Class III camouflage orthodontic treatment in adult patient with anterior crossbite and abnormal functional shift: A case report

@#Skeletal Class III malocclusion is a complex malformation with a prevalence of 81.6% in Airlangga University Dental Hospital, distributed in patients aged 15-45 years old. Camouflage treatment of skeletal Class III malocclusion improves prognosis with a mild-to-moderate shift. This study aimed to discuss orthodontic camouflage as an option for adult patients with Class III malocclusion, emphasizing its indications, implications, and expected results. This report presents the case of a 17-year-old male patient with poor facial aesthetics associated with protruded chin, abnormal functional shift, and temporomandibular joint pain. The facial profile was concave with lower anterior multiple diastemas, mandibular lip protrusion, mandibular displacement, and anterior crossbite. This case was treated by camouflage therapy using straight wire appliance system combined with elastic class III. After 24 months of treatment during the pandemic, the mandibular displacement and the crossbite were corrected, the teeth were arched, the anterior crossbite fixed, and the profile became convex. Camouflage orthodontic treatment can be an effective management option to achieve functional occlusion, stability, and a satisfactory aesthetic impression in adult patients with mild to moderate skeletal Class III deformities, anterior cross bite, and functional shift.

The effect of maxilla impacted canine positions on root resorption of adjacent teeth using cone-beam computed tomography imaging

Objective@#To determine the effect of the impacted position of the maxillary canine on the root resorption of the adjacent incisor using Cone-beam Computed Tomography (CBCT) imaging. @*Methods@#This was an analytic quantitative study. The research sample determined CBCT images of treatment patients at the Orthodontic Specialist Policlinic in Dental Hospital of Airlangga University over a three-year period and secondary data taken from Pramita Laboratory. CBCT photos that met the inclusion criteria, including mesially impacted canine or close to central or lateral incisors with completely formed anatomy were then analyzed. Multiple linear regression was used to determine x-axis, y-axis, z-axis position of the impacted canine on the severity of root resorption of the adjacent incisor, and the effect of impacted canines on all axes simultaneously on the severity of root resorption of the adjacent incisors. @*Results@#The position of the impacted canine in the x-axis and z-axis planes had a significant influence on the root resorption of the adjacent incisor. Meanwhile, impacted canine from the y-axis plane showed non-significant influence on the root resorption. @*Conclusion@#The position of the impacted canine when viewed in all planes of the tooth axis has a significant effect on the severity of root resorption of the adjacent incisor

Non-extraction orthodontic treatment in angle class I malocclusion with severe crowding, deep bite, and midline shifting: A case report

@#Crowding is the most common dental case worldwide. This case report describes the diagnosis and management of a 20-year-old woman with severe crowding, deep bite, and midline shifting. The patient presented with the chief complaint of crowding and an unaesthetic smile. Upon examination, the patient had Angle Class I Malocclusion. The severe crowding was treated comprehensively and successfully corrected using fixed orthodontic appliances and without extraction, only interproximal reduction (IPR).

Non-extraction treatment of class II division 2 malocclusion with cover bite: A case report

@#Increased overbite has always been a challenging orthodontic problem in treating most periodontal-associated problems. This case report described the management of a class II division 2 malocclusion with cover bite without extraction. A 19-year-old female patient came with a chief complaint of irregularities on the anterior teeth. A fixed appliance was placed without extraction. The patient was instructed to use intermaxillary elastic band class II to correct the canine and molar relation. Treatment time was 16 months. A class I canine and molar relation with good interdigitation was achieved. The treatment of class II division 2 malocclusion without extraction in the adult patient showed promising results.

Comparison of trabecular bone in impacted and normal erupted unilateral maxillary canine teeth using cone-beam computed tomography in patients scheduled for orthodontic treatment at the Universitas Airlangga Dental and Oral Hospital

