Restorative Rehabilitation of the Cleft Affected Occlusion - A Service Evaluation.

Cleft Lip and/or Palate (CLP) is the most common cranio-facial abnormality thought to be caused by a combination of genetic and environmental factors causing challenges with feeding, dental development and speech. Cleft affected individuals often present a unique set of challenges with regards to their oro-facial and dental development and require multidisciplinary care. This article aims to describe the role of the restorative dentist in the multidisciplinary management of cleft affected individuals and outlines the various clinical presentations and restorative challenges. This article describes the various treatment modalities provided for cleft affected individuals under the National Health Service (NHS) at Liverpool University Dental Hospital (LUDH) and ranges from minimally invasive techniques to conventional fixed and removable prosthodontics.

State of the Art Management of Aortic Valve Disease in Ankylosing Spondylitis.

PURPOSE OF REVIEW: Cardiac involvement in patients with ankylosing spondylitis (AS) generally manifests itself as aortic insufficiency, aortitis, disturbance in cardiac conduction, and myocardial dysfunction. We have used a case-based approach to review the current state of the art knowledge regarding the diagnosis and management of aortic valve disease and aortitis in patients with AS. RECENT FINDINGS: The risk for aortic valve disease and aortic valve replacement or repair is significantly higher than in people without AS, and this risk increases with age. Echocardiography, cardiac MRI, and CT can serve as effective tools for screening and follow-up. Surgical repair/replacement remains the mainstay of therapy for aortic insufficiency and aortic dilation, whereas transcatheter-based techniques may be favorable in the setting of aortic stenosis. Aortic valve and atrioventricular conduction abnormalities contribute to overall cardiovascular burden in AS. Optimal timing and therapeutic technique are dependent on assessment of overall risk and serial follow-up.

Outbreaks of influenza-like illness in care homes in the East of England: impact of variations in neuraminidase inhibitor provision.

OBJECTIVES: To examine the differences in outcomes related to variable provision of antivirals in care home respiratory outbreaks. STUDY DESIGN: This is a retrospective observational study. METHODS: Routinely collected outbreak surveillance data reported from care home staff was recorded using a standard template and extracted from the Public Health England health protection electronic records. Data included numbers of people affected, provision of oseltamivir, hospitalization, and deaths during the outbreak in the care home. Oseltamivir provision was categorized by proportion of eligible residents prescribed it on advice. Additional data on microbiological diagnoses were obtained directly from the hospital laboratories. Logistic regression was used to examine associations between oseltamivir provision and hospitalizations and deaths in care homes. RESULTS: One hundred and sixty-eight outbreaks were reported from 28th July 2016 until 27th March 2017, affecting 1459 residents and 347 staff. There were 76 hospital admissions and 37 deaths overall. Although deaths and hospital admissions also occurred in outbreaks caused by other respiratory viruses, outbreaks caused by influenza had the highest median number of people affected and a greater proportion of hospital admissions and deaths. Of the 56 outbreaks caused by influenza, there was a significant increase in the odds of the care home reporting deaths when oseltamivir was not used (odds ratio = 8.15, 95% confidence interval = 1.38-48.20, P = 0.02). There were also non-significant reductions in duration of outbreak and hospital admissions in care home outbreaks with oseltamivir treatment. CONCLUSIONS: Partial or no provision of oseltamivir was associated with poorer outcomes in laboratory-confirmed influenza outbreaks.

Obesity and symptoms of depression contribute independently to the poor asthma control of obesity.

