Time benefits of 3D planning in orthognathic surgery: a systematic review.

This systematic review aimed to evaluate the possible time benefits when using 3-dimensional (3D) planning prior to orthognathic surgery compared with a conventional method alone. The databases utilised were PubMed, Medline, Web of Science, and the Cochrane Library. Studies were selected based on eligibility criteria and reviewed independently by two authors. A total of eight studies were included. The review concludes that there are a limited number of studies with the appropriate experimental protocols in place. Therefore, although there is low-grade evidence to suggest that 3D planning in orthognathic surgery is more time-efficient, the field would benefit from the publication of more rigorous studies.

Synchronous mucosal and intraosseous oral cavity carcinomas: a case of rare occult second primary malignancy.

Secondary primary malignancies within the head and neck region are well documented. Within this group, synchronous tumours with an index oral cancer are usually found in the oropharyngeal or laryngeal sites. We present a rare case of an index squamous cell carcinoma in the tongue with a synchronous primary intraosseous squamous cell carcinoma. We discuss the challenges associated with investigation, diagnosis and subsequent management. Treatment aims remain the same; namely, eradicating the disease using surgery, radiotherapy, chemotherapy or a combination of these modalities. It is important to acknowledge the unpredictable pattern of tumour presentation and the need to maintain a high index of suspicion.

Complete Sets of Elastic, Dielectric, and Piezoelectric Properties of [001]-Poled Rhombohedral Pb(Zn1/3Nb2/3)O3-(4.5-7)%PbTiO3 Single Crystals.

Complete sets of elastic, dielectric, and piezoelectric properties of flux grown rhombohedral Pb(Zn1/3Nb2/3)O3-xPbTiO3 (PZN-PT; x = 0.0475 , 0.055, and 0.065) single crystals poled along [001] crystal direction have been determined in the present work. Their phase transformation temperatures, coercive fields, and mechanical quality factors are also provided. The results show that [001]-poled rhombohedral PZN-PT single crystals exhibit superior longitudinal piezoelectric properties ( k33 ≥ 0.90 , d33 ≈ 1580 -2500 pC/N). While the piezoelectric properties increase with PT content, the T RT and hence temperature stability of the crystal degrade accordingly. These unique properties, together with the property matrices provided in this work, can be used advantageously to design high-performance piezoelectric devices of longitudinal activation/sensing mode to suit various application needs.

Association between teriparatide treatment persistence and adherence, and fracture incidence in Taiwan: analysis using the National Health Insurance Research Database.

UNLABELLED: Medication persistence and adherence are critical for osteoporosis outcomes. Using the Taiwan National Health Insurance Research Database, we found that persistence and adherence to teriparatide were low in Taiwanese patients with osteoporosis and that greater persistence and adherence were associated with a lower incidence of hip and other nonvertebral fractures. INTRODUCTION: The purpose of this study was to determine the persistence and adherence to teriparatide treatment in Taiwanese patients with osteoporosis, and to examine the association between persistence and adherence to teriparatide with fracture risks. METHODS: Medical and pharmacy claims for 4,692 patients with vertebral or hip fractures and teriparatide prescriptions between 2005 and 2008 were identified (Taiwan National Health Insurance Research Database). Persistence was the time from the start of treatment to the first 90-day gap between two teriparatide prescriptions. Adherence was the number of teriparatide pens (each pen is used over 1 month) prescribed over 24 months. Association of persistence and adherence to teriparatide with fracture incidence was assessed using adjusted Cox proportional hazards models. RESULTS: The proportion of patients persisting with teriparatide for >6 months and >12 months was 44.6 and 24.9 %, respectively. Over 24 months, 53.6 % of patients were adherent for >6 months and 33.9 % were adherent for >12 months. Patients persisting for >12 months had a significantly lower incidence of hip (adjusted hazard ratio [HR], 0.61 [95 % confidence interval (CI), 0.40-0.93], P = 0.0229) and nonvertebral fracture (HR, 0.79 [95 % CI, 0.63-0.99], P = 0.0462) compared with those who persisted for ≤12 months. Patients adherent for >12 months had a lower incidence of hip (HR, 0.66 [95 % CI, 0.46-0.96], P = 0.0286) and nonvertebral fracture (HR, 0.81 [95 % CI, 0.66-0.99], P = 0.0377) compared with those adherent for ≤12 months. CONCLUSIONS: Persistence and adherence to teriparatide over 24 months were low in Taiwanese patients with osteoporosis; greater adherence and persistence were associated with a lower incidence of nonvertebral fractures.