Background@#Cone-beam computed tomography is being utilized in more clinical contexts and determining bone density with this method is becoming more important. Dentists, particularly dentomaxillofacial radiologists, orthodontists, and oral surgeons, must have a solid understanding of gray value. The gray values acquired from conebeam computed tomography images are used to assess dental implant bone density, diagnose dental ankylosis, and diagnose and differentiate pathological lesions.@*Objective@#To determine the difference in the gray value of the trabecular bone in the impacted and normal erupted maxillary canine teeth using cone computed tomography.@*Methods@#We retrospectively evaluated the cone-beam computed tomography images of patients scheduled for orthodontic treatment at the Universitas Airlangga Dental and Oral Hospital. On cross-sectional cone-beam computed tomography images, the region of interest determination of 5 mm2 in the area was placed in the trabecular bone and the gray value measurements were collected using Digital Imaging and Communications in Medicine (OnDemand3D™) dental software. The images were categorized by type of impacted canine teeth after assessing the gray values of all the teeth. Using images on the mesial, distal, buccal, and palatal areas, gray values of impacted and non-impacted teeth were compared. We used the SPSS 24 software.@*Results@#From a total of 13 patient radiographs, we found types I (6/13), II (6/13), and VII (1/13). The mean pixel values of impacted maxillary unilateral canine teeth were 1972.92 (mesial), 2016.55 (distal), 1990.66 (buccal), and 1904.39 (palatal). The mean pixel values of normal erupted maxillary canines were 1754.93 (mesial), 1710.53 (distal), 1852.94 (buccal), and 1674.49 (palatal). There were significant differences between impacted and normal erupted maxillary canines: mesial (P = 0.018), distal (P = 0.000), buccal (P = 0.003), and palatal (P = 0.036).@*Conclusion@#There were statistically significant differences between affected and unaffected gray values in the canines in FOV size 51 × 55 mm. However, no statistically significant differences were found in the gray values in trabecular bone of unilateral maxillary impacted canines and normal erupted canines on the mesial, distal, buccal, and palatal sides.

Treatment of a patient with class I malocclusion with moderate crowding and missing first molar: A case report

@#The most common occlusal feature of Class I malocclusion is crowding. Crowded and irregular teeth occur in a majority of the population and are the most common complication in adults. This is a case report of a 21-year-old woman with moderate crowding and a missing lower left first molar. The first permanent molars are sometimes unnoticed by the child or their parents and bring a risk of caries to the first permanent molar. Caries in the first molars that persist without any treatment will give a poor prognosis. Treatment was performed using a fixed orthodontic appliance with the extraction of the two upper and one lower first premolars.

Multidisciplinary treatment of Class I Angle Malocclusion with severe crowding and peg lateral incisor: A case report

@#Class I malocclusions with severe crowding and tooth size discrepancies may be successfully treated orthodontically with extraction therapy, and co-management with other specialists. Correction of the discrepancies will optimize occlusal result (overjet, overbite, midline shift, and smile esthetics). This is a case of a 19-year-old male with severe crowding in upper and lower teeth and peg lateral incisor. The patient had malocclusion Class I. This case was treated comprehensively and successfully using fixed orthodontic appliances with extraction of four premolars, and veneer composite for peg lateral incisor with the help of a conservative dentist at the end of orthodontic treatment.

Indian Academy of Pediatrics Guidelines on Screen Time and Digital Wellness in Infants, Children and Adolescents

Justification: Screen-based media have become an important part of human lifestyle. In view of their easy availability and increasing use in Indian children, and their excessive use being linked to physical, developmental and emotional problems, there is a need to develop guidelines related to ensure digital wellness and regulate screen time in infants, children, and adolescents. Objectives: To review the evidence related to effects of screen-based media and excessive screen time on children’s health; and to formulate recommendations for limiting screen time and ensuring digital wellness in Indian infants, children and adolescents. Process: An Expert Committee constituted by the Indian Academy of Pediatrics (IAP), consisting of various stakeholders in private and public sector, reviewed the literature and existing guidelines. A detailed review document was circulated to the members, and the National consultative meet was held online on 26th March 2021 for a day-long deliberation on framing the guidelines. The consensus review and recommendations formulated by the Group were circulated to the participants and the guidelines were finalized. Conclusions: Very early exposure to screen-based media and excessive screen time (>1-2h/d) seems to be widely prevalent in Indian children. The Group recommends that children below 2 years age should not be exposed to any type of screen, whereas exposure should be limited to a maximum of one hour of supervised screen time per day for children 24-59 months age, and less than two hours per day for children 5-10 years age. Screen time must not replace other activities such as outdoor physical activities, sleep, family and peer interaction, studies, and skill development, which are necessary for overall health and development of the children and adolescents. Families should ensure a warm, nurturing, supportive, fun filled and secure environment at home, and monitor their children’s screen use to ensure that the content being watched is educational, ageappropriate and non-violent. Families, schools and pediatricians should be educated regarding the importance of recording screen exposure and digital wellness as a part of routine child health assessment, and detect any signs of cyberbullying or media addiction; and tackle it timely with expert consultation if needed.