UNLABELLED: Obesity is a major risk factor for poorly controlled asthma, but the reasons for poor asthma control in this patient population are unclear. Symptoms of depression have been associated with poor asthma control, and increase with higher body mass index (BMI). The purpose of this study was to assess whether depressive symptoms underlie poor asthma control in obesity. METHODS: We determined the relationship between BMI, psychological morbidity and asthma control at baseline in a well-characterized patient population participating in a clinical trial conducted by the American Lung Association-Asthma Clinical Research Centers. RESULTS: Obese asthmatic participants had increased symptoms of depression (Center for Epidemiologic Studies Depression Scale score in lean 10.1 ± 8.1, overweight 10.0 ± 8.1, obese 12.4 ± 9.9; p = 0.03), worse asthma control (Juniper Asthma Control Questionnaire score in lean 1.43 ± 0.68, overweight 1.52 ± 0.71, obese 1.76 ± 0.75; p < 0.0001), and worse asthma quality of life (scores in lean 5.21 ± 1.08, overweight 5.08 ± 1.05, obese 4.64 ± 1.09; p < 0.0001). Asthmatics with obesity and those with symptoms of depression both had a higher risk of having poorly controlled asthma (adjusted odds ratio of 1.83 CI 1.23-3.52 for obesity, and 2.08 CI 1.23-3.52 for depression), but there was no interaction between the two. CONCLUSION: Obesity and symptoms of depression are independently associated with poor asthma control. As depression is increased in obese asthmatics it may be an important co-morbidity contributing to poor asthma control in this population, but factors other than depression also contribute to poor asthma control in obesity.

A case of isolated cutaneous Rosai-Dorfman-Syndrome.

UNLABELLED: Rosai-Dorfman Syndrome (RDD) is a rare, benign, self-limiting disorder which is characterized by the non-malignant proliferation of distinctive histiocytic cell within lymphatic system. RDD has been described as a dynamic entity in the spectrum of histiocytosis with non-Langerhans cell histiocytosis at one end and Langerhans cell histiocytosis at the other. The exact etiology of this disease is uncertain despite widespread search for infectious or immunological reasons. We present a case of purely cutaneous Rosai-Dorfman Syndrome presenting as abdominal wall swelling. KEYWORDS: Rosai-Dorfman Disease, Lymphoma.

Toxigenic Corynebacterium ulcerans infection in a veterinary student in London, United Kingdom, May 2010.

We report on a case of toxigenic Corynebacterium ulcerans infection in a fully immunised veterinary student, investigated in London, United Kingdom, in May 2010. There was no ongoing transmission in human contacts. Possible animal sources were identified.

Do the extent and direction of arterial remodelling predict subsequent progression of coronary atherosclerosis? A serial intravascular ultrasound study.

OBJECTIVE: Despite the link between positive coronary remodelling and acute ischaemic events, no data exist about the impact of arterial remodelling on subsequent progression of coronary atherosclerosis. The objective of this study was to examine whether extent and direction of arterial remodelling are predictors of progression of coronary atherosclerosis. DESIGN, SETTING AND PATIENTS: From the Reversal of Atherosclerosis with Aggressive Lipid Lowering (REVERSAL) trial, 210 focal coronary lesions (single lesion per patient) were identified with

Advances in the percutaneous treatment of aortic and mitral valve disease.

The healthcare burden of valvular heart disease continues to increase as our population ages. Because of advances in operative techniques and cardiac anesthesiology, surgery has excellent safety and durability for many patients, and surgery remains the gold standard for treating valvular heart disease. Because many patients have comorbidities that increase operative risk, interest in catheter-based valve repair and replacement has grown. Early human experience with aortic stent-valve prostheses has been quite encouraging. For mitral regurgitation, percutaneous annuloplasty and leaflet repair are being developed by numerous companies, and early human studies have demonstrated feasibility of percutaneous repair. Continuing advances in technology and experience promise to expand the role of percutaneous repair and replacement in the treatment of valvular heart disease. Ongoing trials will help define long-term durability and safety, along with appropriate patient selection for percutaneous treatment.

Assessment of total thrombus load in symptomatic patients with venous thromboembolism.

Pulmonary embolism (PE) and Deep vein thrombosis (DVT) are separate but related aspects of the same dynamic process termed as venous thrombembolism (VTE). The existing Asian literature has shown a wide variation in the prevalence of VTE, with very limited data from the Indian subcontinent. Between January 2001 and July 2004, 1,552 patients with clinically suspected lower limb DVT underwent a combined ascending radionuclide venogram and lung perfusion scan for assessment of the total thrombus burden. Of 744 patients with radionuclide venography proven DVT, 294 (40%) had a high probability lung scan. Nearly half of these patients were asymptomatic for pulmonary embolism. The high prevalence of PE in patients with DVT suggests the need for evaluation of thrombus load in the venous as well as pulmonary circulation. A combination radionuclide ascending venography with lung perfusion scan is a useful and reliable single test for this purpose.