Stigma among workers attending a hospital specialist diabetes clinic.

BACKGROUND: Stigma among sufferers of chronic diseases such as obesity, human immunodeficiency virus disease and mental health disorders has been studied. This study addresses stigma affecting workers with diabetes. AIMS: To investigate diabetes-related stigma and associated factors in a group of workers receiving care in a Singapore diabetes outpatient clinic. METHODS: Type 2 diabetes mellitus (T2DM) patients receiving subsidized care and holding full-time employment were consecutively recruited over 9 months. A questionnaire was individually administered by an interviewer. RESULTS: One hundred and twenty-five participants were recruited. Fifteen, who reported experiencing stigma, had higher median hospitalizations compared with the rest of the study group (2 (interquartile range (IQR) 0-6) versus 0 (0-1.75), P < 0.05). They were more likely to report that their diabetes affected work (8 (53%) versus 25 (23%), P < 0.05); having heard others experience diabetes-related stigma (9 (60%) versus 33 (30%), P < 0.05) and that employment prospects were affected (6 (40%) versus 18 (16%), P < 0.05), as well as having higher HbA1c (9.5% versus 8.5%, P > 0.05). Fifty-three per cent (66) of respondents reported that work affected their diabetes. There was no significant difference between the stigma and non-stigma groups in age (mean 50 years), body mass index (BMI; mean 28kg/m(2)), diabetes duration (12 years) and insulin use. CONCLUSIONS: Twelve percentage of employed T2DM outpatients reported experiencing stigma because of diabetes. This was associated with frequency of hospitalization (a surrogate for poorer health) and poorer diabetes control. Strategies to reduce stigma include optimizing diabetes control, patient support and educating employers to improve understanding of diabetes and its work implications.

Subdural haematoma due to dural metastases from bronchogenic carcinoma in a previously well patient: an unusual cause of non-traumatic recurrent intracranial haematomata.

Subdural haematomata (SDH) are usually traumatic in aetiology. Non-traumatic instances of SDH are uncommon, and can rarely be due to metastases involving the dura. Computed tomography or magnetic resonance imaging can be misleading, as the underlying aetiology may be masked by the SDH, or the appearance can simulate meningiomas. A high index of suspicion for SDH is thus required. Under such circumstances, when no overt cause is identified, dural tissue should be sent for histological analysis and blood clot for cytology, even if the appearances are grossly normal at surgery. We present a rare case of a 42-year-old woman who was previously well, but presented with progressive weakness due to acute spontaneous SDH. She required repeated surgical evacuations for SDH and for subsequent recurrent extradural haematomata. After extensive investigations, the cause was identified to be secondary dural metastases from a primary lung carcinoma.

Ministry of health clinical practice guidelines: clinical blood transfusion.

The Health Sciences Authority (HSA) and the Ministry of Health (MOH) publish clinical practice guidelines on Clinical Blood Transfusion to provide doctors and patients in Singapore with evidence-based guidance for blood transfusion. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the HSA-MOH clinical practice guidelines on Clinical Blood Transfusion, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=25700). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Attainment of at least a very good partial response after induction treatment is an important surrogate of longer survival for multiple myeloma.

The importance of achieving a very good partial response or better (≥VGPR) after induction treatment of myeloma has traditionally only been discussed in the context of high-dose therapy with auto-SCT (HDT/auto-SCT). Of late, the advent of novel agents for induction treatment has resulted in improved CR and VGPR rates, which are comparable with those observed with HDT/auto-SCT. We show that in an unselected group of 179 myeloma patients with diverse baseline characteristics, and treated with different modern induction regimens within a single institution, the attainment of ≥VGPR with or without HDT/auto-ASCT represents a major surrogate marker of better clinical outcomes. On the basis of a 1-year landmark survival analysis, patients achieving ≥VGPR enjoy a significantly longer PFS, which translated to a longer OS. Superseding the adverse effects of advanced age, high International Staging System (ISS) stage, adverse cytogenetics and independent of the transplant status, the attainment of ≥VGPR emerged as the single most significant predictor of long-term survival on multivariate analysis.