Molecular characterization of BK virus detected in renal transplant patients in Sri Lanka: a preliminary study

Background & objectives: BK virus (BKV) is a polyomavirus and cause of a common infection after renal transplantation which could be preceded to BKV-associated nephropathy. It has four main subtypes (I–IV). BKV subtypes II and III are rare, whereas subtype I shows a ubiquitous distribution. The objective of the present study was to investigate the prevailing BKV subtypes and subgroups in renal transplant patients in Sri Lanka. Methods: The presence of BKV in urine was tested through virus load quantification by real-time PCR from 227 renal transplant patients who were suspected to have BKV infection. Of these patients only 41 were found to be BKV infected (>103copies/ml) and those were subjected to conventional PCR amplification of VP1 gene followed by BKV genotyping via phylogenetic analysis based on DNA sequencing data. Results: Persistent BK viral loads varied from 1×103 to 3×108 copies/ml. Of the 41 patient samples, 25 gave positive results for PCR amplification of subtyping region of VP1 gene of BKV. BKV genotyping resulted in detecting subtype I in 18 (72%) and subtype II in seven (28%) patients. BKV subgroups of Ia, Ib-1 and Ib-11, and Ic were identified with frequencies of 6/18 (33.3%), 6/18 (33.3%), 5/18 (27.8%), and 1/18 (5.6%), respectively. Interpretation & conclusions: Findings from this preliminary study showed a high occurrence of subtype I, while the presence of subtype II, which is rare and less prevalent, was a novel finding for this Asian region. This emphasizes the need for further molecular and serological studies to determine the prevalence of different BKV subtypes in Sri Lanka

Management of a patient with angle class I Malocclusion with Anterior Crossbite and Maxillary Central Diastema caused by high attachment of the Maxillary Labial Frenulum

@#Maxillary Central diastema is common and normal for the growth and development of the anterior segment. If the central diastema persists after the eruption of the permanent cuspids, the orthodontist should clarify the etiology and establish a treatment plan. This case report discusses a 22-year-old woman with anterior crossbite and central diastema due to a high maxillary labial frenulum attachment. Treatment was performed using a fixed orthodontic appliance with a posterior bite raiser. Frenectomy was performed at the end of the orthodontic treatment.

Non-purulent pharyngitis: adult still’s disease

 Adult Still’s disease is rare and may present as pyrexia of unknown origin. Due to lack of expertise, diagnosis may be delayed inadvertently. The patient usually presents with spiked fever, polyarthralgia or arthritis, evanescent skin rash, non-purulent pharyngitis, lymphadenopathy and hepatosplenomegaly. Leukocytosis, predominantly of neutrophils, elevated erythrocyte sedimentation rate and C-reactive protein without obvious infection are the hallmarks of the disease. Delay in diagnosis may expose the patient to the side effects of antibiotics as they are repeatedly prescribed in view of elevated leukocytes. The majority of patients report pain in the throat without evidence of infection. This was an important clue to our diagnosis of this patient. Grossly elevated serum ferritin is diagnostic of adult onset still's disease. As the white cell counts are grossly elevated, a bone marrow examination to rule out hematological malignancy may be mandatory. Serum ferritin value has prognostic value too. Minor illness may respond to non-steroidal anti-inflammatory drugs (NSAIDs), but steroids are the mainstay of the treatment.  Methotrexate is of additional value for those presenting predominantly with arthritis. Anakinra, Infliximab and Tocilizumab are other options. Those patients presenting with severe disease and organ involvement require high dose intravenous steroids followed by high dose oral steroids.