Effect of aspirin on phase gradient of 2F1-F2 distortion product otoacoustic emissions.

It is well known that aspirin consumption temporarily reduces overall otoacoustic emission (OAE) amplitude in humans. However, little is known about changes in the separate components of distortion product otoacoustic emissions (DPOAE), which may be distinguished by examining phase gradients. The effects of aspirin on the phase gradient of the DPOAE 2F1-F2 obtained with fixed frequency ratio sweeps were studied longitudinally in a group of twelve subjects in whom a temporary hearing loss was induced by aspirin consumption. DPOAE were recorded daily for two days pre-aspirin consumption, during the three days of aspirin consumption and two days afterwards. DP-grams were recorded over a restricted frequency range centered on 2,3,4 and 6 kHz with the following stimulus levels: L1/L2 of 60/50-80/70 in 10-dB steps. The effects of aspirin on the phase gradients varied between the subjects and across frequency: the general trend was that the phase gradient became steeper across successive sessions for the higher frequencies, while no significant effect was found at the lower frequencies. These results suggest that aspirin may have more persistent effects on cochlear function than are disclosed by measurements of hearing threshold level or DPOAE amplitude. Particularly, DPOAE phase gradient appears to be increased by aspirin consumption and has not recovered two days after cessation of aspirin intake, despite almost complete recovery of DPOAE amplitude and hearing threshold levels. These findings may suggest differential effects on the distortion and reflection mechanisms considered to underlie DPOAE generation.

Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting.

BACKGROUND: Carotid artery stenting is being used as an alternative to carotid endarterectomy, both within the context of clinical trials and in non-surgical candidates. Though stenting is known to activate platelets, the role of antithrombotic therapy in carotid stenting has not been fully characterized. METHODS AND RESULTS: Consecutive patients (n = 162) were followed in a single-center carotid stent registry. The cumulative rate of 30-day death, stroke, transient ischemic attack and myocardial infarction in those patients receiving a thienopyridine was determined, as were rates of stent thrombosis and intracranial hemorrhage. The mean age of the patients was 70.3 years and there was an extremely high prevalence of cardiovascular comorbidities, including 40% with unstable angina. The carotid lesion was symptomatic in 59% of patients. The average pre-treatment stenosis was 83%. The cumulative 30-day rate of death, stroke, transient ischemic attack and myocardial infarction was 5.6%. Specifically, in the patients who received ticlopidine (n = 23), the rate was 13%, versus 4.3% in the patients who received clopidogrel (n = 139) (p = 0.01). In this series, there were no cases of stent thrombosis and 1 intracranial hemorrhage. CONCLUSION: Dual antiplatelet therapy with clopidogrel plus aspirin in patients receiving carotid artery stents is associated with a low rate of ischemic events. Furthermore, clopidogrel appears superior to ticlopidine. Thus, our findings lend support to the dual antiplatelet strategy of clopidogrel plus aspirin for patients undergoing carotid artery stenting.

Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery.

OBJECTIVES: This study was conducted to evaluate follow-up results in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent either percutaneous transluminal septal myocardial ablation (PTSMA) or septal myectomy. BACKGROUND: Controversy exists with regard to these two forms of treatment for patients with HOCM. METHODS: Of 51 patients with HOCM treated, 25 were treated by PTSMA and 26 patients via myectomy. Two-dimensional echocardiograms were performed before both procedures, immediately afterwards and at a three-month follow-up. The New York Heart Association (NYHA) functional class was obtained before the procedures and at follow-up. RESULTS: Interventricular septal thickness was significantly reduced at follow-up in both groups (2.3 +/- 0.4 cm vs. 1.9 +/- 0.4 cm for septal ablation and 2.4 +/- 0.6 cm vs. 1.7 +/- 0.2 cm for myectomy, both p < 0.001). Estimated by continuous-wave Doppler, the resting pressure gradient (PG) across the left ventricular outflow tract (LVOT) significantly decreased immediately after the procedures in both groups (64 +/- 39 mm Hg vs. 28 +/- 29 mm Hg for PTSMA, 62 +/- 43 mm Hg vs. 7 +/- 7 mm Hg for myectomy, both p < 0.0001). At three-month follow-up, the resting PG remained lower in the PTSMA and myectomy groups (24 +/- 19 mm Hg and 11 +/- 6 mm Hg, respectively, vs. those before procedures, both p < 0.0001). The NYHA functional class was also significantly improved in both groups (3.5 +/- 0.5 vs. 1.9 +/- 0.7 for PTSMA, 3.3 +/- 0.5 vs. 1.5 +/- 0.7 for myectomy, both p < 0.0001). CONCLUSIONS: Both myectomy and PTSMA reduce LVOT obstruction and significantly improve NYHA functional class in patients with HOCM. However, there are benefits and drawbacks for each therapeutic method that must be counterbalanced when deciding on treatment for LVOT obstruction.