High SUV uptake on FDG-PET/CT predicts for an aggressive B-cell lymphoma in a prospective study of primary FDG-PET/CT staging in lymphoma.

BACKGROUND: Data assessing the role of positron emission tomography (PET)/computed tomography (CT) imaging in lymphoma staging is still being accumulated and current staging is based primarily on CT. This study aims to compare the value of PET/CT over conventional CT and bone marrow biopsy (BMB) in the initial evaluation of patients with lymphoma. METHODS: Data on 122 patients with PET/CT scans as part of their initial staging were prospectively collected and reviewed. All patients had complete staging, including BMB. RESULTS: Among the 122 patients, 101 had non-Hodgkin's lymphoma (NHL) and 21 had Hodgkin's lymphoma (HL). Compared with conventional CT, PET/CT upstaged 21 (17%) cases [B-cell non-Hodgkin's lymphoma (B-NHL), 12; T-cell non-Hodgkin's lymphoma (T-NHL), 3; HL, 6]. Of significance, in 13 patients with 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG)-avid splenic lesions, four had normal CT findings. A maximum FDG uptake of >10 standardized uptake value (SUV) seems to significantly correlate with an aggressive B-cell lineage (odds ratio 2.47, 95% confidence interval 2.23-2.70). Overall, PET scan was concordant with BMB results in 108 (89%) and discordant in 14 (11%) cases. In HL, our data show that PET scan and marrow results agreed in 19 of the cases (90%), being concordantly negative in 18 cases and concordantly positive in one, giving a negative predictive value (NPV) of 100%, sensitivity of 100% and specificity of 90%. Of note, all 13 with early-stage HL had negative PET/CT scan and BMB. In NHL, all 17 cases of T-NHL had concordant PET and BMB results. In patients with aggressive B-NHL, BMB and PET/CT agreed in 58 patients (92%) and disagreed in five (8%), while the corresponding rates in indolent B-cell lymphoma were 14 (67%) and seven patients (33%), respectively. All seven were falsely negative. CONCLUSIONS: PET/CT upstages 17% of cases and detects occult splenic involvement. This may have potential therapeutic and prognostic implications. SUV >10 may predict for an aggressive histology. Except for indolent B-NHL, our data show that PET scans have a good overall NPV in excluding lymphomatous bone marrow involvement. This is particularly true of early-stage HL, suggesting that BMB may be safely omitted in this group.

Thymic carcinoid in multiple endocrine neoplasia 1: genotype-phenotype correlation and prevention.

Thymic carcinoid is a rare multiple endocrine neoplasia type 1 (MEN1)-associated tumour that is a major cause of death in MEN1 patients. Here, we describe a previously unreported MEN1 family in which two siblings presented with malignant thymic carcinoids. All six siblings share a novel nonsense mutation Q395X on exon 8 of the MEN1 gene. The index patient developed a thymic carcinoid despite an earlier prophylactic transcervical thymectomy, and one other sibling had an incidental malignant thymic carcinoid discovered following prophylactic thymectomy, both cases demonstrating the weakness and strength of this surgical approach. We then review the spectrum of germline MEN1 mutations associated with thymic carcinoids to evaluate the possibility of a genotype-phenotype correlation. In the 22 separate MEN1 families with thymic carcinoids, all but two (91%) have mutations coding for a truncated protein. There is clearly a high prevalence of truncating mutations in MEN1-related thymic carcinoids although when compared with the prevalence of truncating mutations in all reported MEN1 mutations, it is not statistically significant (P = 0.39). Further studies are warranted to evaluate pathways of tumorigenesis of thymic carcinoids with regard to loss of function of menin.

Management of brain metastases.

