Expression of wound healing markers in gingival crevicular fluid following root-coverage procedures: A systematic review of randomized clinical trials.

OBJECTIVE: Although several surgical techniques have been developed for treatment of gingival recession (GR), the underlying wound healing process remains relatively unexplored. This systematic review aimed to investigate the expression of wound healing markers in gingival crevicular fluid (GCF) before and after surgical treatment of GR. DESIGN: Randomized clinical trials (RCTs) reporting changes in the expression of GCF markers following any root coverage surgical procedure were identified from 4 electronic databases and manual searches followed by data extraction and result synthesis. The risk of bias (RoB) was assessed using Cochrane RoB 2.0 tool. Overall certainty of evidence was summarized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. RESULTS: Four RCTs comprising 100 patients and investigating 15 biomarkers were included. Post-surgery, GCF levels of cytokines and inflammatory proteins were raised during the first 2-10 days of healing. MMP-8 levels increased during the first week followed by a gradual decline. RoB was found to be high for all studies and the overall certainty of evidence was very low. CONCLUSION: A limited number of studies with large methodological variations precluded reliable conclusions. Well-designed studies powered for GCF markers' levels that follow a standardized protocol for GCF sampling and processing are needed to draw conclusive evidence.

Application of 4D printing in dentistry: A narrative review.

4D printing is an innovative digital manufacturing technology that originated by adding a fourth dimension, i.e., time, to pre-existing 3D technology or additive manufacturing (AM). AM is a fast-growing technology used in many fields, which develops accurate 3D objects based on models designed by computers. Dentistry is one such field in which 3D technology is used for manufacturing objects in periodontics (scaffolds, local drug-delivering agents, augmentation of ridges), implants, prosthodontics (partial and complete dentures, obturators), oral surgery for reconstructing jaw, and orthodontics. Dynamism is a vital property needed for the survival of materials used in the oral cavity since the oral cavity is constantly subjected to various insults. 4D printing technology has overcome the disadvantages of 3D printing technology, i.e., it cannot create dynamic objects. Therefore, constant knowledge of 4D technology is required. 3D printing technology has shortcomings, which are discussed in this review. This review summaries various printing technologies, materials used, stimuli, and potential applications of 4D technology in dentistry.

Private Doctors' Perspective towards "Patient First" in TB Diagnostic Cascade, Hisar, India.

TB diagnosis has been simplified in India following advances in available diagnostic tools. This facilitates private doctors' "patient first" approach toward early diagnosis; however, costs remain high. India's NTEP established a TB diagnostic network, which is free for patients and incentivizes private doctors to participate. Drawing from this context led to the design and implementation of the One-Stop TB Diagnostic Solution model, which was conducted in the Hisar district, Haryana, allowing specimens from presumptive TB patients from private doctors to be collected and tested as per NTEPs diagnostic algorithm. A subset of data pertaining to private doctors was analyzed for the project period. Qualitative data were also collected by interviewing doctors using a snowball method to capture doctors' perception about the model. Out of 1159 specimens collected from 60 facilities, MTB was detected in 32% and rifampicin resistance was detected in 7% specimens. All specimens went through the diagnostic algorithm. Thirty doctors interviewed were satisfied with the services offered and were appreciative of the program that implements this "patient centric" model. Results from implementation indicate the need to strengthen private diagnostics through a certification process to ensure provision of quality TB diagnostic services.

ECG manifestations of occlusion of septal perforator of left anterior descending artery.

The fourth universal definition of MI defines requires presence of j point elevation in two contiguous leads except v2-3 where the elevation should be equal to or >2 mm in men (2.5 mm in <40 years) and 1.5 mm in women.(1) We present two cases of patients who presented with electrocardiographic manifestations of occlusion of septal perforator of left anterior descending artery and discuss the salient feature of ECG in such patients. We also present the limitations of STEMI criteria given the dynamic nature of acute coronary occlusion and stress on early recognition of this MI.