Utilization of antenatal services among mothers and its impact on birth weight: a community based cross-sectional study

Background: Safe motherhood initiatives was a worldwide effort launched by WHO in 1987 with an aim to reduce the number of deaths of women associated with pregnancy and childbirth. Appropriate antenatal care (ANC) is one of the pillars of this initiative and an important component of reproductive and child health. The present study was conducted to assess the utilization of antenatal care services, its contributing factors and its impact on birth weight of new-born.Methods: A community based cross-sectional study was conducted for a period of 3 months at Ankuli, field practice area of urban health training centre, Department of Community Medicine. A total of 138 mothers (delivered within 2 years) were included by cluster sampling. Women who were sick and did not give consent were excluded from the study. A pre-designed and pre-tested questionnaire was used for data collection and analysed in SPSS version 16. Chi-square test and bivariate logistic regression was applied at p value <0.05.Results: About 55.07% of mothers were in 25-34 years of age group, 47.82% had studied secondary education and 36.23% mothers belonged to lower middle-class socioeconomic status (SES). About 60.87% of mothers had availed antenatal services completely. Education of the participant and her husband, SES and family type were significant contributors of ANC service utilization. There was a significant association between complete ANC utilization and birth weight of the baby (p<0.05).Conclusions: The utilisation of the antenatal services was low among the mothers in our study which can be increased by proper IEC activities.

Post Oral Administration of Epigallocatechin Gallate from Camelia sinensis Extract Enhances Vascular Endothelial Growth Factor and Fibroblast Growth Factor Expression during Orthodontic Tooth Movement in Wistar Rats.

Background:East Java green tea leaf (Camelia sinensis)possesed active compound such as EpigallocatechinGallate (EGCG) is well known for enhancing the boneremodelling through enhancement of VascularEndothelial Growth Factor (VEGF) and FibroblastGrowth Factors (FGF-2). Remodelling of alveolar boneis very important to obtain optimal Orthodontic ToothMovement (OTM) to align the tooth. Aim: Toinvestigate the expression of VEGF and FGF-2expression during OTM in Wistar rat afteradministration of EGCG from C. sinensis Extract(EGCG-CSE) Wistar rats. Material and Methods: Thisstudy was true experimental study with post-test onlycontrol group design. Twenty eight Wistar rats wererandomly selected and divided into four groupsaccordingly; K- group which did not get both EGCGCSE administration and OTM; K+ group with OTM for14 days, but no EGCG-CSE administration; 1 (T1) with4 days of OTM and 7 days of EGCG-CSEadministration; treatment group 2 (T2) with both 14days OTM and EGCG-CSE administration. Ten g2 force/mm of NiTi close coil spring was installedbetween the upper left molars and cental insicive tomove the molar mesially that induce OTM. All OTMthanimal model were terminated in the 14 days.Maxillary was isolated for immunohistochemistryinvestigation. Tukey Honest Significant Difference(HSD) was done after Analysis of Variance (ANOVA)test to investigate the significant difference betweengroups (p<0.05). Results: The highest positive VEGFexpression was found in the T2 in both area.Meanwhile, the highest positive FGF-2 expression wasfound in the K-group in both area. There weresignificant different of VEGF and FGF-2 expression inboth area between groups except T1 and T2.Conclusion: Post administration of EGCG-CSE canstimulate the VEGF and FGF-2 expression during OTMin Wistar rats.

Multidisciplinary treatment of Class I angle Malocclusion with severe Crowding and Peg Lateral Incisor: A case report

@#Class I malocclusions with severe crowding and tooth size discrepancies may be successfully treated orthodontically with extraction therapy, and co-management with other specialists. Correction of the discrepancies will optimize occlusal result (overjet, overbite, midline shift, and smile esthetics). This is a case of a 19-year-old male with severe crowding in upper and lower teeth and peg lateral incisor. The patient had malocclusion Class I. This case was treated comprehensively and successfully using fixed orthodontic appliances with extraction of four premolars, and veneer composite for peg lateral incisor with the help of a conservative dentist at the end of orthodontic treatment.

Soluble Human Leukocyte Antigen Molecules Detected in Orofacial Cleft Patients: A Case-Control Study

Abstract Objective: To compare soluble HLA-C and HLA-DR molecules present in the plasma of orofacial cleft and non-orofacial cleft populations. Material and Methods: Orofacial cleft patients were recruited using an accidental sampling approach (n=15). Peripheral blood was collected from the participants and processed for Enzyme Linked Immunosorbent Assay (ELISA) against HLA-C and HLA-DR with specific antibodies. The absorbance was calculated utilizing ELISA reader. Data were statistically analyzed using an independent t-test to compare the disease and control groups. Results: The levels of soluble HLA-C and HLA-DR were significantly higher in the diseased group compared to the control group (p<0.05). Conclusion: The role of HLA molecules in non-communicable disease and congenital anomalies, particularly orofacial cleft, remains speculative despite the positive results of this study and those of previous investigations. It suggests that the variables examined may affect specific pathways involved in the pathogenesis of orofacial cleft, and predispose the individuals concerned to the oral cleft.