Solid tumour brain metastases are a frequent clinical dilemma for oncologists and general physicians. The sound management of brain metastases requires a multidisciplinary approach. In this review we discuss the diagnosis and management of brain metastases including the role of surgery, radiotherapy, and chemotherapy. The standard approaches of surgical excision and primary radiotherapy have evolved from randomised studies. However, controversies remain regarding post-surgery irradiation in the setting of a solitary metastasis and the role of palliative chemotherapy.

Efficacy of donor vaccination before hematopoietic cell transplantation and recipient vaccination both before and early after transplantation.

Allogeneic hematopoietic cell transplantation is followed by humoral immunodeficiency. We evaluated whether antibody levels can be improved by recipient vaccination on day -1 and 50 and whether the levels can be further improved by donor vaccination on day -20. A total of 85 patients were randomized or assigned to one of the following strategies of immunization with Streptococcus pneumoniae polysaccharides, Haemophilus influenzae polysaccharide-protein conjugate, tetanus toxoid (protein recall antigen) and hepatitis B surface antigen (protein neo-antigen): (1) donor on day -20, recipient on days -1, +50 and +365 (D(-20)R(-1,50,365)); (2) donor nil, recipient on days -1, +50 and +365 (D(N)R(-1,50,365)); or (3) donor nil, recipient on day +365 (D(N)R(365)). For H. influenzae and tetanus, IgG levels after grafting were the highest in the D(-20)R(-1,50,365) patients, intermediate in the D(N)R(-1,50,365) patients and the lowest in the D(N)R(365) patients. For S. pneumoniae and hepatitis B, antibody levels appeared to be similar in all three patient groups. The results suggest that for polysaccharide-protein conjugate antigens or protein recall antigens, recipient immunization on days -1 and 50 improves antibody levels and that donor vaccination on day -20 further improves the levels. In contrast, neither recipient immunization on days -1 and 50 nor donor immunization on day -20 appears to be efficacious for polysaccharide antigens and poorly immunogenic protein neo-antigens.

A case of generalised cutaneous granulocytic sarcoma in an elderly patient with myelodysplastic syndrome.

Granulocytic sarcoma is a rare extramedullary malignant mass composed of primitive cells of the granulocytic lineage. It can arise from any part of the body and is frequently associated with haematological diseases, commonly acute myeloid leukaemia. Rarely, it has been found in conjunction with myelodysplastic syndrome. We report a case of cutaneous granulocytic sarcoma in a 73-year-old lady. The patient presented with a two-month history of multiple skin nodules which were confirmed by skin biopsy to be granulocytic sarcoma. Bone marrow examination was consistent with myelodysplastic syndrome. Localised radiotherapy to the skin lesions were given. She died from septicaemia six months after presentation. The management of this condition presents a diagnostic and therapeutic dilemma for both the pathologist and physician. In cases which are poorly differentiated as in this case, histological diagnosis is particularly difficult. Its definitive diagnosis would then require the additional use of a broad panel of immunohistochemical and cytochemical stains.

ERPs associated with and without an "orienting reflex" in patients with schizophrenia.

In this study, we measured traditional late components of the Event Related Potential (ERP: N 100, P 200, N 200 and P 300) in a conventional auditory oddball paradigm, but additionally and simultaneously assessed electrodermal "orienting reflexes (ORs)" in 40 patients with schizophrenia and 40 age and gender matched normal controls. The single epoch ERPs that did and did not evoke an OR, were sub-averaged separately. The control subjects (but not the patient group), revealed delayed P 300 latency in the ERP sub-averages without ORs (ERP-OR), compared with ERP sub-averages with ORs (ERP+OR). Between-group analysis showed reduced N 100, N 200 and P 300 amplitudes (as well as delayed P 300 latency) in the ERP+OR sub-average in patients with schizophrenia. In the ERP-OR sub-average, the patient group also had smaller N 100, N 200 and P 300 amplitudes, but larger P 200 amplitude (compared with normal controls). This study shows the potential to tease out physiologically based OR sub-processes, by simultaneous acquisition and analysis of ERPs and autonomic electrodermal activity. Such ERP sub-averages (based on autonomic responses) highlight that multiple processes overlap across the trial, and their delineation may elucidate more specific patterns of disturbance in schizophrenia, than traditional averaged measures.