Temporary pacing through umbilical venous route for neonatal heart failure due to complete atrioventricular block.

We present a case of a neonate who presented with worsening heart failure due to congenital complete atrioventricular (AV) block, secondary to maternal anti Ro/SSA and anti-LA/SSB antibodies. The patient was implanted a temporary pacemaker in view of hemodynamic deterioration and subsequently was weaned off ionotropic support and referred for permanent epicardial pacemaker implantation. We report temporary pacemaker implantation in a neonate with hemodynamic instability as a stabilizing measure and discuss technical challenges for the same.

Creation of a Prototype Cochlear Training Model.

OBJECTIVE: Creation of a novel 3D-printed physical cochlear model that demonstrated the feasibility of creating the model, and impact of a Graphical User Interface (GUI) system on training insertion metrics. STUDY DESIGN: Feasibility study with a pilot prospective data collection. SETTING: Tertiary academic center. METHODS: The study was IRB exempt. Five resident trainees (PGY1-PGY5) practiced electrode insertions in cadaveric temporal bones before using the simulator. Nine students were educated on how to hold the electrodes and position them, and then allowed to use the simulator. All trainees were instructed that slower insertions were favorable. One cochlear implant (CI) surgeon used the simulator. The GUI captured the real video feed, but also provided distance, trajectory, and velocity measurements. The program is designed to plot the real-time depth of insertion and speed of insertion of the electrode; the user is also provided real-time occurrence of any kinks and back-outs. RESULTS: A total of 14 trainees and 1 CI surgeon inserted the electrode at least 5 times without the use of the GUI (before) and then at least 5 times with the use of the GUI (after). Average Speed before and after (100.84 and 53.23 mm/s); Average minimum speed before and after (59.34 and 9.65 mm/s); and Average maximum speed before and after (416 and 285.81 mm/s). Statistically significant improvements were noted in all the measured speeds of insertion (P < .001). The other variables improved but not to a statistical significance. CONCLUSIONS: Real-time training using the 3D-printed model and GUI for cochlear implantation can help improve surgical resident training and comfort levels with electrode insertion for surgical trainees. The advantage of this model is that surgeons/trainees can use it as many times as they like, as the whole set-up is easy, economical, and reusable. The real time graphical user interface enhances training and retention of the practiced skills.

Clinical effectiveness of periosteal pedicle graft for the management of gingival recession defects-a systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to evaluate the effectiveness of periosteal pedicle graft (PPG) in terms of root coverage and patient related outcomes. To the best of our knowledge this is the first systematic review with meta-analysis on PPG. MATERIAL AND METHODS: A comprehensive search was performed using electronic and hand searches upto January 2023. Primary outcomes were Recession depth Reduction (Rec Red), mean root coverage (mRC) and complete root coverage (CRC). Secondary outcomes were gain in width of keratinized gingiva (WKG) and patient reported outcome measures (PROMs). Meta-analysis was performed when possible. The risk bias assessment was done using RevMan5.4.1 and Joanna Briggs institute scale for the included RCTs and case series respectively. RESULTS: A total of 8 RCTs and 2 case series (538 recession sites) were included based upon the predefined inclusion and exclusion criteria. The follow up period ranged from 6 months to 18 months. Results demonstrated that mRC of PPG + Coronally advanced flap (CAF) was 87.7% for localized gingival recession defects (GRDs) and 84.83% for multiple GRDs. An overall gain in WKG (Weighted Mean =1.49 ± 0.27 mm) was observed among all the included studies in the PPG + CAF group with mean difference (-0.10 (95% CI [-0.52, 0.33], p = 0.66)). Sub-group meta-analysis comparing PPG + CAF with sub-epithelial connective tissue graft (SCTG) + CAF resulted in similar outcomes in terms of Rec Red (0.10 (95% CI [-0.56 to 0.77], p = 0.76)) and gain in WKG (-0.03 (95% CI [-0.25 to 0.18], p = 0.76)). In terms of PROMs systematic review revealed better patient satisfaction with PPG + CAF than SCTG + CAF. CONCLUSION: PPG + CAF is a viable treatment modality for management of GRDs. The primary and secondary outcomes achieved utilizing PPG + CAF were found to be comparable to other conventional techniques including the gold standard i.e., SCTG.