Self-expanding stents for carotid interventions: comparison of nitinol versus stainless-steel stents.

BACKGROUND: Angioplasty and stenting are becoming increasingly accepted techniques for the treatment of carotid stenosis. However, the optimal stent for carotid intervention is not known. METHODS: We compared the short- and intermediate-term results of carotid stenting using either nitinol or stainless-steel self-expanding stents in 178 high surgical risk patients undergoing carotid stenting at our institution. Of these 178 patients, eighty-nine received stainless-steel stents and 89 received nitinol stents. The groups were similar with respect to age, gender, diabetes, hypertension, left ventricular function, and symptom status. There were more patients with contralateral carotid occlusion in the nitinol stent group. Independent neurological evaluation was performed in all patients pre- and post-carotid stenting. RESULTS: At 6 months, there was a similar incidence of stroke (3.3% versus 2.2%) in the stainless-steel group and nitinol stent group, respectively. There was higher 6-month mortality noted in the stainless-steel stent group, but there were no neurological deaths in either group. CONCLUSIONS: In a single-center patient cohort with similar baseline characteristics, patients receiving nitinol stents and stainless-steel stents had similar neurological outcomes.

Initial experience of platelet glycoprotein IIb/IIIa inhibition with abciximab during carotid stenting: a safe and effective adjunctive therapy.

BACKGROUND AND PURPOSE: Abciximab has been shown to decrease periprocedural ischemic complications after coronary intervention. However, the adjunctive use of abciximab in carotid stenting has not been adequately studied. We sought to determine the efficacy and safety of abciximab in carotid stenting. METHODS: Carotid stenting was performed in 151 consecutive patients determined to be at high surgical risk by a vascular surgeon. Of these, 128 consecutive patients received adjuvant therapy with abciximab (0.25 mg/kg bolus before the lesion was crossed with guidewire and 0.125 micro. kg(-1). min(-1) infusion for 12 hours.). A heparin bolus of 50 U/kg was given, and activated clotting time was maintained between 250 to 300 seconds. All patients received aspirin and thienopyridine. Procedural and 30-day outcomes were compared between the control (n=23) and abciximab (n=128) groups. RESULTS: The 2 groups had similar baseline characteristics. Procedural events were more frequent in the control group (8%; 1 major stroke and 1 neurological death) compared with the abciximab group (1.6%; 1 minor stroke and 1 retinal infarction; P=0.05). On 30-day follow-up, 1 patient presented with delayed intracranial hemorrhage in the abciximab group. There were no other major bleeding complications. CONCLUSIONS: Adjunctive use of abciximab for carotid stenting is safe with no increase in the risk of intracranial hemorrhage. This adjunctive therapy with potent glycoprotein IIb/IIIa inhibition may help to reduce periprocedural adverse events in patients undergoing carotid stenting.

Percutaneous transluminal alcohol septal myocardial ablation after aortic valve replacement.

When left ventricular outflow tract obstruction develops after aortic valve replacement, few treatment choices have been available until now. We present a patient with prior aortic valve replacement who developed left ventricle outflow tract obstruction that was successfully treated with a percutaneous transcoronary myocardial septal alcohol ablation. This technique is a useful tool for the treatment of obstructive hypertrophic cardiomyopathy, especially in those patients with prior heart surgery.