Year Index to establish dental arch relationship. Results: Multiple logistic regression showed no significant association between lisping and dento-occlusal index (p = .802) and age (p = .662). Substantial interjudge agreement during auditory-perceptual ratings was found (kappa = .63). Almost perfect agreement was found between orthodontists while establishing the dental arch relationship (kappa = .81). Discussion: This study failed to reveal an association between lisping and dental arch relationship in children with operated UCLP. Multiple variables may play a role in determining occurrence of lisping, warranting further investigation.

Correlation between maxillary central incisor crown morphology and mandibular dental arch form in normal occlusion subjects

The aim of this study was to evaluate the correlation between the morphology of the mandibular dental arch and the maxillary central incisor crown. Cast models from 51 Caucasian individuals, older than 15 years, with optimal occlusion, no previous orthodontic treatment, featuring 4 of the 6 keys to normal occlusion by Andrews (the first being mandatory) were observed. The models were digitalized using a 3D scanner, and images of the maxillary central incisor and mandibular dental arch were obtained. These were printed and placed in an album below pre-set models of arches and dental crowns, and distributed to 12 dental surgeons, who were asked to choose which shape was most in accordance with the models and crown presented. The Kappa test was performed to evaluate the concordance among evaluators while the chi-square test was used to verify the association between the dental arch and central incisor morphology, at a 5% significance level. The Kappa test showed moderate agreement among evaluators for both variables of this study, and the chi-square test showed no significant association between tooth shape and mandibular dental arch morphology. It may be concluded that the use of arch morphology as a diagnostic method to determine the shape of the maxillary central incisor is not appropriate. Further research is necessary to assess tooth shape using a stricter scientific basis.

Reestablishment of occlusion through overlay removable partial dentures: a case report

Loss of posterior teeth may cause an imbalance in the stomatognathic system. Overlay removable partial dentures (ORPD) are a reversible and relatively inexpensive treatment for patients with severely worn teeth. This paper presents a treatment with ORPD in a 55-year-old male patient who had severe attrition in the maxillary and mandibular teeth, temporomandibular joint pain and reduced vertical dimension of occlusion (VDO). The treatment consisted in the reestablishment of the VDO using Lucia’s jig, fabricating removable partial denture with reconstruction of the worn teeth without preparation. This therapy can be used as an alternative treatment to provide esthetic, function and stable occlusion in patients with severely worn teeth.

Evaluation of the dental arch asymmetry in natural normal occlusion and Class II malocclusion individuals

OBJECTIVE: To verify the presence and degree of asymmetry of dental arches in Brazilian individuals with natural normal occlusion and Class II, Divisions 1 and 2 malocclusions. METHODS: The study evaluated the symmetry of the maxillary and mandibular dental arches of 180 pairs of dental casts, divided into: Group I = 60 pairs of natural normal occlusion individuals; Group II = 60 pairs of Class II, Division 1 malocclusion individuals; and Group III = 60 pairs of Class II, Division 2 malocclusion individuals. A device was used to measure dental midline deviation and the canine tip in the dental arches (in degrees). It was also verified the distance of the upper canines from the palatal suture, intercanine distance, and anteroposterior upper and lower first molar position. RESULTS: Dental arches of individuals from all groups presented asymmetry, regardless of the presence of malocclusion. Group I showed a lower asymmetry degree in relation to Groups II and III. The asymmetry in Groups II and III was similar. CONCLUSION: The dental arches of individuals with natural normal occlusion and with Class II, Division 1 and Division 2 malocclusions showed asymmetry. The asymmetry degree was higher in the mandibular dental arches than in the maxillary dental arches in all 3 evaluated groups.

Influence of palatoplasty on occlusion of patients with isolated cleft palate

OBJECTIVE: This study compared the dental arch morphology of adult patients with isolated cleft palate in order to verify the influence of palatoplasty on occlusion. METHODS: Cast models of 77 patients, 30 males and 47 females, with an average age of 21 years and no syndromes were taken. They were in the permanent dentition and had not undergone orthodontic treatment. The sample was divided into non-operated and operated patients, the latter having been submitted to palatoplasty at a mean age of 2.2 years. RESULTS: Almost 80% of the sample exhibited sagittal discrepancies in the inter-arch relationship, with a Class II malocclusion prevailing (59.74%) followed by Class III (20,78%), regardless of palatoplasty. Transverse analysis showed a 23% incidence of posterior crossbite also not influenced by palatoplasty. Intra-arch relationship indicated that constriction and crowding on the upper arch were more frequent in the operated group (p=0.0238 and p=0.0002, respectively), showing an influence of palatoplasty on its morphology. The predominant morphological characteristics in patients with isolated cleft palate were a Class II malocclusion, upper dental arch constriction and upper and lower anterior crowding. CONCLUSION: The influence of palatoplasty was restricted to constriction and crowding of the upper dental arch, with no interference from the extension of the cleft, except for the upper crowding, which occurred more in patients with complete cleft palates.

An indicator of sudden cardiac death during brief coronary occlusion: electrocardiogram QT time and the role of collaterals

The coronary collateral circulation has a beneficial role regarding all-cause and cardiac mortality. Hitherto, the underlying mechanism has not been clarified. The aim of this prospective study was to assess the effect of the coronary collateral circulation on electrocardiogram (ECG) QTc time change during short-term myocardial ischaemia.