Stromal Vascular Fraction Cells from Individuals Who Have Previously Undergone Radiotherapy Retain Their Pro-Wound Healing Properties.

Beneficial effects have been observed following the transplant of lipoaspirates containing adipose-derived stem cells into chronic wounds caused by oncologic radiotherapy. It is not yet certain whether adipose-derived stem cells are resistant to radiation exposure. Therefore, the aims of this study were to isolate stromal vascular fraction from human breast tissue exposed to radiotherapy and determine the presence of adipose-derived stem cells. Stromal vascular fraction from irradiated donor tissue was compared to commercially sourced pre-adipocytes. Immunocytochemistry was used to determine the presence of adipose-derived stem cell markers. Conditioned media from stromal vascular fraction isolated from irradiated donors was used as a treatment in a scratch wound assay of dermal fibroblasts also isolated from irradiated donors and compared to pre-adipocyte conditioned media and serum free control. This is the first report of human stromal vascular fraction being cultured from previously irradiated breast tissue. Stromal vascular fraction conditioned media from irradiated donors had a similar effect in increasing the migration of dermal fibroblasts from irradiated skin to pre-adipocyte conditioned media from healthy donors. Therefore, the ability of adipose-derived stem cells in the stromal vascular fraction to stimulate dermal fibroblasts in wound healing appears to be preserved following radiotherapy. This study demonstrates that stromal vascular fraction from irradiated patients is viable, functional and may have potential for regenerative medicine techniques following radiotherapy.

Diagnostic reproducibility of the 2018 Classification of Gingival Recession Defects and Gingival Phenotype: A multicenter inter- and intra-examiner agreement study.

BACKGROUND: The aim of this study was to investigate the inter- and intra-examiner agreement among international experts on the diagnosis of gingival recession defects using the 2018 Classification of Gingival Recession Defects and Gingival Phenotype as proposed in the 2017 World Workshop. METHODS: Standardized intraoral photographs from 28 gingival recession defects were evaluated twice by 16 expert periodontists. Recession type (RT), recession depth (RD), keratinized tissue width (KTW), gingival thickness (GT), detectability of the cemento-enamel junction (CEJ), and presence of root steps (RS) were recorded and used for the analysis. Intra- and inter-examiner agreements were calculated for individual variables and for the overall classification. Intraclass correlation coefficient with 95% CI was used for RD and KTW; Kappa with 95% CI was used for GT, CEJ, and RS; quadratic weighted Kappa with 95% CI was used for RT. RESULTS: Overall intra- and inter-examiner agreements were highest for KTW (0.95 and 0.90), lowest for GT (0.75 and 0.41), with the other variables in between (RD: 0.93 and 0.68, RS: 0.87 and 0.65, RT: 0.79 and 0.64, CEJ: 0.75 and 0.57). Overall intra- and inter-examiner agreements for the matrix were 62% and 28%, respectively. Significant effects existed between one variable's measurement and other variables' agreements. CONCLUSIONS: The 2018 Classification of Gingival Recession Defects and Gingival Phenotype is clinically reproducible within the examiners, and when the variables forming the matrix are analyzed individually. The between-examiner agreement for the complete matrix showed lower reproducibility. The agreement was highest for KTW and RD, and least for GT.

Experts' Consensus on Use of Long-Acting Nitroglycerine in the Management of Angina and Chronic Coronary Syndrome in India.