High Mobility Group Box 1 and Heat Shock Protein-70 Expression Post (-)-Epigallocatechin-3-Gallate in East Java Green Tea Methanolic Extract Administration During Orthodontic Tooth Movement in Wistar Rats

Abstract Objective: To investigate the expression of High Mobility Group Box 1 (HMGB1) and Heat Shock Protein-70 (HSP-70) during orthodontic tooth movement (OTM) after (-)- Epigallocatechin-3-Gallate (EGCG) in East Java Green Tea (Camelia Sinensis) Methanolic Extract (GTME) administration in vivo. Material and Methods: 28 Wistar rats (Rattus Novergicus) was used and divided into 4 groups accordingly: K- without EGCG and OTM; K+ with OTM, without EGCG for 14 days; T1with OTM for 14 days and EGCG for 7 days; treatment group 2 (T2) with OTM and EGCG for 14 days. OTM animal model was achieved through the installation of the OTM device by means of NiTi close coil spring with 10g force placed between the first incisor and first maxillary molars. The samples were terminated on Day 14. The pre-maxillary was isolated for the immunohistochemical examination. Analysis of Variance (ANOVA) then continued with Tukey Honest Significant Difference (HSD) (p<0.05) was performed to analyze the data. Results: The highest HMGB1 and HSP-70 expression were found in the K+ group pressure side, meanwhile the lowest HMGB1 and HSP-70 expression were found in K- group tension side in the alveolar bone. There was a significant decrease of HMGB1 and HSP-70 expression in T2 compared to T1 and K+ with significant between groups (p<0.05; p=0.0001). Conclusion: The decreased expression of HMGB1 and HSP-70 in alveolar bone of OTM wistar rats due to post administration of GTME that consisted EGCG.

Receptor Activator of Nuclear Factor-Kappa Ligand and Osteoprotegerin Expressions on Hyperglycemic Wistar Rats (Rattus Novergicus) During Orthodontic Tooth Movement

Abstract Objective: To investigate the differences of receptor activator of nuclear factor-κB ligand (RANKL) and Osteoprotegerin (OPG) expressions between normoglycemic and hyperglycemic Wistar rats (Rattus Novergicus) during Orthodontic Tooth Movement (OTM). Material and Methods: This study was true experimental with post-test group only. Thirty-two healthy male Wistar rats, weighted around 200-250 grams, 12-20 weeks old, were used as OTM animal study. They were divided into 2 groups (n=16), normoglycemic rats (normal blood glucose 80-120 mg/dl) and hyperglycemic rats (>250 mg/dl) induced by Streptozotocin with a dose of 30 mg in PBS injection intraperitoneally. A NiTi closed coil spring was mounted between maxillary first molar and incisors with the light force 10gf/mm2 in both groups to induce OTM. The studied animals were then terminated on days 1, 3, 6, and 9, respectively, and premaxilla was extracted. RANKL and OPG expression were examined utilizing immunohistochemistry (IHC) analysis. One-way ANOVA and Tukey HSD (p<0.05) were utilized to analyze the differences in the expression of RANKL and OPG between groups. Results: The hyperglycemic group on day 1, 9 rats showed a significant increase in the expression of RANKL, whereas OPG expression decreased significantly on days 1, 3, and 9. Conclusion: There was a significant increase of RANKL expression and a decrease of OPG expression in hyperglycemic rats as documented immunohistochemically.