In Vivo Evaluation of the Phenox CRC Mechanical Thrombectomy Device in a Swine Model of Acute Vessel Occlusion

Mechanical thrombectomy in ischemic stroke is of increasing interest as it is a promising strategy for fast and efficient recanalization. Several thrombectomy devices have been introduced to the armentarium of mechanical thrombectomy. Currently, new devices are under development and are continuously added to the neurointerventional tool box. Each device advocated so far has a different design and mechanical properties in terms of thrombus-device interaction. Therefore, a systematic evaluation under standardized conditions in vivo of these new devices is needed. The purpose of this study was to evaluate the efficiency, thrombus-device interaction, and potential complications of the novel Phenox CRC for distal mechanical thrombectomy in vivo. The device was evaluated in an established animal model in the swine. Recanalization rate, thromboembolic events, vasospasm, and complications were assessed. Radiopaque thrombi (2 cm length) were used for the visualization of thrombus-device interaction during retrieval. The Phenox CRC (4 mm diameter) was assessed in 15 vessel occlusions. For every occlusion a maximum of 3 retrieval attempts were performed. Complete recanalization (TICI 3/TIMI 3) was achieved in 86.7% of vessel occlusions. In 66.7% (10/15), the first retrieval attempt was successful, and in 20% (3/15), the second attempt led to complete recanalization of the parent artery. In 2 cases (13.3%) thrombus retrieval was not successful (TICI 0/TIMI 0). In 1 case (6.7%) a minor embolic event occurred in a small side branch. No distal thromboembolic event was observed during the study. Thrombus-device interaction illustrated the entrapment of the thrombus by the microfilaments and the proximal cage of the device. No significant thrombus compression was observed. No vessel perforation, dissection, or fracture of the device occurred. In this small animal study, the Phenox CRC was a safe and effective device for mechanical thrombectomy. The unique design with a combination of microfilaments and proximal cage reduces thrombus compression with a consequently high recanalization and low complication rate.

The Benefits of Intravenous Thrombolysis Relate to the Site of Baseline Arterial Occlusion in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET)

In ischemic stroke, the site of arterial obstruction has been shown to influence recanalization and clinical outcomes. However, this has not been studied in randomized controlled trials, nor has the impact of arterial obstruction site on reperfusion and infarct growth been assessed. We studied the influence of site and degree of arterial obstruction patients enrolled in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET).

Intravenous thrombolysis in patients with stroke attributable to small artery occlusion

Intravenous thrombolysis (IVT) for stroke seems to be beneficial independent of the underlying etiology. Recent observations raised concern that IVT might cause harm in patients with strokes attributable to small artery occlusion (SAO).

Preliminary experimental evaluation of the immediate angiographic occlusion time with use of the AMPLATZER vascular plug II for carotid artery occlusion

Delayed occlusion time in parent artery occlusion of brain-supplying vessels might carry risk for thromboembolic complications. Vascular plug devices are successfully used in cardiopulmonary and peripheral interventions to occlude high-flow lesions and have been adapted for use in neurointerventions. The purpose of the present study was to experimentally evaluate the immediate occlusion time of the AMPLATZER vascular plug (AVP) II-a second-generation cylindrical, self-expandable, resheathable nitinol wire mesh consisting of three lobes-in the carotid artery.

Acute basilar artery occlusion in the Basilar Artery International Cooperation Study: does gender matter?

Randomized trials suggested a different benefit of intravenous thrombolysis (IVT) and intra-arterial thrombolysis (IAT) between men and women with anterior circulation stroke because of a worse outcome of women in the control group.

Safety of diagnostic balloon occlusion in normal coronary arteries

Diagnostic coronary balloon occlusion (CBO) is mandatory for collateral function assessment, during angioscopy and optical coherence imaging, and when using certain coronary protection devices against emboli. Thus far, the safety of diagnostic CBO regarding procedural and long-term complications in normal coronary arteries has not been studied. In 316 patients, diagnostic CBO was performed for collateral function measurement in 426 angiographically normal vessels. The angioplasty balloon was inflated for 60 to 120 seconds using inflation pressures of 1 to 3 atm, followed by control angiography during and after CBO. Patients were divided into groups with entirely normal (n = 133) and partially normal (n = 183) vessels. Primary end points were procedural and long-term complications. De novo stenosis development was assessed by quantitative coronary angiography in 35% of the patients. Secondary end points were cardiac events at 5 years of follow-up. Procedural complications occurred in 1 patient (0.2%). In 150 repeat angiographic procedures in 92 patients (follow-up duration 10 +/- 15 months), quantitative coronary angiography revealed no difference in percentage diameter narrowing between baseline and follow-up (4.1% vs 3.9%, p = 0.69). During follow-up periods of 14 and 72 months, respectively, a new stenotic lesion was detected in 1 patient in each group (1.3%). Major cardiac events and percutaneous coronary intervention for stable angina were less frequent in the group with entirely normal than with partially normal vessels (0.8% vs 5.5%, p = 0.02, and 0.8% vs 18%, p <0.0001). In conclusion, low-inflation pressure diagnostic CBO in angiographically normal coronary arteries bears a minimal risk for procedural and long-term complications and can therefore be regarded as a safe procedure.

Sudden cardiac arrest during acute coronary occlusion - who is at risk?

Many people with acute myocardial infarction die from sudden cardiac arrest before reaching the hospital. The current clinical understanding of the mechanisms and risk factors surrounding sudden cardiac death is limited. However, 2 factors related to sudden death, namely the occluded coronary vessel (right coronary, left circumflex, or left anterior descending artery) and the extent of collateral circulation, are of potential relevance. Recent data suggest that the risk differs between the different coronary arteries and that coronary collateral circulation seems to have an important protective 'antiarrhythmic' effect. This editorial will address possible mechanisms and potential implications in clinical practice.

Three-Month and Long-Term Outcomes and Their Predictors in Acute Basilar Artery Occlusion Treated With Intra-Arterial Thrombolysis

Intra-arterial thrombolysis can be used for treatment of basilar artery occlusion. Predictors of outcome before initiation of treatment are of special interest.