AIM: To address the existing gaps in knowledge about long-acting nitroglycerine (LA-NTG) and provide recommendations to address these issues. METHODOLOGY: Approved LA-NTG questionnaire that included 17 questions related to the role of LA-NTG in the management of angina and chronic coronary syndrome (CCS) was shared with 150 expert cardiologists from different regions from India. Results of these survey questionnaires were further discussed in 12 regional level meetings. The opinions and suggestions from all the meetings were compiled and analyzed. Further, recommendations were made with the help of attending national cardiology experts and a consensus statement was derived. RESULTS: This is the first consensus on LA-NTG, summarizing the clinical evidence from India and suggesting recommendations based on these data. The experts recommended early use of LA-NTG as a first-line antianginal therapy in combination with beta-blocker since it improves exercise tolerance in patients with CCS. A strong consensus was observed for using LA-NTG in patients with co-morbid hypertension, diabetes, chronic kidney disease and post-percutaneous coronary intervention angina. As a part of cardiac rehabilitation, LA-NTG allows patients with angina to exercise to a greater functional capacity. CONCLUSIONS: A national consensus was observed for several aspects of LA-NTG in the management of angina and CCS. The clinical experience of the experts confirmed an extremely satisfied patient perception about the efficacy of LA-NTG.

30-Day and 1-Year Outcomes With HYDRA Self-Expanding Transcatheter Aortic Valve: The Hydra CE Study.

OBJECTIVES: This study sought to evaluate the 30-day and 1-year safety and performance of the Hydra transcatheter aortic valve (THV) (in the treatment of symptomatic severe aortic stenosis in patients at high or extreme surgical risk. BACKGROUND: The Hydra THV is a novel repositionable self-expanding system with supra-annular bovine pericardial leaflets. METHODS: The Hydra CE study was a premarket, prospective, multicenter, single-arm study conducted across 18 study centers in Europe and Asia-Pacific countries. The primary endpoint was all-cause mortality at 30 days. All endpoints were adjudicated by an independent clinical events committee. RESULTS: A total of 157 patients (79.2 ± 7.1 years of age, 58.6% female; Society of Thoracic Surgeons score 4.7 ± 3.4%) were enrolled. Successful implantation was achieved in 94.3% cases. At 30 days, there were 11 (7.0%) deaths, including 9 (5.7%) cardiovascular deaths, of which 5 (3.2%) were device related. At 1 year, there were 23 (14.6%) deaths, including 13 (8.3%) cardiovascular deaths. At 30 days, there were significant improvement of effective orifice area (from 0.7 ± 0.2 cm2 to 1.9 ± 0.6 cm2) and mean aortic valve gradient (from 49.5 ± 18.5 mm Hg to 8.1 ± 3.7 mm Hg), which were sustained up to 1 year. Moderate or severe paravalvular leak was observed in 6.3% of patients at 30 days and 6.9% of patients at 1 year. The rate of new permanent pacemaker implantation was 11.7% at 30 days and 12.4% at 1 year. CONCLUSIONS: The Hydra CE study demonstrated that transcatheter aortic valve replacement with Hydra THV offered favorable efficacy at 1 year, providing large effective orifice area and low transvalvular gradient as well as acceptable complication rates with regard to new permanent pacemaker and paravalvular leak. (A Clinical Evaluation of the HYDRA Self Expanding Transcatheter Aortic Valve; NCT02434263).

Arrhythmia spectrum and outcome in children with myocarditis.