A comparison of antibacterial inhibitory effect on Streptococcus mutans and tensile strength between chitosan-based bonding adhesives and commercial products

Background: Adhesive bonding is the material used to attach a bracket to the enamel surface of the tooth. Streptococcus mutans contributes to enamel demineralization during orthodontic treatment. Objectives: To analyze the antimicrobial inhibitory effect of Streptococcus mutans bacteria and tensile strength of chitosan and CaCO3-based adhesive bonding material. Materials and Methods: The investigation constituted laboratory experimental research featuring analytical observation and a random sampling method. The antibacterial inhibitory effect of chitosan and CaCO3-based adhesive bonding against Streptococcus mutans involved six groups: two control groups using commercial light cure and self-cure adhesive bonding products and four groups using adhesive bonding consisting of 75% CaCO3 + 17.6% Bis-GMA + 22.4% MMA with various percentages of chitosan composition (A1: 25%, A2: 50%, A3: 75%, and A4: 100%) each group consisting of two samples (n = 12). A diametric test was conducted consisting of three samples (n = 15) to measure the tensile strength of each group. Data were analyzed by a combination of one-way analysis of variance and least significant difference tests. Result: The antibacterial inhibitory effect showed significant differences between groups (A1: 2.9467 ± 0.4163, A2: 3.6500 ± 0.6245, A3: 5.1267 ± 0.2517, A4: 4.7267 ± 0.9238; P = 0.0000; P < 0.05). A diametric tensile strength test confirmed significant differences between groups (A1: 7.2733 ± 5.0046, A2: 6.7667 ± 4.4346, A3: 6.4533 ± 2.9994, A4: 1.0058 ± 1.0058, K1: 15.6167 ± 3.1250; P = 0.009; P < 0.05). Conclusion: Chitosan-based adhesive bonding with good tensile strength has an antibacterial inhibitory effect against Streptococcus mutans.

A clinical study of effects of pregnancy on diseases like painful crisis, seizure disorders, hepatopathy, acute anemia and its outcome

Background: The ability of the blood cells to carry oxygen is especially important in pregnancy. Anemia may result in lower amount of oxygen going to the fetus and slowed fetal growth. Because it affects so many organs and body systems, women with the disease are more likely to have complications in pregnancy. The main objective was to study the effects of pregnancy on disease and its outcomes.Methods: It is a hospital based prospective study. The study was conducted at Narayana Medical College Nellore, Andhra Pradesh. The patients admitted in Obstetrics and Gynecology Department were included in the study. The study included total of 45 patients. Detailed history included age, socioeconomic status, address, education and occupation of the patient’s Permission from Institutional Ethics Committee was obtained.Results: Maximum patients were gravida 2-3, and minimum were gravida 4 or more. Maximum numbers of patients were in group 20-25. The patients with preterm birth that is delivery before 37 weeks of pregnancy were 15. Low birth weights were 20 and of still birth and new born death was 4.Conclusions: The present study was carried out in 45 cases and appropriate prenatal care and careful monitoring throughout pregnancy, can have healthy pregnancy with significant improvement in pregnancy outcome.

Serum Uric Acid in Acute Coronary Syndromes

Introduction: Uric acid (urate), an organic compound ofcarbon, nitrogen, oxygen and hydrogen has been thought to beprotective against ageing, oxidative stress and oxidative cellinjury owing to its oxidant property. Recent epidemiologicaland clinical evidences suggest that hyperuricaemia might be arisk factor for cardiovascular disease where enhanced oxidativestress plays an important pathophysiological role. The studyis taken up to determine serum uric acid levels in AcuteCoronary Syndromes (ACS) and to compare the incidence ofcomplications in hyperuricaemic and normouricaemic acutecoronary syndrome patients.Material and Methods: A prospective cohort study wasconducted in the Department of Medicine in collaborationwith Department of Biochemistry, RIMS, Imphal fromOctober 2014 to September 2016, among 73 normouricaemicACS patients and 73 hyperuricaemic ACS patients. Clinicaland anthropometric data were taken from each subject.Laboratory evaluation involves serum uric acid by enzymaticcolorimetric method.Results: The mean serum uric acid level in the studypopulation was 5.96 ± 1.88 mg/dl. Arrhythmias occurred in27.4% of hyperuricemic patients and 5.5% of normouricemicpatients. It is observed that 27 patients developed congestivecardiac failure (CCF), out of which 17 patients (22.3%)were hyperuricaemic and 10 patients (13.7%) werenormouricaemic. Pulmonary edema (PE) was observed in 35hyperuricaemic and 28 normouricaemic patients (47.9% and38.4% respectively).Conclusions: Complications of ACS such as arrhythmias,CCF and PE occurred more frequently in hyperuricaemicindividuals. Thus, it can be concluded that serum uric acidlevel can be considered a suitable marker for predicting ACSrelated future adverse events.