INTRODUCTION: Myocarditis remains an under-diagnosed entity among children. We evaluated the spectrum of electrocardiogram (ECG) changes and arrhythmias in children with myocarditis. METHODS: A single-center prospective observational study was conducted over a period of 18 months at a public university hospital, which included all cases with myocarditis from the ages of 1 month to 12 years. Myocarditis was diagnosed according to standard criteria. Arrhythmias were detected by 12-lead ECG or by multiparameter monitors. RESULTS: There were 63 children with myocarditis. Sinus tachycardia remained the most important ECG finding (61, 96.8%) followed by ST-T changes (30, 47.6%), low voltage QRS complexes (23, 36.5%), and premature complexes (11, 17.4%). Sustained arrhythmias were seen in 14/63 (22.2%) of the children (Group A), while the remaining 49 patients were designated as Group B. There were 11 (17.5%) cases with sustained tachyarrhythmias, comprising 5 with supraventricular tachycardia, 4 with ventricular tachycardia, and 2 with atrial flutter/fibrillation. Bradyarrhythmias were seen in 3 patients, including 2 children with atrioventricular block and 1 with severe sinus bradycardia. A longer hospital stay of 18.5 (4.75) days vs. 13 (4) days, P = 0.001), and more ST-T changes [12 (85.7%) vs. 18 (36.73%), P = 0.003] were seen in Group A. Multivariate regression analysis found only the presence of ST-T changes as predictors for arrhythmia. CONCLUSIONS: A variety of arrhythmias and other ECG changes were commonly seen in children with myocarditis. Sustained arrhythmias were seen in one-fifth of the patients, being associated with ST-T changes and a longer hospital stay.

Etiology of chronic atrioventricular block in young adults in a public university hospital in India.

In young adults, chronic atrioventricular (AV) block has scant systematic documentation in India. This prospective study included patients 18-40 years old, presenting with AV block without a reversible cause. There were 27 patients, aged 32 +/- 6.3 years, with 16 males. All patients had complete AV block with a narrow QRS escape rhythm (rate 40.5 ± 6.5 beats/min). Three patients were ANA positive and of these, 2 patients were anti ds DNA positive. The ESR and CRP levels were mildly elevated in 12 and 8 patients respectively. The rest of the tests were unremarkable. Despite performing multiple tests, the etiology remained idiopathic in most.

A Rare Case of Transposition of Great Arteries Uncovered With Progressive Rheumatic Aortic Stenosis.

The authors describe a case of transposition of great arteries with a large atrial septal defect with fusion of tricuspid valve leaflets and severe aortic stenosis. The latter two were likely rheumatic in etiology. The patient's condition improved after atrial switch and aortic valve replacement surgery. (Level of Difficulty: Intermediate.).

Is left atrial fibrosis an independent determinant of atrial fibrillation in mitral stenosis?

We prospectively studied whether left atrial (LA) fibrosis is a determinant of atrial fibrillation (AF) in mitral stenosis in patients who underwent balloon mitral valvotomy. There were 2 groups: Group A (n = 16), with AF and Group B (n = 27), without AF. Fibrosis was assessed by MRI. Patients underwent cardioversion before MRI. There were 27 females and 16 males, aged 29 ± 6 years. The LA areas in Groups A and B were 54.3 ± 4.4 mm2 and 39.4 ± 2.3 mm2 (p < 0.05) and the LA volume index was 46.2 ± 2.9 ml/m2 vs 33 ± 3 ml/m2 respectively (p < 0.0001). The presence of LA scarring was not statistically different in the two groups.

A case report of successful complex percutaneous coronary intervention for acute coronary syndrome in a paediatric patient with familial hypercholesterolaemia.

BACKGROUND: Familial hypercholesterolaemia (FH) is a primary genetic dyslipidaemia characterized by elevation in serum low-density lipoprotein cholesterol and its deposition in systemic arteries, which causes premature atherosclerosis. CASE SUMMARY: A 10-year-old girl presented with severe symptomatic coronary artery disease. She demonstrated characteristic morphological features of FH. Despite aggressive medical management and lipid-lowering therapy, her symptoms were not relieved and she had dynamic electrocardiogram changes. Coronary angiography showed a distal left main coronary artery lesion along with significant lesions in ostio-proximal and mid-left circumflex artery which were managed by provisional left main coronary artery to left circumflex artery stenting technique, with good immediate- and short-term results and angina relief. DISCUSSION: To the best of our knowledge, this is the first reported case of a paediatric patient with FH and acute coronary syndrome treated with percutaneous coronary intervention to left main coronary artery and left circumflex artery using provisional stenting technique. Revascularization strategies for symptomatic coronary artery disease in paediatric patients with FH have multiple unique challenges and remain an unexplored and under-reported subject.